Multiple Coronary Artery Research Articles

Multiple postpartal coronary artery dissections and fibromuscular renal artery dysplasia

A 42-year-old postpartal woman presented 5 months after delivery of her second child with sudden onset of chest pain following exercise. The clinical investigation was unremarkable except for a blood pressure of 185/110 mmHg and a positive troponin test. Her past medical history included controlled arterial hypertension and two episodes of a troponin-positive acute coronary syndrome due to spontaneous coronary artery dissection (SCAD) that were treated conservatively. The first episode was not pregnancy associated and was caused by single SCAD of the posterior descending coronary artery. The second episode occurred 2 months after delivery of …

Current status of coronary artery bypass grafting

The number of cases of coronary artery bypass grafting (CABG) reached more than 21 000 in Japan in 2002, and the operative mortality decreased to less than 1%, including emergency operations. The annual number of CABGs in Japan declined 17% after 2003 to 18 000 cases in 2005 owing to unrestricted percutaneous coronary intervention (PCI) with drug-eluting stents. However, CABG is the best treatment for multivessel coronary artery disease based on the comparative data of PCI versus CABG. There have been two trends in CABG during the last decade. One is the widespread use of off-pump (OP) CABG, and the other is multiple coronary artery revascularization. In 2004 and 2005, approximately 60% of all isolated CABG procedures in Japan were performed without cardiopulmonary bypass. In a study of long-term outcomes comparing PCI with drug-eluting stents versus CABG with only arterial grafts, the latter was carried out in 52% of total cases and in 66% of OPCAB cases. OPCAB with multiple arterial grafts has become the standard CABG in Japan.

Intraoperative Transesophageal Echocardiography Enables Characterization of Coronary Artery Fistula in Coexistence with Multiple Giant Coronary Artery Aneurysms

Intraoperative Transesophageal Echocardiography Enables Characterization of Coronary Artery Fistula in Coexistence with Multiple Giant Coronary Artery Aneurysms

Results of Adjunctive Coronary Endarterectomy in 548 Patients

Coronary endarterectomy is a controversial procedure that plays a particular role in the treatment of coronary artery disease. We retrospectively investigated the results for 548 patients who underwent coronary endarterectomy as an adjunctive therapy for coronary artery bypass graft surgery during the period between 1996 and 2004. We assessed short-term outcomes and identified risk factors for adverse outcomes. Mean patient age was 67.9 + 9.3 years and mean angina class was 2.7 + 0.3. The mean number of distal anastomoses was 3.8 + 1.1 patients (73.4%) had single and 151 (27.6%) multiple coronary artery endarterectomies. Of the 151 patients who underwent multiple endarterectomies, 97 (17.7%) had endarterectomies in 2 coronary arteries, 40 (7.2%) in 3 coronary arteries, 11 (2%) in 4 coronary arteries, 2 (0.36%) in 5 coronary arteries, and 1 (0.18%) in 6 coronary arteries. Postoperative mortality was 6.2% (34 patients). The predictors for early mortality were recent myocardial infarction and left ventricular dysfunction. Our results suggest that adjunctive coronary endarterectomy can be accomplished with acceptable results but with higher mortality rates than ordinary coronary artery bypass grafting. Adjunctive coronary endarterectomy should be considered as a last option for the surgical treatment of diffuse coronary disease.

Persistent Thebesian Sinusoids Presenting as Ischemic Heart Disease

A 54-year-old man with no significant past medical history or modifiable cardiovascular risk factors was admitted with chest pains and palpitations. ECG revealed atrial fibrillation with fast ventricular response that reverted to sinus rhythm after intravenous administration of digoxin. His 12-hour troponin I level was marginally elevated (0.07 ng/mL; normal range <0.06 ng/mL). Subsequent serial 12-lead ECGs (Figure 1) demonstrated widespread dynamic ST-segment and T wave changes. The patient was treated for an acute coronary syndrome and became pain free on intravenous administration of glyceryl trinitrate and glycoprotein IIB/IIIA antagonist. Coronary angiography demonstrated pristine epicardial coronaries but a bizarre appearance of capillary blush draining into the left venticular cavity, during both left main stem and right coronary artery injection (Figure 2A and 2B and Movie I and II). In absence of any myocardial tumor, ventricular hypertrophy, or …

Confluence at distal end of multiple coronary artery fistulae: two cases treated with interventional approach

Confluence at distal end of multiple coronary artery fistulae: two cases treated with interventional approach

Modulation of late sodium current by Ca2+, calmodulin, and CaMKII in normal and failing dog cardiomyocytes: similarities and differences.

