Multiple Percutaneous Coronary Interventions Research Articles

Transit-time flowmetry measurement features of coronary bypass grafts after multiple percutaneous coronary interventions

The functionality of coronary bypass grafts after surgical myocardial revascularization in patients with coronary heart disease directly depends on the state of the target coronary arteries. In the presence of widespread and diff use atherosclerotic lesions or microcirculatory dysfunctions, a high frequency of coronary bypass dysfunctions is noted in the near future. In some cases, shunt dysfunction can lead to severe hemodynamic instability, accompanied by acute circulatory disorders.Aim: To assess the function of coronary bypass grafts during myocardial revascularization using the method of ultrasonic flowmetry in patients with and without a history of multiple percutaneous coronary interventions (PCI).Material and methods. The retrospective study included 47 patients who underwent coronary artery bypass surgery. A total of 145 coronary bypass grafts were performed. All patients were divided into 2 groups. Group 1 (PCI group) included patients after multiple previous PCI (n = 25; 74 coronary bypass grafts), group 2 (without PCI) included patients without previous PCI (n = 22; 71 coronary bypass grafts). All patients underwent intraoperative ultrasonic flowmetry of coronary bypass grafts using the VeriQ system (Medistim, Norway).Results. When analyzing the status of coronary bypass grafts in patients after multiple PCI, a significantly low mean volumetric blood flow rate was noted (29.5 ± 8.3 ml/min and 48.2 ± 11.6 ml/min, respectively, p = 0.0001) and lower diastolic filling (55.2 ± 8.2% and 71.9 ± 7.1%, p = 0.0001). Also in the group of patients after multiple PCI, there were 2 (2.7%) cases of revision of the distal anastomosis due to a high pulsatile index and low volumetric blood flow velocity. However, no such events were noted in the group without PCI.Conclusions. Previous percutaneous coronary interventions are compromising factors for the state of the coronary bed, which reduces the functional status of coronary bypass grafts and may increase the perioperative risk of surgical myocardial revascularization.

Mediating Effects of Self-Efficacy and Social Support on the Relationship Between eHealth Literacy and Self-Care Competency in Patients Undergoing Percutaneous Coronary Interventions: A Cross-Sectional Study

Purpose: This descriptive correlational study aimed to investigate the mediating effects of self-efficacy and social support on the relationship between eHealth literacy and self-care competency in patients undergoing percutaneous coronary intervention.Methods: The participants of this study were 146 patients who underwent multiple percutaneous coronary interventions at the Department of Cardiology at Y General Hospital in Jeollabuk-do, South Korea. Data were collected between September 19, 2022 and February 3, 2023, and analyzed using a parallel multiple mediation model in SPSS/WIN 23.0 and Model 4 of the PROCESS Macro 3.5 program. To determine the statistical significance of the indirect effect, 10,000 bias-corrected bootstrapping with 95% confidence intervals was used.Results: The effect size of the indirect effect of eHealth literacy on self-care competency via self-efficacy was 0.07, which was statistically significant, and the effect size of the indirect effect of eHealth literacy on self-care competency via social support was statistically significant at 0.13. These results verified the mediating effects of self-efficacy and social support.Conclusion: This study is significant in that it confirmed the effects of self-efficacy and social support on the relationship between eHealth literacy and self-care competency. In order to improve self-care competency in patients undergoing percutaneous coronary interventions, it is necessary to provide customized education that can improve eHealth literacy. Furthermore, there is a need for self-efficacy enhancement programs and social support strengthening programs that use various educational and material support systems to help individuals accept and access health information easily.

