Coronary Artery Patency Research Articles

A rare case of concomitant acute occlusion of left main coronary artery and right coronary artery with characteristic electrocardiographic pattern

Acute Left Main Coronary Artery (LMCA) occlusion is a rare clinical presentation which often manifests as a cardiogenic shock with worse prognosis. However the clinical outcome depends on the age of the patient, co-morbidities and the patency and dominancy of Right coronary artery.

Successful use of the impella ventricular assist device for management of reverse Takotsubo Cardiomyopathy in the setting of acute intracranial hemorrhage

Reverse Takotsubo Cardiomyopathy (rTTC) is a rare variant of Takotsubo Cardiomyopathy (TTC) that is characterized by hypokinesis of the base and sparing of the mid to apical wall of the left ventricle best seen on echocardiogram. Intracranial hemorrhage (ICH) has been identified as a risk factor rTTC. Nearly around 10% of the patients with TTC develop cardiogenic shock.We hereby report the successful use of the Impella Ventricular Assist Device (Impella CP®) for management of rTTC in the setting of acute ICH. Our patient is a young female who presented with loss of consciousness after an acute headache and imaging studies revealed left posterior cerebral artery aneurysm with intraventricular hemorrhage. Subsequently the patient developed hypoxia, severe hypotension and cardiac arrest. After resuscitation, an echocardiogram showed that the patient had rTTC and a cardiac angiogram showed patent coronary arteries. The Impella CP® was successfully inserted followed by immediate cerebral angiography and aneurysmal coiling. Systemic anticoagulation was started during coiling. In the next three days, the patient's left ventricular function recovered, and she was discharged home. Up to our knowledge, this is the first case report to mark the successful placement of the Impella CP® with delayed initial anticoagulation for management of rTTC. Our patient was challenging as there are no current guidelines in the management of cardiogenic shock secondary to rTTC in the setting of acute ICH.

H-repair in supravalvular aortic stenosis.

H-repair in supravalvular aortic stenosis.

Endothelial Dysfunction and Coronary Vasoreactivity - A Review of the History, Physiology, Diagnostic Techniques, and Clinical Relevance.

The fervency for advancement and evolution in percutaneous coronary intervention has revolutionised the treatment of coronary artery disease. Historically, the focus of the interventional cardiologist was directed at the restoration of luminal patency of the major epicardial coronary arteries, yet whilst this approach is evolving with much greater utilisation of physiological assessment, it often neglects consideration of the role of the coronary microcirculation, which has been shown to clearly influence prognosis. In this review, we explore the narrative of the coronary circulation as more than just a simple conduit for blood but an organ with functional significance. We review organisation and physiology of the coronary circulation, as well as the current methods and techniques used to examine it. We discuss the studies exploring coronary artery endothelial function, appreciating that coronary artery disease occurs on a spectrum of disorder and that percutaneous coronary intervention has a latent effect on the coronary circulation with long-term consequences. It is concluded that greater recognition of the coronary artery endothelium and mechanisms of the coronary circulation should further guide revascularisation strategies.

Porcine Model of the Arterial Switch Operation: Implications for Unique Strategies in the Management of Hypoplastic Left Ventricles

There are no reports on the performance of the arterial switch operation (ASO) in a normal heart with normally related great vessels. The objective of this study was to determine whether the ASO could be performed in a healthy animal model. Cardiopulmonary bypass (CPB) and coronary translocation techniques were used to perform ASO in neonatal piglets or a staged ASO with prior main pulmonary artery (PA) banding. Primary ASO was performed in four neonatal piglets. Coronary translocation was effective with angiograms confirming patency. Piglets could not be weaned from CPB due to right ventricle (RV) dysfunction. To improve RV function for the ASO, nine piglets had PA banding. All survived the procedure. Post-banding RV pressure increased from a mean of 20.3 ± 2.2 mmHg to 36.5 ± 7.3 mmHg (p = 0.007). At 58 ± 1 days post-banding, piglets underwent cardiac MRIs revealing RV hypertrophy, and RV pressure overload with mildly reduced RV function. Catheterization confirmed RV systolic pressures of 84.0 ± 6.7 mmHg with LV systolic pressure 83.3 ± 6.7 mmHg (p = 0.43). The remaining five PA banded piglets underwent ASO at 51 ± 0 days post-banding. Three of five were weaned from bypass with patent coronary arteries and adequate RV function. We were able to successfully perform an arterial switch with documented patent coronary arteries on standard anatomy great vessels in a healthy animal model. To our knowledge this is the first time this procedure has been successfully performed. The model may have implications for studying the failing systemic RV, and may support a novel approach for management of borderline, pulsatile left ventricles.