Augmented and slowed late Na(+) current (I(NaL)) is implicated in action potential duration variability, early afterdepolarizations, and abnormal Ca(2+) handling in human and canine failing myocardium. Our objective was to study I(NaL) modulation by cytosolic Ca(2+) concentration ([Ca(2+)](i)) in normal and failing ventricular myocytes. Chronic heart failure was produced in 10 dogs by multiple sequential coronary artery microembolizations; 6 normal dogs served as a control. I(NaL) fine structure was measured by whole cell patch clamp in ventricular myocytes and approximated by a sum of fast and slow exponentials produced by burst and late scattered modes of Na(+) channel gating, respectively. I(NaL) greatly enhanced as [Ca(2+)](i) increased from "Ca(2+) free" to 1 microM: its maximum density increased, decay of both exponentials slowed, and the steady-state inactivation (SSI) curve shifted toward more positive potentials. Testing the inhibition of CaMKII and CaM revealed similarities and differences of I(NaL) modulation in failing vs. normal myocytes. Similarities include the following: 1) CaMKII slows I(NaL) decay and decreases the amplitude of fast exponentials, and 2) Ca(2+) shifts SSI rightward. Differences include the following: 1) slowing of I(NaL) by CaMKII is greater, 2) CaM shifts SSI leftward, and 3) Ca(2+) increases the amplitude of slow exponentials. We conclude that Ca(2+)/CaM/CaMKII signaling increases I(NaL) and Na(+) influx in both normal and failing myocytes by slowing inactivation kinetics and shifting SSI. This Na(+) influx provides a novel Ca(2+) positive feedback mechanism (via Na(+)/Ca(2+) exchanger), enhancing contractions at higher beating rates but worsening cardiomyocyte contractile and electrical performance in conditions of poor Ca(2+) handling in heart failure.

Cardiac imaging in a symptomatic patient with multiple coronary artery–left ventricular microfistulae

We present the case of a 44-year-old woman with acute coronary syndrome and multiple coronary artery-left ventricular microfistulae at angiography. To evaluate the clinical significance of this observation and to obtain further insights into this rare disease, the patient was further examined with echocardiography and both magnetic resonance imaging and single-photon emission computed tomography, which showed considerable abnormalities.

ROCKI Regulates Growth, Maturation and Migration of Mast Cells.

Mast cell activation plays a critical pathophysiologic role in asthma and allergy. A role for mast cell activation has also been described in multiple sclerosis, rheumatoid arthritis and coronary artery disease. In addition, these cells also play a prominent role in early phases of innate immunity to pathogenic bacteria. While several cytokines influence the growth, survival and maturation of mast cells; stem cell factor (SCF) and its interaction via the tyrosine kinase receptor, KIT is essential for normal mast cell development and function. However the intracellular signals that control mast cell growth, migration and maturation are not completely understood. In non-hematopoietic cells, Rho family GTPases are key regulators of many different biological processes including cell motility, growth, and differentiation. Cdc42, Rac and Rho are the most extensively studied members of this family. Although the role of Rac GTPases is becoming increasingly clear in mast cells and in hematopoietic cells in general, virtually nothing is known about the role of downstream effectors of Rho GTPases in these cells. RhoA and RhoC activate the serine/threonine protein kinases ROCKI and ROCKII. We show that both ROCKI and ROCKII are expressed in hematopoietic cells, including in bone marrow cells, splenocytes as well as in thymocytes. To determine the role of ROCK kinases in mast cells, we generated mice deficient in the expression of ROCKI. Here, we demonstrate that Rho-kinase ROCKI plays an essential role in regulating mast cell growth and maturation. We show that deficiency of ROCKI results in impaired maturation of bone marrow derived mast cells in response to IL-3 stimulation. Furthermore, the reduced maturation of ROCKI−/− mast cells is associated with reduced expression of KIT as well as reduced expression of the high affinity receptor for IgE at different stages of maturation (13% vs 7% at week1, 80% vs 52% at week2, and 93% vs 67% KIT/IgE receptor double positive cells at week3, n=3). KIT induced proliferation in response to SCF was also significantly reduced in ROCKI deficient mast cells, which was associated with reduced activation of MAPKinase Erk1 and Erk2. To test if the decreased growth in response to SCF was simply due to reduced KIT expression or due to cell intrinsic defects in ROCKI signaling, we isolated KIT positive WT and ROCKI−/− mast cells and measured growth in response to SCF and/or IL-3 stimulation by thymidine incorporation over a period of 24 and 48 hours. KIT positive ROCKI−/− mast cells showed reduced growth in response to SCF as well as in response to a combination of SCF and IL-3, suggesting a critical role of ROCKI in normal growth and maturation of mast cells. Since ROCK kinases also regulate migration in non-hematopoietic cells, we next examined the role of ROCKI in integrin (haptotactic) as well as in cytokine induced (chemotaxis) migration of mast cells. Mast cells deficient in ROCKI showed a 68% reduction in directional migration on fibronectin alone (64±7 [WT] vs 20±4, p<0.05) and a 31% reduction in the presence of SCF and fibronectin (181±16 [WT] vs 124±11 [ROCK1−/−], p<0.05), although no defects in SCF induced chemotaxis were observed. Taken together, our results identify ROCKI as a novel molecule that regulates growth, maturation and integrin-directed (haptotactic) migration of mast cells. Our results suggest that commercially available ROCK kinase inhibitors could prove to be useful small molecule inhibitors for treating diseases involving mast cells such as chronic inflammation and allergy.