Myocardial Work Evaluation—A Useful Non-Invasive Method to Predict Coronary Artery Sub-Occlusion in a Patient with Unstable Angina and Multiple Myocardial Revascularization Interventions

While lifestyle changes, management of coronary artery disease (CAD) risk factors, myocardial revascularization procedures, and medication can improve a patient's prognosis, de novo native coronary lesions and in-stent restenosis (ISR) remain significant clinical concerns. ISR is more frequent with a bare-metal stent than with a drug-eluting stent and has been documented in around 12% of DES patients. Acute coronary syndrome (ACS) manifests as unstable angina in about 30% to 60% of ISR patients. Myocardial work imaging is a modern, non-invasive technique able to identify individuals with critical coronary artery lesions with high sensitivity and specificity. We present the case of a 72-year-old Caucasian gentleman with multiple cardiovascular risk factors, admitted to the Cardiology Clinic of Timișoara Municipal Hospital with unstable angina. From 1999 to 2021, the patient experienced two myocardial infarctions, a double aortocoronary bypass graft, and multiple percutaneous coronary interventions with 11 stent implantations, including 6 for ISR. Using two-dimensional speckle-tracking echocardiography and myocardial work assessment, we detected that the lateral wall of the left ventricle had a severely impaired deformation pattern. Angio-coronarography was performed, and sub-occlusion of the posterolateral branch of the right coronary artery was found. Angioplasty was performed and a DES was inserted, with a good final angiographic result and complete release of symptoms. In patients with a history of multiple myocardial revascularization interventions and ISR, it is challenging to identify the critical ischemia region by non-invasive methods. Myocardial work imaging was beneficial in the detection of the altered deformation patterns indicating significant ischemia, its accuracy being superior to that of LV strain, as proven by coronary angiography. Urgent coronary angiography followed by angioplasty and stent implantation resolved the issue.

Factors affecting the availability of hybrid cerebral and myocardial revascularization

Aim. To analyze factors affecting the availability of hybrid cerebral and myocardial revascularization by synchronous percutaneous coronary intervention (PCI) and carotid endarterectomy (CEA).Material and methods. This retrospective study included 263 patients with coronary and internal carotid artery involvement undergoing PCI and CEA during the period from 2011 to 2017.Results. The study revealed the following factors increasing the availability of revascularization: hybrid cerebral and myocardial revascularization, successful PCI using drug-eluting stents, postPCI TIMI flow grade 3, and radial access for PCI. The following factors reduced the availability: polyvascular disease >50% in three beds, prior PCI, left ventricular ejection fraction <50%, left coronary artery involvement, living without a family, staged revascularization, CEA before PCI, unsuccessful/complicated PCI with post-PCI TIMI flow grades of 0-1, residual SYNTAX score >9, emergency hospitalization and multiple emergency PCI of the coronary arteries in the long-term follow-up period.Conclusion. Comprehensive analysis of clinical, demographic, anatomical, angiographic, and perioperative factors made it possible to identify predictors that affect the availability of hybrid revascularization.

673 A CRACK AND A CLOT

Abstract A 74-year-old man with a history of ischaemic heart disease (multiple percutaneous coronary interventions (PCI)), broke his ankle. Therefore, he discontinued dual antiplatelet therapy (DAPT) -acetylsalicylic acid plus clopidogrel- and started enoxaparin sodium 4000 UI/day on medical advice. A few days later, he was admitted to the emergency department for refractory chest pain, vomit and syncope. Twelve-lead electrocardiogram (ECG) showed a sinus rhythm interrupted by frequent premature ventricular contractions in a pattern of trigeminy. The transthoracic echocardiogram revealed a mildly dilated LV with normal wall thickness and marked hypokinesis/ akinesis in apical, infero-lateral and antero-lateral walls, with a 33% ejection fraction. High sensitivity cardiac troponin was increased, and a second ECG showed a diffuse ST segment depression. The patient was loaded with aspirin and emergently taken to the cardiac catheterization lab. Coronary angiography showed a very late stent thrombosis of the left circumflex artery (LCx), with occlusion of the extreme distality of the second obtuse marginal artery and a 50-60% intrastent restenosis of the ostium-proximal tract of the left anterior descending artery (LAD). Given the non-obstructive nature of the thrombus, risk of peripheral embolization, TIMI flow grade 3 and improvement of symptoms, the decision was made to adopt a conservative strategy with loading dose of ticagrelor, heparin and tirofiban infusion. Besides, an optical coherence tomography (OCT) control was scheduled for the next day. OCT of the LCx revealed a well apposed and well expanded stent with a non-obstructive residual thrombus, nevertheless not visible on angiography. Thus, the tirofiban infusion was prolonged up to 48 hours. OCT of the LAD detected a fibro-calcific disease determining a significant restenosis of the distal left main (LM)-LAD ostium. OCT-guided provisional stenting with two drug eluting stents on LM-LAD-LCx was performed successfully. The patient was discharged home on acetylsalicylic acid (lifelong), ticagrelor (for 12 months) and enoxaparin sodium 4000 UI/day (according to specialist indication). DAPT is superior to anticoagulant therapy in preventing stent thrombosis in patients undergoing PCI, and a more informed inter-specialist communication is needed. Intracoronary imaging can help in the management of stent failure and in the guidance of complex PCI, allowing a patient-tailored treatment.