Program «Smart ECG – ranolazin» - own experience and world approach

Purpose - comprehensive analysis of the world approach of the use of ranolazine in various clinical trials and the introduction of the program "Smart ECG" to assess the effectiveness of ranolazine.Matherial and methods. Evaluation of European guidelines, analysis of global randomized clinical trials of the ranolazine use, presentation of our own trial: we examined 40 patients with Q wave myocardial infarction (STEMI), were instituted basic therapy according to the modern recommendations which contained interventional treatment with restoration of patency of a heart attack-conditioned coronary artery, double antiplatelet therapy, statins, β-adrenergic blocker, angiotensin-converting enzyme inhibitors, aldosterone antagonists with addition of ranolazine (group I, 30 patients diagnosed STEMI), control - group II, 10 patients with STEMI, who received basic therapy without addition of ranolazine. Results. Analysis of clinical trials (CARISA, MARISA, ERICA, TERISA, MERLIN-TIMI, RIVER-PCI, RIMINI-TRIAL) proved the effectiveness of ranolazine as an antianginal and anti-ischemic drugs. The use of own program «Smart ECG» demonstrates the positive effect of ranolazine on STEMI and requires further implementation.Conclusion. In the European Society of Cardiology guidelines of the management of stable angina pectoris, ranolazine is given a class IIa (level of evidence B) recommendation as a second-line treatment to reduce angina frequency and improve exercise tolerance in subjects who cannot tolerate, have contraindications to, or whose symptoms are not adequately controlled by β- adrenergic blockers, calcium channel blockers and long-acting nitrates. In subjects with baseline low heart rate and low blood pressure, ranolazine may be considered as a first-line drug to reduce angina frequency and improve exercise tolerance - class IIa (level of evidence C) recommendation. Own study, which partially reflects the global approach according to the analyzed clinical studies, demonstrates the positive effect of ranolazine for patients with STEMI - analogue scale EQ–VAS indicates a positive effect, positive influence on the markers of electrical myocardial instability: decreasing of the probability of cases of SDNN decrease, depression of QT and maybe increase of ratio of maximum velocity for differentiated T wave.

Abstract 16404: Allergy Associated Myocardial Infarction: A Comprehensive Review of Clinical Presentation, Diagnosis and Management of Kounis Syndrome

Introduction: Kounis syndrome (KS) is defined as acute coronary syndrome (ACS) in the context of a hypersensitivity reaction. Patients may present with normal coronary arteries (Type I), established coronary artery disease (Type II) or in-stent thrombosis and restenosis (Type III). Hypothesis: We sought to investigate the clinical presentation, underlying pathophysiology, diagnosis and medical management of patients with KS. Methods: We searched PubMed until 1/1/2020 for case reports of KS. Patients with age <18 years, non-coronary vascular manifestations and without an established KS diagnosis were excluded. Information regarding patient demographics, medical history, clinical presentation, allergic reaction trigger, angiographic results as well as management were manually extracted from every report. All data were pulled in a combined data set and descriptive statistics were analyzed. Results: Out of the 269 unique patients with KS, 157 (58.4%) had Type I, 64 (23.8%) Type II and 18 (6.7%) Type III while 30 (11.2%) could not be classified. Their mean age was 54.1 years and 190 (70.6%) were male. The majority presented with a combination of cardiac and allergic symptoms [Panel A] and medication was the most commonly reported trigger [Panel B]. Electrocardiographically, 75.1% of cases had ST segment elevation with only 3.3% demonstrating no abnormalities. Coronary imaging was available in 228 (84.8%) patients showing occlusive lesions (32.5%), vascular spasm (16.2%), or normal coronary arteries (51.3%). Percutaneous coronary intervention or coronary artery bypass grafting was performed in 70 (29.4%) of the 238 patients with available information. Conclusions: Hypersensitivity induced ACS is most frequently triggered by medications, and the majority of patients have patent coronary arteries suggesting microvascular dysfunction. KS should be considered in the differential diagnosis of myocardial infarction with non-obstructive coronary arteries.

