Proximal LAD Research Articles

Abstract 17367: Infusion of the Ketone Body β-Hydroxybutyrate Improves Left Ventricular Systolic Function in an Animal Model of Heart Failure With Reduced Ejection Fraction

Introduction: In vitro, ketone bodies (KB) are the most energetically efficient fuel for myocardium. Ex vivo, KB infusion in the perfusion medium of working rat hearts increases the heat of combustion (produced energy) by 31%. However, there is no report about the in vivo effects of KB on LV function. We hypothesized that KB infusion in HFREF would improve energy production and thus LV systolic function. Methods: HFREF was induced in 15 pigs by 2-hour balloon occlusion of LAD: proximal LAD (n=8, severe HREF) and mid LAD (n=7, moderate HFREF). At 2 months, LV systolic function was evaluated during saline infusion and during infusion of the KB β-hydroxybutyrate. Severe HFREF animals underwent cardiac MRI for baseline LVEF, feature tracking strains, and contractile reserve (ΔLVEF under dobutamine 5μg/kg/min). Moderate HFREF pigs underwent invasive hemodynamic assessment (dP/dt) and 3D-echocadiography (3D-LVEF and 3D-strains). Simultaneous sampling from coronary artery and coronary sinus was performed to measure myocardial fuel consumption. Results: Proximal and mid LAD occlusion resulted in severe and moderate LV systolic dysfunction, respectively. In the severe HFREF, ketone infusion improved baseline LVEF, feature-tracking strains (both longitudinal and circumferencial strain), and contractile reserve. In the moderate HFREF, ketone infusion improved 3D-LVEF, 3D-strains and dP/dt (Table). Ketone infusion switched myocardial metabolism from glucose to ketone consumption. Conclusions: Continuous infusion of the KB hydroxybutyrate improves LV systolic function independent of LV systolic dysfunction severity via a shift in myocardial fuel metabolism away from glucose oxidation (energy inefficient) toward a more energy-efficient fuel like KB. This effect can explain the mechanism of action of the benefits of SGLT2 inhibitors in heart failure, as empagliflozin-induced mild kyperketonemia may increase LV systolic function and thus improve patient outcomes.

Pre-test characteristics of unstable angina patients with obstructive coronary artery disease confirmed by coronary angiography

ObjectivePatients referred for acute coronary angiography (CAG) with unstable angina (UA) have low mortality and low rate of obstructive coronary artery disease (CAD). Better pre-test selection criteria are warranted. We...

57-Year-Old Man With Atypical Chest Pain

57-Year-Old Man With Atypical Chest Pain

THE PERFECT CORONARY STORM: ACUTE MI WITH 100% LAD OCCLUSION IN A 26-YEAR-OLD MALE

SESSION TITLE: Cardiovascular Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Sudden onset of chest pain accounts for 10% of Emergency Department visits. Although MI’s more commonly present in older patients, practitioners may question the urgency as well as the necessity for cardiac catherization in young individuals with elevated troponins without ST elevations on EKG. We present a case of an acute MI and significant LAD occlusion in a 26-year-old male with no prior medical history. CASE PRESENTATION: A 26-year-old male presented to the ED after 8 hours of mild, persistent substernal chest pain. He denied any previous episodes, and denied alcohol or drug usage. He reported a 5 pack year smoking history. EKG showed RBBB with T wave inversions in V1, V2, & V3. Initial troponin was 9.5. A few hours later, his pain worsened. Echocardiogram revealed moderate anterolateral, septal, & apical hypokinesis with an LVEF of 40%. Repeat troponin was 36.5. Coronary angiogram showed extensive non-occlusive thrombus in the proximal LAD with embolization and 100% occlusion of the distal LAD. Extensive mid-LAD myocardial bridging was also found. PCI was performed with a bare metal stent. The following day the patient’s symptoms resolved. Hypercoaguable workup showed a significant acquired protein C and S deficiency. He was discharged on DAPT and Coumadin. DISCUSSION: Myocardial bridging (MB) is a congenital abnormality in which a coronary artery tunnels through the myocardial fibers. Studies suggest MB having a correlation between various CV pathologies such as acute MI, ventricular rupture, life-threatening arrhythmias, hypertrophic cardiomyopathy, apical ballooning or sudden death. The majority of MI’s with MB are caused by atherosclerotic plaque rupture, fissure, or erosion with occlusive thrombus formation. One mechanism is the MB produces systolic retrograde flow and overall flow disruption, leading to the development of atherosclerosis. Due to these pressure gradients, the resulting coronary endothelial dysfunction also adds to early atherosclerosis. MB therapy remains unclear in complicated patients. Beta blockers are first line in symptomatic patients without obstructive CAD whereas surgical myotomy or CABG can be considered in patients with significant disease. Angioplasty with stenting has shown to have a high frequency of repeated revascularization. Protein C & S deficiencies have a known increased risk of venous thrombosis. However, there are numerous reports regarding these deficiencies being linked to coronary thrombosis as well as MI in young adults. These deficiencies alone may not significantly increase the risk of arterial thrombosis; however, when coupled with smoking and myocardial bridging, there's a higher incidence of premature MI. CONCLUSIONS: There are numerous etiologies for elevated troponins in young individuals, including cardiac and non-cardiac causes. Early recognition and diagnosis can lead to long-term benefits in morbidity and mortality. Reference #1: Loukas M, Curry B, Bowers M, et al. The relationship of myocardial bridges to coronary artery dominance in the adult human heart. J Anat. 2006;209:43-50. Reference #2: Arbab-Zadeh A, Nakano M, Virmani R, Fuster V. Acute coronary events. Circulation. 2012;125:1147-1156. Reference #3: Coller et al. Deficiency of plasma protein S, protein C, or antithrombin III and arterial thrombosis. Arteriosclerosis 1987;1:456-462. DISCLOSURES: No relevant relationships by Jeffrey Roan, source=Web Response