Excimer Laser coronary atherectomy as adjunctive treatment of severe stent underexpansion with bulky calcification

Excimer Laser coronary atherectomy has improved significantly in recent years, emitting high-energy ultraviolet and short wavelength with less penetration and heat emission, ultimately leading to less tissue damage and fewer complications. We described a case of a 66-year-old male patient, former smoker and suffering from hypertension, diabetes mellitus, and dyslipidemia. He underwent multiple percutaneous coronary interventions in the left anterior descending artery with bare metal and drug-eluting stents. In the last percutaneous coronary intervention, the stent was underexpanded and the patient presented acute stent thrombosis and recurrent stent restenosis. New percutaneous coronary interventions with adjunctive Excimer Laser coronary atherectomy were undertaken due to refractory angina, using progressive load and saline injection, followed by subsequent high-pressure balloon inflation and drug-eluting stent implantation with an excellent result. At 8-month follow-up, the patient was asymptomatic.

Abstract 14396: Periprocedural Myocardial Injury After Elective Percutaneous Coronary Intervention is Associated With Excess Long-Term Mortality

Introduction: Periprocedural myocardial injury (pMI), characterized by elevations in circulating cardiac biomarkers, is common following percutaneous coronary intervention (PCI) for stable ischemic heart disease. We sought to characterize incidence, risk factors, and long-term outcomes of pMI early after PCI. Methods: Patients who underwent elective PCI at a large academic medical center between 2011 and 2020 were included in this retrospective, observational study. We characterized patient and procedural characteristics from local submissions to the NCDR CathPCI registry. All patients underwent routine measurements of CK-MB at 1 and 3 hours post-PCI. Patients with abnormal CK-MB or troponin pre-PCI were excluded. For patients with multiple PCI, only the first PCI was included in the analysis. pMI was defined as any post-PCI CK-MB >99th percentile upper reference limit of the assay. The primary outcome was all-cause mortality derived from the Social Security Administration Death Master File. Cox proportional hazards models were generated to estimate the hazard of mortality associated with pMI. Results: We identified 10,923 patients undergoing elective PCI with routine post-PCI CK-MB measurement, with 47,959 patient-years of follow-up (mean: 4.4 years, range: 0 - 9.7). pMI occurred in 1843 cases (16.9%). Patients with pMI were older, more likely to be men, and had a higher burden of cardiovascular risk factors compared to those without pMI ( Table ). Over long-term follow-up, 483 patients (4.4%) died. Long-term, all-cause mortality was higher among patients with versus without pMI (8.0% vs. 3.7%, p<0.001). After adjustment for age and sex, pMI was associated with an excess hazard for long-term mortality (hazard ratio 1.48, 95% CI 1.22-1.80). Conclusion: Myocardial injury detected early after PCI is common and is associated with increased long-term all-cause mortality. Efforts to reduce pMI incidence are needed.

Coronary Artery Bypass Grafting Following COVID-19 Infection: Difficulties and Challenges.