Koroner Arter Bypass Greft Cerrahisi Hastalarının Nativ Koroner Arterlerinde Yeni Kronik Total Oklüzyon Gelişimi

Aim: Postoperative de novo chronic total occlusions (CTOs) of preoperatively non-occluded native coronary arteries are commonly seen in coronary artery bypass grafting (CABG) surgery patients in the clinical follow-up; however, data about this course is limited. The aim of this study was to investigate the prevalence of new CTO development in native coronary arteries postoperatively and the clinical factors which may play role in this context. Methods: A total of 492 CABG patients has been searched from the computer database at Başkent University Hospital Alanya Application and Research Center and patients with a recurrent coronary angiography (CAG) procedure after the first 6 months following surgery were involved in the study population. Recurrent CAG recordings were evaluated for the presence of new CTO development. Logistic regression analysis was used to search the role of demographical and angiographical characteristics in the development of de novo CTOs in native coronary arteries. Results: Seventy-three CABG patients with recurrent CAG were involved in statistical analysis (Mean age was 65.2 ± 9.8 years; male gender 76.7%). Two hundred eighteen preoperatively non-occluded native coronary arteries were evaluated and 119 new CTOs were detected (54.5% of involved vessels). Preoperative proximal stenosis ≥90% is related to more than 3 times new CTO development (67.8% vs. 22.2%) (p<0.001). Dual antiplatelet therapy (DAPT) is found as a protective factor for the patency of native coronary arteries (HR:-0.259; 95% CI:-0.475 to -0.017; p=0.036). Conclusion: De novo CTO development in native coronary arteries is commonly seen in CABG patients postoperatively. Significance of preoperative stenosis and absence of DAPT seem to be the essential factors in new CTO occurrence.

A rare manifestation of Takotsubo Cardiomyopathy associated with non-tuberculous mycobacterium

BackgroundTakotsubo Cardiomyopathy or broken heart syndrome is a rare cause of non-ischemic cardiomyopathy that produce left ventricular dysfunction with characteristic left ventricular apical ballooning. It rarely caused by infection. We present an atypical manifestation of non-tuberculous mycobacterial (NTM) infection with myocardial involvement and its diagnostic challenge. Case illustrationA 57-year-old female presented with prolonged fever, fatigue and weight loss for one and half months. General examination was unremarkable with elevated C-Reactive Protein and normal troponin. Electrocardiogram (ECG) showed diffuse T wave inversion with prolonged QTc. Echocardiography showed hypokinetic apical with normal ejection fraction. Angiography showed patent coronary arteries. Ventriculography showed apical ballooning. Workup with ethambutol scan revealed active mycobacterial infection in both lung and mesentery. Sputum polymerase chain reaction (PCR) was positive for non-tuberculous mycobacterium. Follow up ECG and echocardiography showed improvement in QTc interval and left ventricular wall motion abnormalities. ResultsTakotsubo Cardiomyopathy may manifest as asymptomatic ventricular dysfunction following non-tuberculous mycobacterial infection. A thorough investigation will help identify the systemic disease with cardiac involvement which potentially could be fatal. ConclusionTakotsubo cardiomyopathy may be triggered by infection. Identification of causal is crucial as a management strategy to restore cardiac function.

