Preoperative Coronary Angiography Research Articles

Robotic Totally Endoscopic Off-Pump Unroofing of Myocardial Bridge: Early Experience and Midterm Outcomes.

Myocardial bridging (MB) occurs when a coronary artery, commonly the left anterior descending (LAD), has an intramyocardial course. In symptomatic patients who fail medical therapy, surgical unroofing can provide symptomatic relief by improving coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing. There were 34 patients with an LAD-MB who failed medical therapy and underwent robotic totally endoscopic, off-pump unroofing between January 2017 and October 2023. Patients were evaluated by a multidisciplinary team and underwent provocative coronary angiography to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients for midterm follow-up, including completion of a modified Seattle Angina Questionnaire (SAQ). The mean age was 48 ± 8 years, and 56% were female patients. One patient had prior septal myectomy via sternotomy. All patients had significant dobutamine Pd/Pa reduction on preoperative coronary angiography. One patient had atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. The mean procedure time was 140 ± 69 min. All were completed totally endoscopically off-pump without intraoperative conversions. The mean MB length was 4.5 ± 1.4 cm, and the mean depth was 1.6 ± 0.9 cm. Of the patients, 76% were extubated in the operating room. The mean intensive care unit and hospital length of stay were 0.97 ± 0.58 and 1.73 ± 1.1 days, respectively. There were no mortalities or strokes. There was 1 postoperative take-back for bleeding. At midterm follow-up (19 ± 14 months), 28 patients completed the SAQ; 86% reported "much less angina" during activity compared with before surgery, and 93% reported taking no antianginal medication since surgery. In appropriate patients with hemodynamically significant LAD-MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. Further studies are warranted.

Diagnosis and treatment of ischemia-producing coronary stenoses improves 5-year survival of patients undergoing major vascular surgery

ObjectivePatients undergoing vascular surgery procedures have poor long-term survival due to coexisting coronary artery disease (CAD), which is often asymptomatic, undiagnosed, and undertreated. We sought to determine whether preoperative diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with postoperative ischemia-targeted coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery MethodsIn this observational cohort study of 522 patients with no known CAD undergoing elective carotid, peripheral, or aneurysm surgery we compared two groups of patients. Group I included 288 patients enrolled in a prospective Institutional Review Board-approved study of preoperative coronary CT angiography (CTA) and FFRCT testing to detect silent coronary ischemia with selective postoperative coronary revascularization in addition to best medical therapy (BMT) (FFRCT guided), and Group II included 234 matched controls with standard preoperative cardiac evaluation and postoperative BMT alone with no elective coronary revascularization (Usual Care). In the FFRCT group, lesion-specific coronary ischemia was defined as FFRCT ≤0.80 distal to a coronary stenosis, with severe ischemia defined as FFRCT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular death, myocardial infarction (MI), and major adverse cardiovascular events (MACE [death, MI, or stroke]) during 5-year follow-up. ResultsThe two groups were similar in age, gender, and comorbidities. In FFRCT, 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Usual Care. Vascular surgery was performed as planned in both cohorts with no difference in 30-day mortality. In FFRCT, elective ischemia-targeted coronary revascularization was performed in 103 patients 1 to 3 months following surgery. Usual Care had no elective postoperative coronary revascularizations. At 5 years, compared with Usual Care, FFRCT guided had fewer all-cause deaths (16% vs 36%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.22-0.60; P < .001), fewer cardiovascular deaths (4% vs 21%; HR, 0.11; 95% CI, 0.04-0.33; P < .001), fewer MIs (4% vs 24%; HR, 0.13; 95% CI, 0.05-0.33; P < .001), and fewer MACE (20% vs 47%; HR, 0.36; 95% CI, 0.23-0.56; P < .001). Five-year survival was 84% in FFRCT compared with 64% in Usual Care (P < .001). ConclusionsDiagnosis of silent coronary ischemia with ischemia-targeted coronary revascularization in addition to BMT following major vascular surgery was associated with fewer adverse cardiovascular events and improved 5-year survival compared with patients treated with BMT alone as per current guidelines.