The COVID-19 pandemic has raised challenges and dilemmas to perform cardiac surgery in the patients following COVID-19 infection due to lasting adverse impacts of the disease on the lungs. A 74-years-old patient, recently infected by COVID-19, with previous myocardial infarction and multiple percutaneous coronary interventions, in-stent thrombosis to the left anterior descending artery, and low resting saturation, presented with chest pain and underwent urgent coronary artery bypass grafting. His postoperative period remained challenging due to high oxygen requirements. He had otherwise an uneventful recovery and was discharged on domiciliary oxygen, which was weaned off over three months and he continues to do well at six months of follow-up. Keywords: Cardiac surgery; COVID-19; coronary artery bypass surgery; pandemic.

Coronary Artery Bypass With Multiarterial Grafting vs Percutaneous Coronary Intervention

BackgroundData comparing patients who undergo multiarterial grafting during coronary artery bypass grafting (CABG) vs percutaneous coronary intervention (PCI) in patients with multivessel coronary disease are scarce. This study addresses the relevance of using multiple arterial conduits vs PCI for appropriate patients. MethodsThis retrospective study included all patients with coronary artery disease who underwent CABG with multiple arterial conduits or PCI. Propensity score matching was performed for baseline characteristics. Kaplan-Meier estimates, cumulative incidence, and freedom from major adverse cardiac and cerebrovascular events (MACCE) curves were performed. ResultsThe total patient population consisted of 3648 patients from 2011 to 2018 divided into 902 CABG patients and 2746 PCI patients. Patients were propensity matched (PCI, n = 838; CABG, n = 838). In the CABG cohort the left internal mammary artery was used in 837 patients (99.9%), the right internal mammary artery in 770 patients (92%), and radial arteries in 108 patients (12.9%). Patients in the PCI cohort had significantly higher 30-day mortality (24 [2.9%] vs 7 [0.8%], P < .01). Survival over follow-up (median, 4.9 years; range, 3.3-6.8) was better for the CABG cohort (730 [87.1%] vs 625 [74.6%], P < .01). Patients in the CABG cohort had greater freedom from MACCE (607 [72.4%] vs 339 [40.5%], P < .01). Cox multivariable regression showed that patients who underwent CABG had a significantly reduced risk of mortality (hazard ratio, 0.49; 95% confidence interval, 0.39-0.61; P < .01) and of MACCE (hazard ratio, 0.33; 95% confidence interval, 0.28-0.38; P < .01). ConclusionsPatients with coronary artery disease who undergo CABG with multiple arterial conduits have significantly fewer major adverse events, improved survival, and reduced hospital readmissions.

P60: A decade on LVAD support

Objective: The use of left ventricular assist devices (LVADs) to support patients with end-stage heart failure (HF) has been progressively adopted over the past 2 decades, with long-term outcomes reporting 50% survival at 5 years, particularly related to development of complications on support. However, there is a paucity of information related to survival beyond 10 years. Herein, we report the case of an 85-year-old man with end stage ischemic cardiomyopathy with an 11-year continuous LVAD support as destination therapy (DT). Case Report: An 85-year-old man transferred from an outside hospital, presented to the emergency department due to concerns for a driveline infection. The patient has an 11-year-old history of HeartMate2-LVAD support as destination therapy (DT) due to an end-stage ischemic cardiomyopathy. Patient has undergone automatic implantable cardioverter defibrillator secondary to atrial fibrillation, as well as a primary coronary artery disease requiring multiple percutaneous coronary interventions, in addition to an aortic and mitral valve repair. He was last seen 2 years prior to this consultation for an external LVAD drive line replacement and a chronic infection which is under oral Cefalexin management (500mg/day). Additionally, the patient continues anticoagulation therapy (aspirin 81 mg/day; warfarin 10 mg/day) with a target INR of 2.5, and has not experienced any thromboembolic or hemorrhagic complications. On clinical evaluation, driveline insertion showed a non-tender, mild erythematous aspect, with no exudation. A CT scan of the thorax and abdomen was performed, demonstrating no involvement of deep tissues. Results: Initial echocardiographic evaluation showed a left ventricular ejection fraction of 20%, moderate-to-severely reduced right ventricular systolic function, a right atrial pressure of 15 mmHg, moderate tricuspid regurgitation, and a left ventricular end diastolic diameter of 6.5 cm. Upon physical examination the patient was warm and well-perfused with an euvolemic appearance. The LVAD settings remain steady at 9400 rpm and a 5.0 L/min flow. The driveline exit site elicited no pain at palpation, with mild erythema. Due to a sustained hemodynamic function in perspective to the patient’s end-stage heart failure, 500 mg of cefalexin/daily was continued and patient was discharged with no complications and continued monitorization. Conclusion: To the authors’ knowledge, this case represents one of longest reports of LVAD support as DT. The continuing improvement of LVAD management has led to the safe and feasible application of long-term cardiac function support as DT for patients deemed not transplant candidates. As our elderly population expands, and over 80% of patients with heart failure are older than 65 years, the role LVAD for long-term support will become more relevant, and this case reveals that safe LVAD support is possible beyond 10 years.