Multiple extensive coronary artery stenting: does it compromise future surgical revascularization?

In the era of percutaneous coronary intervention, surgeons are confronted with performing coronary artery bypass graft surgery on patients with previous balloon dilatation or stenting. This review evaluates the impact of previous percutaneous coronary intervention on patient survival and choice of optimal myocardial revascularization technique. Aggressive atherosclerosis has been remarked in patients complicated with intrastent stenosis. Moreover, bypass grafting with venous grafts has shown an extremely high incidence of graft failure in the restenosis population due to limited nitric oxide (a natural vasodilator) production of venous grafts. The challenge is to achieve complete revascularization in an unfavourable setting (greater co-morbidities, complex coronary lesions) with a greater risk of graft occlusion. The internal thoracic artery is the optimal graft for myocardial revascularization in patients with and without previous in-stent restenosis. Coronary artery reconstruction by exclusive internal thoracic artery grafting gives superior patency rates and clinical outcomes. It is the most appropriate approach for myocardial revascularization in these patients.

Multiple Coronary Artery Aneurysms Detected by Cardiac Magnetic Resonance Imaging

Multiple Coronary Artery Aneurysms Detected by Cardiac Magnetic Resonance Imaging

Head-to-Head Comparison of Sirolimus- and Paclitaxel-Eluting Stent in the Same Diabetic Patient With Multiple Coronary Artery Lesions

It is still controversial whether sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES) are equally effective in patients with diabetes. In these patients, multiple individual variables may be responsible for neointimal hyperplasia, thus making difficult the comparison of the two drug-eluting stents (DES). We designed a prospective, randomized study to compare the efficacy in prevention of restenosis of SES and PES, both implanted in the same diabetic patient with multiple de novo coronary artery lesions undergoing elective percutaneous coronary intervention. We enrolled 60 patients with diabetes with at least two significant de novo angiographic stenoses in different coronary segments. The primary end point was in-stent late luminal loss (LLL) at 8-month angiographic follow-up. A total of 120 lesions were successfully treated with the randomly assigned DES (SES, n = 60; PES, n = 60). In-stent LLL was lower in the SES than in the PES group (0.26 +/- 0.4 vs. 0.50 +/- 0.6 mm; P = 0.01). Coronary lesions treated with SES presented a reduced in-stent LLL in 40 (68%) patients, while PES resulted in a lower in-stent LLL in 19 (32%) patients (P = 0.0002). At multivariable analysis, the type of DES implanted was the only independent predictor of in-stent LLL (odds ratio 2.3 [95% CI 1.1-5.0]; P = 0.03). SES directly compared with PES in the same diabetic patient is associated with a decrease in the extent of in-stent LLL at 8 months, suggesting a reduced risk of restenosis.