Diagnostic performance of noninvasive computed tomography-derived fractional flow reserve in patients with severe aortic stenosis

Abstract Background Noninvasive fractional flow reserve derived from coronary computed tomography angiography (FFRct) is developed as a decision-making tool in daily clinical practice. However, its diagnostic performance has not been sufficiently explored in patients with severe aortic stenosis (AS). Purpose To identify the diagnostic performance of FFRct in patients with severe AS using invasive fractional flow reserve (FFR) as the reference standard. Methods This study was a retrospective observational that included consecutive patients with severe AS undergoing TAVI who had concomitant intermediate coronary artery stenosis based on preoperative invasive coronary angiography. Preoperative invasive FFR and CT data preoperatively before TAVI were prospectively collected. Results We analyzed the data of patients with severe AS demonstrating intermediate coronary artery stenosis and compared the FFRct values with the invasive FFR values. Among 93 patients (100 vessels), the median FFR and FFRct (Q1, Q3) were 0.85 (0.78, 0.90) and 0.83 (0.72, 0.88), respectively. The FFRct values significantly correlated with the FFR values (r = 0.57; p &amp;lt; 0.0001). The vessel-based analysis of the accuracy of FFRct showed a sensitivity of 90.3%, specificity of 73.9%, positive predictive value of 60.9%, and negative predictive value of 94.4%. Conclusions FFRct demonstrated a significant correlation with invasive FFR and a high negative predictive value in patients with severe AS. These findings suggest that FFRct would be a clinically beneficial noninvasive tool for excluding functional coronary artery stenosis in patients with severe AS.

Caught Between Heart and Limbs: Navigating the Treatment of Patients With CAD and PAD in an Overwhelmed Healthcare System.

Peripheral arterial disease (PAD) and coronary artery disease (CAD) are manifestations of atherosclerosis, affecting a substantial proportion of the population. Despite their interrelation, the prevalence of CAD in severe PAD varies, prompting the need to understand their complex relationship. This study retrospectively analyzes prospectively collected data from a high-volume vascular center to assess CAD prevalence, risk factors, and implications for patients undergoing vascular surgery. Among 667 arterial disease patients, 19.5% underwent coronary angiography, with CAD detected in 61.5% of cases. CAD varied across vascular beds. Decision-making around preoperative coronary angiography and revascularization remains complex, with benefits for high-risk patients still being debated. In accordance with current guidelines, the routine practice of coronary revascularization preceding vascular surgery is generally discouraged. This study underscores the need for risk stratification to identify patients who might benefit from coronary revascularization prior to vascular surgery while adhering to cost-effectiveness and avoiding unnecessary and time-consuming diagnostics in the majority of patients. Patient demographics, risk factors, and clinical presentation were analyzed alongside hospital stay, mortality, and complications. The study highlights the challenges in managing patients with concurrent CAD and PAD and calls for improved protocols for treating this high-risk group.

P30 A STONE ON THE HEART

Abstract We report a case of a 71–year–old female patient presented to our observation with worsening episodes of chest pain associated with cold sweat and spontaneous regression. Seven months earlier, the patient had undergone mitral valve replacement surgery with bioprosthesis for severe insufficiency. Pre–operative coronary angiography had documented the absence of significant lesions of the coronary arteries. Four months after the operation, hospitalisation was necessary due to an infective endocarditis on the prosthetic valve, effectively treated with specific antibiotic therapy. The patient came to the Emergency Department reporting episodes of stress related angina, lasting for a few days. The ECG documented sinus rhythm and non–specific anomalies of the ventricular repolarization phase. The haematochemical tests showed a minimal increase in the HS troponine values. Ultrasound documented normal left ventricular dimensions, no regional kinetic abnormalities with normal global systolic function and good functioning of the mitral bioprosthesis. The patient was admitted in our department of cardiology for further investigations. The next day the patient complained of severe oppressive chest pain with ECG evidence of diffuse ST–T segment depression and elevation in aVR and V1. Blood pressure was 170/90 mmHg and ultrasound showed apex hypokinesia with severely reduced systolic function. Nitrate s.l was administered with gradual improvement of symptoms and normalisation of the ECG. The patient underwent coronary angiography but during the first injection of contrast test, an anomalous stagnation of the contrast was highlighted in the aorta. It was urgently decided to perform aortic CT scan. The examination showed the presence of a voluminous pseudoaneurysm starting from the aortic bulb, partially thrombosed, which compressed the left main and the origin of the circumflex artery. The patient was therefore subjected to cardiac surgery the following day, with a good follow–up result one month after discharge.