Discussion

Presenter: Dr Satoshi Kainuma Dr Robert E. Michler (New York, NY). Dr Kainuma, the American Association for Thoracic Surgery selection committee made an excellent decision in selecting your abstract for oral presentation. The topic is provocative in answering the question of whether multiple percutaneous coronary intervention (PCI) negatively influences clinical outcomes for ischemic mitral regurgitation, and your work could change clinical practice. Now, with the opportunity to carefully review your manuscript, it appears that an answer is close, but not yet definitive. The unifying aspect of the 2 comparison populations that you studied is that they both underwent restrictive annuloplasty for ischemic mitral regurgitation. Apart from this fact, the 2 groups were in fact very different. An operation such as coronary artery bypass grafting (CABG) is a major predictor of survival as is left ventricular ejection fraction. CABG was performed in significantly different numbers in each comparison group, 85% of 211 in the group with one or fewer PCIs, versus 47% of the 98 patients in the group with multiple PCIs. This fact alone may have led to differences in the outcomes measured and served as the primary driver of why the multiple PCI group did less well, in comparison to the single or no PCI group. Moreover, each additional operation performed would likely have influenced the outcomes measured. Because the multiple PCI group included 50% fewer total patients, the influence of these additional procedures may have negatively influenced the results for the group. And, another cofounding variable such as surgical ventricular reconstruction, which is a highly technical and demanding operation, with its own morbidity and mortality, was performed in 61 of the 211 patients with no or 1 PCI and 35 of the 98 patients with multiple PCIs. Was CABG required less frequently in the multiple PCI group because PCI was so successful in reperfusion of the at-risk territory or because the coronary anatomy was inherently bad? Or worse yet, perhaps the PCI—the prior PCI—had inflamed, sclerosed, and narrowed the distal vessel, making it ungraftable in the eyes of the surgeon? Dr Satoshi Kainuma (Suita, Osaka, Japan). Thank you, Professor Michler, for your great comments and important question. I think both are the reasons why patients with multiple PCI groups were not amenable to CABG. I mean that they were more likely to have more severe disease of the vessel, so bypass surgery was difficult. In addition to that, the result of the PCI was excellent for some patients, whereas not in others. So, I guess both factors were the reasons to explain the infrequent rates of concomitant bypass surgery for patients with multiple PCIs. Dr Michler. Was ischemic mitral regurgitation present at the time of the original PCI? And if it was, was the decision to perform a restrictive annuloplasty made because the desire was to avoid bypass surgery or was the belief that it might in and of itself reduce the grade of ischemic mitral regurgitation? Dr Kainuma. Thank you for your great question. Unfortunately, every patient was not evaluated in terms of ischemic mitral regurgitation at the time of the PCI. This is a problem. And secondly, interventionists in Japan are quite aggressive and prefer to do PCI whenever they see the ischemic mitral regurgitation. Probably because they do not consider that CABG is the best coronary revascularization therapy for patients with ischemic mitral regurgitation and myocardial dysfunction. So, Japanese cardiologists and interventionists are well trained in terms of the procedural aspect, but not with patient selection or indication for the PCI, especially for patients with stable coronary artery disease.