IMPLEMENTATION OF INFORMATION SYSTEMS IN DIAGNOSTICS-ECG DIGITALIZATION AND «SMART-ECG» IMPLEMENTATION WITH АNALYSIS OF RANOLASINE EFFICIENCY, OPTIMIZATION OF TREATMENT OF ST SEGMENT ELEVATION SYNDROME

This paper presents the possibility and expediency of using information systems in diagnostics – ECG digitalization and «Smart-ECG» implementation with analysis of ranolasine efficiency, optimization of treatment of ST segment elevation syndrome. Purpose – to introduce ECG digitalisation and the program «Smart ECG» to evaluate the effectiveness of ranolasine and to optimize the treatment of ST segment elevation syndrome. Material and methods. We examined 40 patients with Q-MI (STEMI), admitted to regional clinical cardiology center in Chernivtsi, were instituted basic therapy according to the modern recommendations which contained interventional treatment with restoration of patency of a heart attack-conditioned coronary artery, double antiplatelet therapy, statins, β- adrenergic blocker, angiotensin-converting enzyme inhibitors, aldosterone antagonists with edition of ranolasine (group I, 30 patients diagnosed STEMI). Control - group II, 10 patients STEMI, who received basic therapy without addition of ranolasine. Results. Own results allow us to determine the positive effect of ranolazine on stabilization of the studied indicators of ECG digitalization according to the heart rate variability (SDNN) and QT variability (dQT), phenomena of the phase of repolarization («angle QRS-T» and “ST slope”), the first derivative of ECG ratio of maximum velocity of the differentiated deflection T and the definition of quality of life according to the EQ-5D-3L questionnaire, which partially presents the world approach. Conclusion. Analog scale EQ–VAS indicates a positive effect of Ranolazine on the quality of life of patients diagnosed with STEMI. Ranolasine (STEMI diagnosed patients) has positive influence on the markers of electrical myocardial instability and its ischemia - as evidenced: decreasing of the heart rate, probability of cases of SDNN decrease, depression of QT and maybe increase of ratio of maximum velocity for differentiated deflection T.

Referral Bias in Coronary Micro vascular Dysfunction: a Retrospective Study

Obstructive coronary artery disease (CAD) is a well-defned condition and a signifcant cause of myocardial ischemia. Patients with angina typically undergo non-invasive cardiac investigations initially as a means of risk-stratifying. Coronary angiography is the diagnostic test of choice for patients with chest pain (angina) and signs of myocardial ischemia on noninvasive testing. Typically CAD is diagnosed based on the patency of the epicardial coronary arteries [1]. Approximately 30% of patients with angina have non-obstructive arteries on coronary angiogram and area diagnostic and management challenge for clinicians, contributing to signifcant social and economic burden [2]. They undergo multiple angiograms, experience a hospitalization rate 80% greater than patients with single vessel CAD and up to 50% have persistent symptoms leading to functional disability [3]. Historically, this population was given reassurance as long-term prognosis was believed to be benign [4]. We now know that a subset of these patients sui¬Â€er from coronary micro vascular dysfunction (MVD) [1] and are at increased risk for adverse cardiac events including congestive heart failure (CHF), myocardial infarction (MI), left ventricular (LV) dysfunction, and death [1,5]. The Cardiovascular Integrated Physiology (CVIP) program at Southlake Regional Health Centre (SRHC) investigates and manages patients with MVD. CVIP has received referrals for only a small fraction of patients with angina and non-obstructive angiograms at SRHC. It is unclear what factors promote referral. We hypothesized that referrals were not random and that the clinical characteristics of the referred patients dii¬Â€ered from the larger population of patients with angina and nonobstructive CAD. The primary objective of this study was to determine whether the patients referred to CVIP are an accurate representation of the overall population of patients with angina and non-obstructive coronary arteries.

The disutility of stress testing in low-risk HEART Pathway patients.

The HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients. An academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score≤3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing. There were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45-3.24) and being male (aOR 1.59, 95% CI 1.02-2.49) were associated with testing. Stress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score.

Less Invasive Reoperative Ventricular Assist Device Insertion for Patients With Patent Bypass Grafts

We report our technique for left ventricular assist device insertion that is useful in patients with patent coronary artery bypass grafts or mediastinal adhesions from other previous surgeries. An inverted-T upper hemisternotomy is made at the level of the second or third intercostal space, and with the left sternal section retracted, dissection is carried along the chest wall into the left pleural space. The device is implanted in the left ventricular apex via a left thoracotomy in the fifth or sixth intercostal space. The outflow graft is routed through the left pleural space and anastomosed to the ascending aorta.