C55 A GIANT PSEUDOANEURYSM OF MITRAL–AORTIC INTERVALVULAR FIBROSA PRESENTING AS RECENT–ONSET ANGINA AND CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION

Abstract A 66–year–old man was suddenly referred to the emergency department (ED) for an extra–hospital cardiac arrest due to ventricular fibrillation, promptly treated by a single DC shock. Four months prior, he had undergone aortic valve replacement with a biological valve prosthesis (BVP, Perimount Magna n. 23) for severe aortic stenosis. One month after cardiac surgery the patient was hospitalized for acute cholecystitis requiring antibiotics and percutaneous cholecystostomy. On arrival to the ED the patient was awake and completely asymptomatic; no fever during days before the episode. He had been complaining of constricting retrosternal chest pain during physical exertion for ten days. However, no signs of ischemia were seen on the EKG. TT echo showed a very large pulsatile anaechogenic area posteriorly to BVP. Transesophageal echocardiography (TEE 2D, Traditional 3D and TrueVue) highlighted a very large pseudoaneurysm of mitral–aortic interventricular fibrosa (P–MAIVF; Figures 1 and 2, long axis and short–axis views). TEE features included: 1) a very large cavity with thickened walls, extended for more than two–thirds of the prosthetic circumference and with multiple septa; 2) a large communication between the left ventricular outflow tract (LVOT) and P–MAIVF (see yellow dotted line in Fig.1A) with a to–and–fro flow into the cavity and a prominent systolic pulsation; 3) no paraprosthetic leak and absence of any attached mass or intraprosthetic aortic regurgitation. These findings suggested a prosthetic aortic valve endocarditis with an extensive periannular involvement. Moreover, the P–MAIVF may have led to “ab extrinseco” compression of the left coronary artery, with a potential role in the genesis of chest pain and ventricular arrhythmia (in absence of significant CAD at preoperative coronary angiography). An empiric antibiotic therapy with daptomycin and piperacillin–tazobactam was started. The patients subsequently underwent Bentall surgery with a subannular implantation technique (Perimount valvular prosthesis n.23 and Gelweave vascular prosthesis n.28). Figure 3 shows an intraoperative image and postoperative TEE. In conclusion, P–MAIVF is an ominous complication of prosthetic valve endocarditis. Presentation with exertional angina and cardiac arrest is unusual. TEE is sensitive for diagnosis and 3D echo provides better insights into the anatomy helping formulate an appropriate surgical strategy.

Obstructive Coronary Artery Disease in Patients Undergoing Rheumatic Valvular Heart Surgery