Multiple percutaneous coronary interventions worsen outcomes for subsequent surgical correction of chronic ischemic mitral regurgitation

ObjectiveWe investigated whether or not a history of multiple percutaneous coronary interventions (PCIs) is associated with clinical outcomes after surgery for ischemic mitral regurgitation. MethodsA total of 309 patients with chronic ischemic mitral regurgitation and left ventricular ejection fraction ≤40% who underwent restrictive mitral annuloplasty were classified as follows: patients with no or 1 previous PCI (nonmultiple PCI group [n = 211]) and patients with 2 or more previous PCIs (multiple PCIs group [n = 98]). Mean follow-up duration was 53 ± 40 months. ResultsBefore surgery, there were no intergroup differences in patient demographic characteristics except for lower estimated glomerular filtration rate in patients with multiple PCIs. These patients underwent concomitant coronary artery bypass grafting less frequently with a lower number of distal anastomoses (P < .05 for both). The 30-day mortality was 3.3% and 2.0% in the nonmultiple and multiple PCIs group, respectively (P = .72). During follow-up, there were 157 deaths. Patients with multiple PCIs showed lower 5-year survival rate (44% vs 64%; P = .002). After adjustments with inverse-probability-of-treatment weighting, multiple PCIs history was an independent risk factor for mortality (adjusted hazard ratio, 1.4; 95% confidential interval, 1.1-1.7; P = .002). Patients with multiple PCIs showed less improvement in left ventricular ejection fraction (interaction effect P < .001). ConclusionsIn patients with ischemic mitral regurgitation, a history of previous multiple PCIs was associated with increased risk of long-term postoperative mortality, with less improvement in left ventricular ejection fraction.

Multiple percutaneous coronary interventions may negatively impact cardiac remodelling after bypass surgery.

Many patients undergo percutaneous coronary intervention (PCI) multiple times before being referred for coronary artery bypass grafting (CABG), in which bypass grafts are often anastomosed to small distal targets with higher risk of graft failure. We aimed to assess whether multiple PCIs adversely affect the long-term outcomes of patients who undergo CABG subsequently. A cohort of 368 patients with no history of PCI underwent initial isolated CABG between 2003 and 2013 (no PCI group). Ninety-seven patients who had undergone PCI 2 or more times preoperatively during the same period constituted the multiple PCI group. After propensity score matching, the group outcomes were compared. There were no significant differences in the 10-year all-cause mortality and major adverse cardiac and cerebrovascular event rates in both groups. Although the left ventricular end-diastolic dimension in the multiple PCI group did not change markedly (from 48.0 ± 6.0 to 47.2 ± 7.9 mm; P = 0.25), it decreased significantly in the no PCI group (from 48.3 ± 6.1 to 44.9 ± 9.1 mm; P < 0.001). The left ventricular end-systolic dimension in the no PCI group decreased significantly (from 34.1 ± 8.7 to 31.4 ± 8.6 mm; P = 0.024), while it in the multiple PCI group did not (from 33.6 ± 8.3 to 32.7 ± 8.6 mm; P = 0.21). For complex coronary artery disease, early surgical intervention could be considered with respect to postoperative left ventricular remodelling during the long-term follow-up.