Prognostic value of microvascular occlusion MRI quantification in assessment of reperfused myocardial infarction

BackgroundReperfusion therapy in patients with acute myocardial infarction (AMI) can salvage the myocardium; however, successful restoration of the coronary artery patency is not always associated with adequate perfusion at the level of microvasculature, known as the no-reflow or microvascular occlusion (MVO). The primary objective of our prospective study was to assess, by cardiac magnetic resonance (CMR), the prognostic value of MVO size, and its impact on left ventricular (LV) remodeling in cases of reperfused AMI.Thirty-three patients with AMI underwent cardiac MRI at 1.5-T scanner within 7 days (baseline) and 3 months (follow-up) after reperfusion. Patients with MVO were included where early gadolinium enhancement (EGE), late gadolinium enhancement (LGE), and cine sequences were acquired. The impact of MVO size on LV ejection fraction (EF%) and LV volumes was quantitively analyzed.ResultsThere was a significant inverse correlation between the MVO size % of the LV mass (LVM) and the EF% values measured at follow-up with a P value of 0.000, while a significant positive correlation was encountered between the MVO% of LVM and both indexed end-systolic volume (ESVI) and indexed end-diastolic volume (EDVI) values measured at follow-up with P values of 0.438 and 0.389, respectively. MVO size was found to be a significant factor affecting the patient’s outcome (P = 0.000) where MVO size of > 10% of the total LVM can be a predictor of a worse outcome and reduced EF% at follow-up.ConclusionThe prognostic value of MVO could be statistically determined with a cut off value to predict a possible good outcome using CMR.

Combinatorial therapy of sirolimus and heparin by nanocarrier inhibits restenosis after balloon angioplasty ex vivo.

Aim: To develop poly(lactide-co-glycolide)-graft-polyethylenimine (PgP) as a dual drug-delivery carrier for sirolimus (SR) and heparin (Hep) to inhibit restenosis after balloon angioplasty. Materials & methods: SR was loaded in the hydrophobic core and negatively charged Hep complexed with the positively charged hydrophilic shell of PgP. SR- and Hep-loaded PgP was tested on rat aortic smooth muscle cells in vitro and injured porcine coronary arteries after balloon angioplasty ex vivo. Results & conclusion: SR and Hep loading efficiency in PgP were approximately 37 and 82%, respectively. SR- and Hep-loaded PgP treatment decreased smooth muscle cell proliferation up to 14days post-treatment and decreased proliferation, collagen deposition and neointimal thickness and increased patency in porcine coronary arteries after balloon angioplasty ex vivo.

Intraoperative echocardiographic coronary artery imaging in congenital and acquired heart disease.

Transoesophageal and epicardial echocardiography are indispensible intraoperative imaging modalities to guide paediatric heart disease surgeries and influence surgical decision-making. A less well-described role of intraoperative imaging is its utility in evaluating coronary artery patency and flow. Focused two-dimensional, colour, and spectral Doppler imaging of the coronary arteries should be performed during surgeries involving coronary manipulation or re-implantation, or in cases where there is unexpected ventricular dysfunction or electrographic signs concerning for ischaemia. Intraoperative imaging allows for any anatomical issues to be detected and addressed promptly in the operating room. Imaging of the coronary arteries should identify unobstructed coronary ostia and proximal course without kinking, angulation, narrowing, or significant calibre change to suggest stenosis or extrinsic compression from neighbouring structures. The aim of this review is to highlight the usefulness of transoesophageal and epicardial echocardiography in evaluating coronary artery patency and flow, provide a how-to guide for optimal imaging, and to introduce a practical guideline to achieve best clinical practice.

THE PLACE OF CARDIAC COMPUTED TOMOGRAPHY IN PREOPERATIVE PLANNING OF EXTENDED SEPTAL MYECTOMY IN PATIENTS WITH OBSTRUCTIVE FORM OF HYPERTROPHIC CARDIOMYOMATHY.