Simultaneous subacute stent thrombosis after implantation of sirolimus-eluting stent and bare-metal stent

Simultaneous multivessel stent thrombosis is a rare, but can cause catastrophic clinical results. We report a case occurred ST simultaneously in DES and BMS. Our case demonstrated that the use of multiple stents, irrespective of stent type, in multiple coronary artery lesions should be undertaken with great attention in the patient who has multiple adverse clinical predictors such as AMI.

A novel ultra-thin bare metal stent (BMS): results from a worldwide registry

To evaluate a new generation, thin strut, stainless steel Tsunami coronary stent in a contemporary percutaneous coronary intervention (PCI) practice across a wide geographical area. Patients (n=1,437) with single or multiple vessel coronary artery disease undergoing PCI in 82 sites in Europe, Asia, and Australia were enrolled in the MATSURI registry. Clinical follow-ups were scheduled at 1, 6 and 18 months. Primary endpoint was major adverse cardiac events (MACE) rate at 6 months. Diabetes was present in 25% of patients, 40% had unstable angina, 54% multivessel disease and 31% previously underwent PCI/CABG. Procedural success was achieved in 98.1% of patients. MACE rate was 1.8%, 7.3%, and 12.6% for 1, 6 and 18 month follow-up, respectively. At 6 months, the incidence of cardiac death, MI and TLR were 1%, 1.9% and 4.5% respectively, and confirmed stent thrombosis occurred in 0.2% of patients. Lower risk patients (43% of registry population) had six months MACE free survival of 96.7%. Based on the results of this large registry we can conclude that the Tsunami BMS combines excellent deliverability and safety for all, together with very low MACE rates for lower risk patients. Long term follow-up confirmed sustained clinical benefit.

Multidetector-row computed tomographic depiction of congenital coronary artery aneurysms and ectasia

Coronary artery aneurysm or ectasia is an uncommon clinical problem in the pediatric population. When found, it is usually associated with the sequelae of Kawasaki disease. We report a 12-year-old boy with multiple focal coronary artery aneurysms and ectasia without history of Kawasaki disease on multidetector-row computed tomography (MDCT).

Successful Revascularization of Multiple Coronary Artery Aneurysms Using a Combination of Surgical Strategies

We report our approach to an unusual case of a 64-year-old man with multiple coronary artery aneurysms (CAAs) of the right, left anterior descending, and ramus coronary arteries. The right CAA was unusually large in size (measuring 5.5 cm). The aneurysms were obstructive, resulting in ischemic heart disease and heart failure. Multiple surgical techniques have been proposed to approach CAAs; however the ideal treatment strategy is poorly defined. This patient underwent successful revascularization using a combination of strategies, including aneurysm ligation, interposition reversed saphenous vein grafting, and bypass grafting. Surgical approach should be determined by aneurysm size, presence of branching vessels, and degree of stenosis.

Long‐term pericardial catheterization is associated with minimum foreign‐body response

The goals of this study were to assess the feasibility and to characterize the foreign-body response of a long-term catheter in the pericardium. Long-term access to the normal pericardial space provides opportunities for diagnostic sampling and therapeutic intervention. After thoracotomy, in 7 anesthetized canines, the pericardium was opened and a 5 French silicone vascular access catheter was advanced 10 cm into the pericardial sac toward the apex of the heart. A hydraulic coronary balloon occluder was implanted (N=6). Pericardium was sealed with Prolene suture. Catheters were tunneled to the nape of the neck, attached to a subcutaneous vascular access port, and buried in the fascia. Animals underwent multiple experimental coronary artery occlusions across months. At sacrifice, we assessed the histopathological response of pericardium and epicardium to chronically indwelling silicone catheters. Post-mortem examinations were performed at 213 days post-operatively (mean, range=96-413, N=6), with one animal maintained for longer-term study. At sacrifice, all catheters were bidirectionally patent and completely mobile in the pericardium without evidence of tissue overgrowth around the intrapericardial segment. Adhesion tissue was found only at the site of catheter entry through the pericardium. Microscopic histopathological examination at catheter entry site, surrounding pericardium, and myocardium revealed minimum chronic inflammation. This subcutaneous system provides dependable, chronic access to the normal pericardial space for drug delivery and sampling. The presence of a chronic silicone catheter in the pericardium does not precipitate clinically significant pathologic changes even after repeated ischemic events.