Patient-centered contrast thresholds to reduce acute kidney injury in high-risk patients undergoing percutaneous coronary intervention

Contrast volume used during percutaneous coronary intervention has a direct relationship with contrast-associated acute kidney injury. While several models estimate the risk of contrast-associated acute kidney injury, only the strategy of limiting contrast volume to 3 × estimated glomerular filtration rate (eGFR) gives actionable estimates of safe contrast volume doses. However, this method does not consider other patient characteristics associated with risk, such as age, diabetes or heart failure. Using the National Cardiovascular Data Registry acute kidney injury risk model, we developed a novel strategy to define safe contrast limits by entering a contrast term into the model and using it to meet specific (eg, 10%) relative risk reductions. We then estimated acute kidney injury rates when our patient-centered model-derived thresholds were and were not exceeded using data from CathPCI version 5 between April 2018 and June 2019. We repeated the same analysis in a sub-set of patients who received ≤3 × eGFR contrast. After excluding patients on hemodialysis, below average risk (<7%), missing data and multiple percutaneous coronary interventions, our final analytical cohort included 141,133 patients at high risk for acute kidney injury. The rate of acute kidney injury was 10.0% when the contrast thresholds derived from our patient-centered model were met and 18.2% when they were exceeded (P < .001). In patients who received contrast ≤3 × eGFR (n = 82,318), contrast-associated acute kidney injury rate was 9.8% when the contrast thresholds derived from our patient centered model were met and 14.5% when they were exceeded (P < .001). A novel strategy for developing personalized contrast volume thresholds, provides actionable information for providers that could decrease rates of contrast-associated acute kidney injury. This strategy needs further prospective testing to assess efficacy in improving patient outcomes.

35 Years Angiographic Follow Up Of Atherosclerotic Cardiovascular Disease Including Redo Cabg, Carotid Artery Stenting &amp; Multiple Interventions To Saphenous Venous Grafts

Percutaneous coronary intervention (PCI) has got more benefit as compared to redo CABG in terms of morbidity &amp; mortality in patients presented with degenerated CABG grafts. We report a case of post CABG patient treated successfully with multiple PCI to SVG grafts- a 35 years follow up.

Fractured Guidewire Entrapped in the Ostium of Right Coronary Artery Mimicking Aortic Flap

An 84-year-old male patient with ischemic heart disease was referred to transesophageal echocardiography evaluation of mitral regurgitation. He previously underwent multiple percutaneous coronary interventions (PCI) in another hospital, the last intervention 3 years ago. Flail anterior leaflet of

Non-syndromic cardiac progeria in a patient with the rare pathogenic p.Asp300Asn variant in the LMNA gene

BackgroundMutations in LMNA gene, encoding Lamin A/C, cause a diverse array of phenotypes, collectively referred to as laminopathies. The most common manifestation is dilated cardiomyopathy (DCM), occurring in conjunction with variable skeletal muscle involvement but without involvement of the coronary arteries. Much less commonly, LMNA mutations cause progeroid syndromes, whereby an early-onset coronary artery disease (CAD) is the hallmark of the disease. We report a hitherto unreported compound cardiac phenotype, dubbed as “non-syndromic cardiac progeria”, in a young patient who carried a rare pathogenic variant in the LMNA gene and developed progressive degeneration of various cardiac structures, as seen in the elderly. The phenotype resembled the progeroid syndromes, except that it was restricted to the heart and did not involve other organs.Case presentationThe patient was a well-developed Caucasian female who presented at age 29 years with an acute myocardial infarction (MI) and was found to have extensive CAD. She had none of the conventional risk factors for atherosclerosis. She underwent coronary artery bypass surgery but continued to require multiple percutaneous coronary interventions for symptomatic obstructive coronary lesions. During the course of next 10 years, she developed mitral regurgitation, degenerative mitral and aortic valve diseases, atrial flutter, and progressive conduction defects. She died from progressive heart failure with predominant involvement of the right ventricle and severe tricuspid regurgitation. Cardiac phenotype in this young patient resembled degenerative cardiac diseases of the elderly and the progeroid syndromes. However, in contrast to the progeroid syndromes, the phenotype was restricted to the heart and did not involve other organs. Thus, the phenotype was dubbed as a non-syndromic cardiac progeria.Genetic screening of several cardiomyopathy genes, including LMNA, which is a causal gene for progeroid syndromes, led to identification of a very rare pathogenic p.Asp300Asn variant in the LMNA gene.ConclusionsWe infer that the LMNA p.Asp300Asn mutation is pathogenic in non-syndromic cardiac progeria. Mutations involving codon 300 in the LMNA gene have been associated with progeroid syndromes involving multiple organs. Collectively, the data provide credence to the causal role of p.Asp300Asn mutation in the pathogenesis of non-syndromic cardiac progeria.