Objectives: The presence of concomitant obstructive coronary artery disease (CAD) in patients with valvular heart disease (VHD) carries significant prognostic implications. Therefore, the objective of this study was to determine the frequency and severity of obstructive CAD in patients undergoing valvular heart surgery for rheumatic heart disease (RHD) at a tertiary care hospital in Karachi, Pakistan. Methodology: This descriptive study included patients of either gender, between 40 to 70 years of age, diagnosed with RHD on transthoracic echocardiography, and undergone valvular heart surgery. As a routine, pre-operative diagnostic coronary angiography was performed and the presence and severity of obstructive CAD were recorded. Results: Among 126 patients, 73% (92) were male, and the mean age was 48.3 ± 7.1 years. Smoking was the most common risk factor with a frequency of 22.2%, followed by hypertension (7.1%) and diabetes (4.8%). Obstructive CAD was observed in 24.6% with 19.4% single-vessel disease, 16.1% with two-vessel disease, and 64.5% with three-vessel disease. The presence of obstructive CAD was found to be positively associated with older age (p=0.040) and type of RHD (p=0.048). Conclusion: The obstructive concomitant CAD is prevalent in around 1/4th of patients, most of them with multi-vessel diseases, undergoing valvular heart surgery for rheumatic heart disease. It has been further observed that older age and the type of RHD are positively associated with the incidence of concomitant CAD in these patients.

Stepwise Multimodality Imaging Assists in Atrial Myxoma Diagnosis and Management

The case of a 67-year-old man who presented for elective gastroenterology procedures and was in atrial fibrillation is discussed. Transthoracic echocardiography revealed a large atrial mass. Preoperative coronary angiography revealed a heavily vascularized mass. Use of cardiac magnetic resonance identified the cardiac mass as likely an atrial myxoma. (Level of Difficulty: Beginner.)

An unusual collateral from the sinoatrial nodal artery to the left carotid artery in a patient with Takayasu arteritis: a case report

BackgroundTakayasu arteritis is a noninfective chronic vasculitis mainly involving the aorta and its main branches. The presentation of the disease is heterogeneous, ranging from asymptomatic to catastrophic illness.Case presentationA 52-year-old Caucasian woman with known Takayasu arteritis was referred to our hospital as she suffered symptoms suspicious for cerebral hypoperfusion. Computed tomography thorax angiography revealed occlusion of all aortic arch arteries and previous surgical bypasses. Cerebral perfusion depended on a few collaterals (from the distal common carotid artery to the right internal carotid artery and from the left and right internal mammary artery and the dorsal thoracic branches to both vertebral arteries). In addition, preoperative coronary angiography revealed an unusual and large collateral arising from the sinoatrial nodal artery to the left carotid artery.ConclusionTakayasu arteritis is a relatively rare disease, with various and sometimes devastating neurological manifestations due to occlusion of the aortic arch branches. Our case highlights the importance of a thorough preoperative evaluation in search of collateral supply in symptomatic patients with Takayasu arteritis.

Angiographic Characteristics of Young Yemeni Patients Undergoing Diagnostic Coronary Angiography: Data from A Major Cardiac Center In Yemen