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy. Extended septalmyectomy (ESM) is one of the priority methods of treatment of drug-refractory obstructive HCM. In recent years,hospital mortality during surgical correction of obstructive HCM in expert centers does not exceed 1-2 %. However,typical threatening complications of septal myectomy, such as iatrogenic ventricular septal defect (VSD) and rupture of the anterior or posterior walls of the left ventricle (LV), remain a topical issue in surgery of HCM. to show the role of preoperative CT-planning to predict and reduce possible technical problems associated with ESM, including iatrogenic VSD. This study includes 217 symptomatic patients with obstructive HCM, who from April 2016to October 2019 as one of the steps of preoperative planning underwent cardiac CT prior to ESM. Cardiac CT was performed to delineate the left ventricular myocardium, assess the distribution of hypertrophy and the presence ofcrypts. Special attention was also paid to the anatomy of the mitral valve (MV) and subvalvular apparatus. Coronaryartery patency was assessed by CAD-RADS, a standardized method for reporting the results of coronary CT angiography to determine tactics for further management of the patient. In the study group, the average age of patients was (49 ± 15) years, 48 % - men. All patientshad a symptomatic, drug-refractory obstructive form of HCM. The mean maximum wall thickness of the interventricular septum (IVS) was (20 ± 5) mm (range 16-33). The average LV mass was (118 ± 23) g/m2. 195 patients (89.9 %)had systolic anterior motion ( SAM) of the MV. MV and subvalvular apparatus anomalies were detected in 62 patients(28.6 %). A zone of scarring and regression of IVS after alcohol septal ablation (ASA) was detected in 7 patients(0.3 %) with residual LV outflow gradient. Coronary arteries atherosclerosis was detected in 32 patients (14.7 %). Preoperative CT-planning of septal myectomy allows to obtain information on morphology of the LV,IVS, MV and subvalvular apparatus, and gives the surgeon the advantage to form a more accurate plan for the location and volume of septal resection, and avoid complications when correcting obstructive HCM. No iatrogenic VSDwas detected in any of the patient in the study group.

P866 Mitraaortic intervalvular fibrosa pseudoaneurysm with aortic paravalvular regurgitation in a marfan-like syndrome patient diagnosed with multimodality imaging

Abstract Introduction The fibrous area. between the mitral and aortic valves described as the mitral-aortic intervalvular fibrosa (MAIF). The MAIF can be damaged by endocarditis, degenerative calcification or mitral and aortic valve surgery . Damage caused by replacement of the aortic valve can lead to the formation of pseudoaneurysms (MAIF) or other complications Case A 64-year-old male admitted to our outpatient department with complaints of dyspnea fatique and atypical chest pain. He has Marfan like syndrome and had a history of mechanical aortic valve replacement 16 years ago and upon dysfunciton of the prosthetic valve and significant ascending aorta aneurysm he had undergone a second Bentall operation 6 years after the first operation. We performed a transthoracic echocardiography and a transesophageal echocariography to clarify the underlying pathology. Transesophageal echocardiography revealed a moderate to severe paravalvular regurgitation, a mitraaortic intervalvular fibrosa pseudoaneurysm and a functional moderate-severe mitral regurgitation. The echocardiographic appearence of MAIF pseudoaneurysm cavity demontrates marked pulsatilty with systolic expansion and diastolic collapse. In order to show the pathology truly and exclude a coronary artery disease, we decided to perform a cardiac CT (CCT). Cardiac CT confirmed mitraaortic intervalvular fibrosa pseudoaneurysm and paravalvular defect clearly with patent coronary arteries. After our heart team meeting, we decided to give the patient to the cardiovascular surgery for the complete treatment of aortic valve, pseudoaneurysm and mitral valve. The patient underwent his 3rd surgery succesfully with a new bioprosthetic aortic valve replacement, repair of the pseudoaneurysm and mitral valve and his potoperative course was uneventful. Conclusion Combination of MAIVF pseudoaneurysm and paravalvular leak together in a connective tissue disorder patient is quite rare. TEE is more sensitive than TTE in accurately predicting this complication but to combine TOE with cardiac CT facilitates the diagnosis and gives a more accurate anatomic description of the defects to cardiologists and cardiovascular surgeons which is very helpful in terms of orientation. Abstract P866 Figure. 2D,3D TOE and CCT images of MAFP and PVL