An Uncommon Association of Familial Partial Lipodystrophy, Dilated Cardiomyopathy, and Conduction System Disease.

A 46-year-old African American woman presented with severe respiratory distress requiring intubation and was diagnosed with nonischemic cardiomyopathy. She had the typical phenotype of familial partial lipodystrophy 2 (FPLD2). Sequence analysis of LMNA gene showed a heterozygous missense mutation at exon 8 (c.1444C>T) causing amino acid change, p.R482W. She later developed severe coronary artery disease requiring multiple percutaneous coronary interventions and coronary artery bypass surgery. She was later diagnosed with diabetes, primary hyperparathyroidism, and euthyroid multinodular goiter. She had sinus nodal and atrioventricular nodal disease and had an implantable cardioverter defibrillator implantation due to persistent left ventricular dysfunction. The device eroded through the skin few months after implantation and needed a re-implant on the contralateral side. She had atrial flutter requiring ablation. This patient with FPLD2 had most of the reported cardiac complications of FPLD2. This case is presented to improve the awareness of the presentation of this disease among cardiologists and internists.

Chronic Total Occlusion of the Left Main Coronary Artery in a 63-Year- Old Woman after Triple Coronary Bypass Surgery

Background: A 63-year-old female with a chronic total occlusion (CTO) of the left main coronary artery (LMCA) after multiple percutaneous coronary interventions (PCI) and triple coronary bypass surgery (CABG). Investigation: physical examination, EKG, TTE, coronary angiography, appropriate lesion preparation before stenting of the LMCA. Diagnosis: Multivessel coronary artery disease presenting as CCS third class with ostial LMCA chronic total occlusion and unsuccessful consecutive revascularization. Management: Recanalization of the LMCA CTO, preparation of the lesion by rotational atherectomy, reverses T-stenting of LMCA.

Implantation of a bioabsorbable vascular scaffold into a coronary vein graft: a two-week angiography follow-up

An 83-year-old patient with a history of coronary artery bypass grafting (CABG) performed 13 years ago was admitted due to unstable angina for diagnostic catheterisation. His medical history consisted of CABG with left internal mammary artery to left anterior descending artery and vein grafts to obtuse margin artery (OM), diagonal artery (D1) and right coronary artery (RCA). Following that, the patient had multiple percutaneous coronary interventions (PCI) in vein grafts: bare metal stent implantation into the Ao-OM (three years ago), two POBA of Ao-OM (one and two years ago), two drug eluting stents (DES) into Ao-OM (six and 12 months ago), and DES into Ao-D1 (two years ago). Coronary angio graphy revealed significant stenosis in distal segment of Ao-RCA and in stent restenosis in DES implanted to Ao-OM. The lesion in Ao-RCA (% diameter stenosis = 82%, minimal diameter = 0.43 mm, lesion length = 5 mm) was treated with an everolimus-eluting bioabsorbable vascular scaffold (BVS) (Absorb, 2.5 × 15 mm) achieving good post procedural angiographic results (% diameter stenosis = 13%, minimal diameter = 2.5 mm) (Fig. 1). Two weeks after the procedure, the patient was hospitalised again for an elective PCI of Ao-OM in stent restenosis. The bypass angiography revealed patent Ao-RCA with sustained good angiographic results at the site of BVS implantation. Drug eluting BVS implantation may be a new option for the treatment of stenotic coronary vein grafts. However, a prospective study is needed to validate the safety of such a BVS application.