Background: Coronary artery disease (CAD) accounts for the greatest proportion of CVDs and is one of the most common causes of death in the developed countries. It is one of the main etiologies of disease burden in developing countries. There is increase in the number of patients with coronary artery disease in Yemen. The number of patients undergoing elective diagnostic coronary angiography is increasing among different age groups. This study was aimed to identify and compare the prevalence of the risk factors, clinical presentation, management, and angiographic characteristics of CAD between young patients (age ≤ 40 years) and older patients (age ≥ 40 years) presented with ischemic heart disease (IHD). Methods: A total of 555 patients were were enrolled between January 2013 and June 2013. Patient admitted in ward as one-day admission and discharged 6 hours after the procedure. Demographic data, clinical findings, and details of electrocardiographic and echocardiographic findings were recorded. The traditional cardiovascular risk factors (smoking, hypertension, Khat chewing, family history and diabetes mellitus, dyslipidemia) were noted. The patient included were patients with sable angina, post myocardial infarction and pre-operative coronary angiography before valve replacement. Results: The older group accounts for 90.3% while younger group accounts for 9.7% of the patients. The majority of patients in both groups were male (81.5% in the young and 74.5% in the older group). Most of the patients in the study were diagnosed as post MI angina. High incidence of diabetes and hypertension among the older group in comparison to the younger group (24.4% diabetes and 43.1% hypertensive Vs. 11.1% diabetes and 29.6% hypertensive). 50% of the younger group were smokers in comparison to 23.8% in older group with statistically significant difference (p=0.0001). Family history of IHD was higher in the younger age group (24.1%) than that in the older age group (16%) (p = 0.129). Dyslipidemia was not common risk factor among both groups. The percentage of Khat chewing did not differ between the two groups (70.4% and 62.5% in younger and older group respectively). Significant left main disease was more than double in younger group (3.7%) when compared older group (1.9%). About one-third (31.5%) of patients of younger group had significant LAD lesion while small number of older patients had significant LAD lesion (1.6%) (p = 0.037). The involvement of right coronary artery (RCA) was significantly higher in older group than in younger group (27.7% and 7.5% respectively; with p = 0.001). Although the incidence of left circumflex artery (LCX) disease was higher in older group (28.8% and 16.7% respectively) it did not reach statistical significance. The left anterior descending artery (LAD) was commonly involved vessel in the young group (31.5%) in comparison to older group (1.6%) while left circumflex artery and right coronary artery was common in in the older group. Conclusion: Coronary angiography is a useful diagnostic and therapeutic tool for CAD. Smoking, male gender as well as family history of cardiovascular diseases showed high prevalence in the in younger patients ≤ 40 years, while hypertension and diabetes were common in the older patients. Khat chewing was highly prevalent among both groups.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Prevalence, risk factors, and clinical effect of coronary artery disease in patients with asymptomatic bilateral carotid stenosis

ObjectiveIn the present report, we have described the prevalence, risk factors, and clinical effects of coronary artery disease (CAD) for patients with asymptomatic bilateral carotid stenosis. MethodsWe conducted a single-center, retrospective cohort study of consecutive patients referred for bilateral carotid stenosis >70% (2014-2021). All the patients had undergone systematic coronary angiography. Depending on the anatomic and clinical characteristics, the patients had undergone combined carotid endarterectomy (CEA) plus coronary artery bypass grafting, coronary percutaneous intervention followed by CEA or carotid artery stenting (CAS), or staged bilateral CEA with cardiac best medical therapy. The cumulative 30-day stroke/myocardial infarction (MI) rate after cardiac and bilateral carotid interventions and long-term survival and freedom from cardiovascular mortality were assessed. ResultsA total of 167 patients with bilateral carotid stenosis >70% had undergone preoperative coronary angiography, identifying severe CAD in 108 patients (65.1%). Echocardiographic abnormalities (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.03-5.78; P = .04) and prior coronary intervention (OR, 11.94; 95% CI, 2.99-63.81; P = .001) were significantly associated with severe CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). The cumulative MI rate was 4.8%; 5.6% for the patients with severe CAD and 1.7% for those without severe CAD (P = .262). The cumulative stroke rate was 1.8%; 1.8% for those with severe CAD and 1.7% for those without severe CAD (P = 1.00). The overall stroke/MI rate was 6.6%; 8.3% for those with severe CAD and 3.3% for patients without severe CAD (P = .33). Patients with severe CAD deemed untreatable for coronary bypass or percutaneous intervention had a higher risk of perioperative stroke/MI (OR, 1.24; 95% CI, 1.00-2.83; P = .04). At 10 years, overall survival was 67.1% (95% CI, 57%-79%), and freedom from cardiovascular mortality was 78.5% (95% CI, 69%-89%). Patients with untreatable CAD maintained a higher risk of 10-year mortality (hazard ratio, 5.5; 95% CI, 1.6-19.9; P < .01). ConclusionsIn the present study, the prevalence of CAD in patients with bilateral carotid stenosis was high, especially for those with abnormal echocardiographic findings. CAD was potentially treatable in 80% of patients, and staged or simultaneous CAD treatment was performed with an acceptable stroke/MI complication rate for these patients. The presence of untreatable CAD was associated with worsened early and long-term outcomes, questioning the benefit of carotid interventions for this subset of patients.