Multiple coronary artery aneurysms that cause thrombosis: 22-month follow-up results with multi-slice spiral computerized tomography without surgery

Aneurysms of the coronary arteries are extremely rare. The most common cause is atherosclerosis. Coronary aneurysms may be asymptomatic, or they may be complicated by thrombosis and rupture. We report a multiple coronary artery aneurysm that caused thrombosis in a patient, along with 22-month follow-up results with multi-slice spiral computerized tomography. A 43-year-old man was admitted to hospital with a diagnosis of acute inferior myocardial infarction. He underwent thrombolytic treatment with streptokinase. Cardiac catheterization revealed multiple large aneurysms of the proximal coronary arteries and intracoronary thrombosis in the midportion of the circumflex coronary artery. His multi-slice spiral computerized tomography revealed an organized thrombus in the CX coronary artery, no critical stenosis and no change in the coronary aneurysm after 22 months. The patient did not experience any problem during the 22-month follow-up period. In our opinion, middle diameter coronary artery aneurysms that are asymptomatic and not accompanied by critical stenosis can be followed up with medical treatment, and multi-slice spiral computerized tomography is a safe way to follow up these patients.

Metabolic syndrome: stronger association with coronary artery disease in young men in comparison with higher prevalence in young women

Being overweight, a constituent of the metabolic syndrome, is also an important contributing factor to the development of coronary artery disease in younger patients, compared with the older patient population. Owing to the above-mentioned fact, we sought to assess the association of the metabolic syndrome with premature coronary artery disease. In an analytic cross-sectional study, 940 patients (553 women<or=55 years and 387 men<or=45 years), 637 with coronary artery disease and 303 without coronary artery disease, were evaluated. The extent of atherosclerosis was assessed with a clinical vessel score. Besides established coronary artery disease risk factors, all patients were evaluated for the presence of metabolic syndrome based on the National Cholesterol Education Program Adult Treatment Panel III criteria. The overall prevalences of metabolic syndrome and coronary artery disease were 56 and 67.8%, respectively. Metabolic syndrome prevalence was higher in women than in men (69.6 vs. 36.4%, P<0.001). The odds ratio of metabolic syndrome for premature coronary artery disease was 1.82 (95% confidence interval 1.17-2.82) after adjusting for age and multiple established coronary artery disease risk factors; the strength of this association varied by sex (2.17 in men vs. 1.22 in women). This study revealed a stronger association between metabolic syndrome and coronary artery disease in men<or=45 years than in women<or=55 years. It seems that endogenous estrogens may play a role in reducing the effects of metabolic syndrome-related risk and therefore in spite of higher prevalence of metabolic syndrome in young women, the effect of this syndrome on coronary artery disease is more dominant in young men.

Off-Pump Strategy in High-Risk Coronary Artery Bypass Reoperations

To determine the role of off-pump coronary artery bypass grafting in the treatment of patients with severe recurrent angina after coronary artery bypass grafting who are not suitable for percutaneous coronary intervention and are considered too high risk for conventional on-pump revascularization. All patients who needed single- or double-vessel revascularization at reoperation with a predicted operative mortality of 10% or higher between March 4, 1994, and December 31, 2002, were studied. Risk stratification was performed using both the Parsonnet risk scoring system and the European System for Cardiac Operative Risk Evaluation. Active follow-up by questionnaire investigated major adverse cardiac events. This study consisted of 84 patients with a median age of 69 years (interquartile range, 62-75 years); 14 (17%) were female. All patients had class III/IV symptoms. Previous operations included multiple coronary artery bypass grafts (15 patients [18%]) and heart transplantation (1 patient [1%]). Internal thoracic artery graft from a previous operation was patent in 43 patients (51%). Perioperative hemodynamic support with inotropes (35%) and intra-aortic balloon pump (14%) or ventricular assist device (2%) was common. The surgical approach varied for each patient. One operative death (1%) occurred. Estimated survival at 5 and 7 years was 77% and 67%, respectively. Late major adverse cardiac events observed during follow-up were cardiac death (n=66), nonoperative reintervention (n=8), and nonfatal myocardial infarction (n=5). Off-pump coronary artery bypass grafting can mitigate reoperative risk in patients with an estimated risk of 10% or higher who are undergoing single- or double-vessel revascularization with satisfactory long-term outcome.