P1816 Cerebral microembolism in low-risk patients with paroxysmal atrial fibrillation before and after pulmonary vein isolationCerebral microembolism in low-risk patients with paroxysmal atrial fibrillation

Abstract BACKGROUND Invasive treatment of atrial fibrillation (AF) becomes more suitable and effective therapy. There are no consistent data describing the occurrence of potential neurological complications in low-risk patients with paroxysmal AF. AIM to determine the occurrence, consequences and risk factors for brain white matter hiperintensities (WMH) assessed in magnetic resonance imaging (MRI) in low-risk patients before and after pulmonary vein isolation (PVI) treatment. METHODS Eighty patients with symptomatic paroxysmal AF (median age: 58 years (IQR 50-63), K/M: 30/50), CHA2DS2-Vasc ≤ 3 (CHA2DS2-Vasc: 2 (IQR 1-2.5)) were included in the study. Before and after a minimum of 6-month period after PVI-RF treatment (med. 9,9 months, IQR 7.6-11.8 months) a clinical evaluation with brain MRI and Mini Mental State Examination (MMSE) test were determined. Severity of brain WMH in MRI was assessed in the Fazekas scale (pic 1). The efficacy of PVI-RF treatment analyzed in a 7-day Holter monitoring was confirmed in 43 (53.8%) patients. RESULTS Baseline WMH lesions were found in 55 (68.8%) patients. Patients with baseline WMH lesion obtained similar results in the MMSE test, compared to patients with a normal brain image in the MRI study. There was a statistically significant more frequent occurrence of cerebral WMH lesions among older patients, with a higher CHA2DS2-Vasc score, with left atrial (LA) dilatation and dysfunction. Factors affecting the severity of the WMH were: the co-occurrence of the patent foramen ovale (PFO) and coronary artery disease (CAD). After PVI-RF treatment there were no significant changes in the presence and severity of WMH lesions. Similarly, there were no significant changes in the cognitive abilities assessed with MMSE test compared to the pre-procedural evaluation. There were also similar factors predisposing to brain WMH changes: older age, higher CHA2DS2-Vasc score and higher BMI. In turn, the degree of the brain WMH severity after observation period was dependent on age, higher CHA2DS2-Vasc score, presence of PFO and CAD and the initial LA function. CONCLUSIONS Cerebral microembolism assessed in MRI is often found in low-risk patients with paroxysmal AF, and its presence and severity are associated with LA dilatation and dysfunction, age and higher CHA2DS2-Vasc score. Additional factors affecting the severity of WMH lesions are: the co-occurrence of PFO and CAD. PVI-RF procedure and its efficacy does not influence on MRI lesions. In the population of relatively young AF patients with no significant cardiovascular disease burden, cerebral microembolism is not related to cognitive impairment. Abstract P1816 Figure. pic 1

Simultaneous Multi-Structure Segmentation of the Heart and Peripheral Tissues in Contrast Enhanced Cardiac Computed Tomography Angiography.

Contrast enhanced cardiac computed tomography angiography (CTA) is a prominent imaging modality for diagnosing cardiovascular diseases non-invasively. It assists the evaluation of the coronary artery patency and provides a comprehensive assessment of structural features of the heart and great vessels. However, physicians are often required to evaluate different cardiac structures and measure their size manually. Such task is very time-consuming and tedious due to the large number of image slices in 3D data. We present a fully automatic method based on a combined multi-atlas and corrective segmentation approach to label the heart and its associated cardiovascular structures. This method also automatically separates other surrounding intrathoracic structures from CTA images. Quantitative assessment of the proposed method is performed on 36 studies with a reference standard obtained from expert manual segmentation of various cardiac structures. Qualitative evaluation is also performed by expert readers to score 120 studies of the automatic segmentation. The quantitative results showed an overall Dice of 0.93, Hausdorff distance of 7.94 mm, and mean surface distance of 1.03 mm between automatically and manually segmented cardiac structures. The visual assessment also attained an excellent score for the automatic segmentation. The average processing time was 2.79 minutes. Our results indicate the proposed automatic framework significantly improves accuracy and computational speed in conventional multi-atlas based approach, and it provides comprehensive and reliable multi-structural segmentation of CTA images that is valuable for clinical application.