Abstract 10907: Woven Coronary Artery: A River With Many Currents

Introduction: Congenital coronary artery anomalies can increase the risk of cardiovascular events and sudden death. A woven coronary artery is a rare abnormality with multiple lumens in a single vessel, giving the appearance of complex coronary plaque or a dissection flap on coronary angiography. Clinical Case: A 57-year-old man with group IV pulmonary hypertension and chronic right-sided heart failure presented for consideration of pulmonary endarterectomy. He underwent preoperative coronary angiography which demonstrated nonobstructive disease within the left anterior descending and circumflex arteries and a complex lesion in the right coronary artery (RCA- Figure 1). The lesion was further evaluated using intravascular ultrasound (IVUS) which demonstrated numerous, complex, communicating lumens and fenestrations within a single external elastic lamina suggestive of a woven coronary artery anomaly (Figure 2). This was recognized as a benign abnormality for which the patient was managed medically, and he underwent a successful pulmonary endarterectomy several days later. Discussion: Woven coronary arteries are rare and complex lesions made up of numerous lumens often found in the proximal to mid-RCA. These lesions typically permit normal blood flow and are found incidentally in asymptomatic patients. Woven coronary arteries can be mistaken for complex lesions, dissection, or recanalized thrombus, leading to unnecessary and potentially dangerous percutaneous coronary intervention. Woven arteries should not be treated with angioplasty in the absence of thrombotic occlusion as this can lead to arterial vessel damage. Intracoronary imaging, including IVUS, is vital to differentiate woven coronary arteries from other coronary pathologies. Conclusion: Woven coronary arteries may mimic dissection or recanalized thrombus, but can be promptly recognized as a benign congenital anomaly with intracoronary imaging modalities such as IVUS.

Impact of unintentional coronary angiography on outcomes of emergency surgery in acute type A aortic dissection: a retrospective study

BackgroundThis study investigated the impact of coronary angiography on outcomes of emergency operation in acute type A aortic dissection (ATAAD) patients who were initially misdiagnosed as an acute coronary syndrome.MethodsFrom October 2016 to April 2019, 129 patients underwent emergency operation for ATAAD in our institution, including 21 patients (16.3%, coronary angiography group) who received preoperative coronary angiography without knowledge of the ATAAD, and the rest 108 did not (Non-coronary angiography group). Preoperative clinical characteristics, 30-day mortality and postoperative complications were compared. Multivariable logistic regression was performed to confirm the independent prognostic factors for short-term and long-term outcomes.ResultsPatients undergoing coronary angiography had higher prevalence of preoperative hypotension or shock (61.9% vs 35.2%, P = 0.022), ischemic changes on electrocardiogram (66.7% vs 37.0%, P = 0.012), platelet inhibition (ADP-induced inhibition 92.0% vs 46.0%, P = 0.001), and coronary involvement (66.7% vs 30.6%, P = 0.002). 30-day mortality was 4.8% versus 9.3% (P = 0.84). Coronary angiography group had more intraoperative bleeding (1900 ml vs 1500 ml, P = 0.013) and chest-tube drainage on the first postoperative day (1040 ml vs 595 ml, P = 0.028). However, preoperative coronary angiography was not independent risk factors for 30-day mortality (OR 0.171, 95%CI 0.013–2.174, P = 0.173) and overall survival (HR 0.407; 95%CI 0.080–2.057; P = 0.277).ConclusionPatients undergoing coronary angiography carried a higher risk of preoperative hemodynamic instability, myocardial ischemia, and perioperative bleeding. However, unintentional coronary angiography did not have a significant impact on short-term and long-term outcomes of emergency surgery in ATAAD.

Coronary Angiography Within 48 Hours Before Cardiac Surgery Increases the Risk of Postoperative Acute Kidney Injury.

Cardiac surgery and coronary examination, such as invasive coronary angiography (CAG), are both possibly associated with acute kidney injury (AKI). Preoperative CAG examination and cardiac surgery within a short interval may increase the incidence of AKI. We retrospectively reviewed 1112 patients who underwent CAG examination within 30 days prior to the cardiac operation in this study. Postoperative AKI was defined, according to Kidney Disease Improving Global Outcomes Definition and Staging (KDIGO) criteria. The total incidence of AKI was 40.8% and cystatin C level was 1.260 (1.028, 1.672) mg/L. For patients who received CAG, age, body mass index, cardiopulmonary time, and the time interval between preoperative CAG examination and cardiac operation within 48h was shown to be independent predictors of postoperative AKI. The incidence of AKI in patients undergoing preoperative CAG within 48h was 11.2% higher than in those more than 48h (P < 0.001). Patients undergoing valve surgery with or without coronary artery bypass grafting (CABG) exhibited a higher AKI risk than those only accepting CABG. The in-hospital stay of patients who developed AKI was 2 days longer than those without AKI. However, undergoing CAG within 48h prior to cardiac operation did not prolong ICU length of stay or hospital length of stay, nor did it increase the risk of death or renal failure after an operation. Undergoing CAG within 48 hours before cardiac surgery increases the risk of postoperative AKI.

P381 A CHALLENGING PACEMAKER IMPLANTATION IN THE PRESENCE OF A GIANT RIGHT CORONARY ANEURYSM COMPRESSING THE RIGHT ATRIUM

Abstract Giant coronary artery aneurysm is an uncommon disease, treated with surgerical intervention or percutaneous coil embolization. A thrombosed aneurysm can cause extrinsic compression on the cardiac chambers, with potential haemodynamic effects and may cause problems when we need to implant a cardiac device. We present a 85–year–old patient, with a previous myocardial infarction and double coronary artery bypass graft in 1995. In 2013 he was hospitalized for heart failure and severe mitral insufficiency, with cardiac surgery indication. Preoperative coronary angiography revealed a giant right coronary aneurysm (65x75mm). The aneurysm was partially thrombosed and in close contact with the posterior sternal wall; it was decided to treat it by coil embolization in order to avoid damage during the initial stages of cardiac surgery (sternotomy and isolation of the pericardium). Subsequently, the replacement of the mitral valve with a bioprosthesis was performed without complications. In 2019 a chest CT scan, in an asymptomatic patient, showed an enlarged coronary aneurysm (85x90mm), completely thrombosed, compressing the right atrium, for which a conservative approach was maintained. The patient was hospitalized in May 2021 following 3 syncopes, with cranial trauma. The EKG shows sinus rhythm with first degree AV block and complete left bundle branch block. Chest CT confirmed the aneurysm, unchanged from 2019 (Fig 1). Transthoracic and transesophageal echocardiography confirmed compression of the mass on the right atrium, reduced to a very small cavity (Fig 2). A stress echocardiogram with dobutamine, performed to evaluate a possible hemodynamic effect of atrial compression, showed no changes in diastolic ventricular filling, arrhythmias, pressure drops, or significant symptoms. Based on these assessments, the syncopes and EKG changes, we implanted a VVIR ventricular pacemaker. The procedure was hampered by the difficulty of passing the lead through the compressed right atrium in order to reach the tricuspid plane and then enter the right ventricle; only after numerous attempts, and with the help of simultaneous echocardiographic and fluoroscopic guidance, was it possible to complete the procedure without complications (Fig 3). This case demonstrates the usefulness of the echocardiogram, in particular contexts, in cardiac electro–stimulation procedure

Five-year epidemiological study of surgical valvular heart diseases in a north African tertiary referral hospital

The etiology of valvular heart disease (VHD) has changed dramatically in the last decades. In middle-income countries, the incidence of rheumatic heart disease (RHD) is still high, yet the prevalence of other valve disorders may be on the rise as the population's life expectancy is increasing. The aim of this study was to assess the epidemiological profile of the patients undergoing valvular surgery in a north African center of cardiology. A retrospective study involving patients hospitalized in our department and proposed for valvular surgery between January 2012 and May 2021. During the study period, 400 patients were referred for valvular surgery. The mean age was 57 ± 13 years. Two hundred and nine patients were male (52,3%) with a sex ratio of 1,1. Rheumatic etiology was the most important (53,8%). Arterial hypertension and diabetes mellitus are respectively present in 33.3% and 22% of the patients. Before surgery mean LVEF was 58.55 ± 11%. Thirty-nine patients (9.8%) were operated with (left ventricular dysfunction (LVEF ≤ 40%). A preoperative coronary angiography was performed in 69.5% of the patients and coronary artery disease was associated with the valvular heart disease in 127 patients (31.7%). Mitral valve replacement, aortic valve replacement, and double valve replacement were respectively performed in 43.6%, 33.9% and 17,7% of the cases. Bioprothesis were implanted in 5.67% of the cases. Forty-nine patients (12,3%) underwent coronary artery bypass graft in addition to the valvular surgery. In 15.9 of the cases, it was a redosurgery. Contemporary epidemiological data shows a rise of the degenerative etiology and associated coronary artery disease. Yet VHD is still high. Further investment in planning and resources for secondary prophylaxis would be a cost and life-saving strategy for in developing and emerging economy nations.

Comparison of Coronary Artery Calcium Scoring with Dobutamine Stress Echo for Detection of Coronary Artery Disease Before Liver Transplantation.

BackgroundDobutamine stress echocardiography (DSE) is commonly used for cardiovascular assessment before orthotopic liver transplantation (OLT). The coronary artery calcium score (CACS) is a useful screening tool for coronary artery disease (CAD). We aimed to compare the sensitivity and specificity of DSE and CACS for CAD in OLT candidates.Material/MethodsA total of 265 of the 1589 patients who underwent OLT at our center between 2008 and 2019 had preoperative coronary angiography (CAG). Of these, 173 had DSE and 133 had a CT scan suitable for CACS calculation within 1 year of OLT. Patients with a nondiagnostic DSE were excluded (n=100). Two reviewers evaluated CACS on CT scans. The sensitivity/specificity of DSE and CACS for detection of angiographically significant CAD were calculated for patients with both tests (n=36).A separate analysis compared the sensitivity/specificity of a diagnostic DSE (n=73) and CACS (n=133) against CAG for all patients with either test.ResultsSensitivity and specificity were 57.1% and 89.7%, respectively, for DSE, compared with 71.4% and 62.1% for CACS at ≥100 Agatston score. For the analysis of all patients with either test, the sensitivity/specificity of DSE for detection of CAD and CACS were 30.8% and 85.0% and 80.0% and 62.8%, respectively. On ROC analysis, CACS was a satisfactory predictor of obstructive CAD (AUC, 0.76±0.06, 95% CI, 0.66–0.87; P<0.001).ConclusionsCACS may be an important tool for cardiovascular assessment in patients undergoing OLT. DSE was nondiagnostic in a large percentage of OLT candidates, limiting its use in this population.

Preoperative coronary angiography in non-coronary cardiac surgery: Is there any role in asymptomatic patients?

Preoperative coronary angiography is often routinely performed in patients undergoing non-coronary cardiac surgery in detecting significant coronary artery disease (CAD) which necessitate coronary revascularization. However, there is limited data and inconclusive evidence in demonstrating the benefit of this invasive investigation in asymptomatic patients.

Uma rara combinação congênita

A 61-year-old female patient was referred to the cardiology department for dyspnea upon exertion. A transthoracic echocardiogram showed a severely stenotic bicuspid aortic valve and normal ejection fraction in both ventricles. She was submitted to a routine preoperative coronary angiography. A right radial access was obtained. Despite numerous efforts, it was not possible to visualize the origin of the left main coronary artery at the left ostium. Catheterization of right coronary artery was done and demonstrated a normal implantation at [...]