METHYLENETETRAHYDROFOLATE REDUCTASE POLYMORPHISM AND PREMATURE CORONARY ARTERY DISEASE

SESSION TITLE: Cardiovascular Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Methylenetetrahydrofolate reductase (MTHFR) catalyzes the conversion of 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate, a co-substrate for homocysteine remethylation to methionine. Its deficiency leads to increased homocysteine levels. Elevated serum levels of homocysteine have been associated with premature coronary artery disease (CAD). we present a case of recurrent acute coronary syndrome in patient with heterozygote mutation for methylenetetrahydrofolate reductase (MTHFR) with normal homocysteine level. CASE PRESENTATION: A 23 year-old man with history of MTHFR polymorphism and anterior wall ST segment elevation myocardial infarction requiring drug eluting stent (DES) in the left anterior descending artery (LAD) presented to the emergency department with substernal chest pain, T wave inversions in inferior leads on his ECG and elevated troponin levels. Coronary angiography demonstrated an acute occlusion of the proximal right coronary artery (RCA) and a chronic total occlusion of the proximal LAD with collaterals from the circumflex territory. Aspiration thrombectomy of the RCA lesion was partially successful and required continuous infusion of unfractionated heparin and tirofiban for 48 hours in addition to aspirin and ticagrelor. He underwent a successful deployment of 3 DES to his RCA. His left ventriculogram showed a mildly reduced left ventricular ejection fraction of 45 % with hypokinesis of the basal inferior wall segment. DISCUSSION: Hypercoagulability workup was unrevealing. Homocysteine levels were normal at the time of his first myocardial infarction two years prior. Repeat homocysteine level was 11.7 mg/dl (n <11.2mg/dl). His total cholesterol was 153mg/dl, LDL 80mg/dl, Apo lipoprotein B was 67 (n 52-109mg/dl), Lp(a) <10(n <75nmol/L). He was then discharge on folic acid. He was brought back to the cardiac catheterization laboratory a month later to reassess the LAD lesion but the angiogram showed complete re-occlusion of RCA. The patient was referred for coronary artery bypass surgery. CONCLUSIONS: This case demonstrates the association of MTHFR polymorphism with premature CAD and myocardial infarction despite normal homocysteine levels. Screening for MTHFR polymorphisms in addition to homocysteine levels should be considered for patients presenting with premature CAD and a normal lipid profile. Aggressive risk reduction with lifestyle modification, guideline-driven medical therapy and folic acid might be necessary for secondary cardiovascular disease prevention until more specific therapeutic options are available for this subgroup of patients. Reference #1: Frosst P, Blom HJ, Milos R, et al. A candidate genetic risk factor for vasculardisease: a common mutation in methylenetetrahydrofolate reductase. Nat Genet.1995; 10: 111–113 Reference #3: DISCLOSURES: No relevant relationships by Corina Iorgoveanu, source=Web Response No relevant relationships by Ahmed Zaghloul, source=Web Response

CRYPTIC CHEST PAIN: WELLEN’S SYNDROME DUE TO MYOCARDIAL BRIDGING

SESSION TITLE: Cardiovascular Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Chest pain of cardiac origin is commonly ischemic in etiology. However, the phenomenon of myocardial bridging as a cause of chest pain has come to attention recently. Herein, an epicardial coronary artery develops a transient myocardial course. During systole, a portion of the vessel is mechanically compressed and results in ischemia. This has been attributed to as a rare cause of angina. Here we present our experience with a patient who was diagnosed with the same. CASE PRESENTATION: A 51 year old man with no past medical history, presented to the emergency room with pressure like chest pain of two days duration. He had multiple episodes of pain and each lasted for around 20 minutes. It was associated with palpitations, and exacerbated by physical exertion. He was a former smoker and reportedly quit smoking 20 years back. His blood pressure was 153/95 mmHg; temperature 98.1F; heart rate 73/min regular; respiratory rate 18/min. ECG showed Type 1 Wellen's biphasic pattern in V2, V3. Three sets of cardiac troponins were normal. Wellens pattern on ECG is highly specific (89%) for critical left anterior descending artery (LAD) stenosis. [1] [2]. Therefore, the patient was sent for emergent cardiac catheterization. Coronary angiography revealed normal left main, left circumflex and right coronary artery. However, LAD artery showed moderate myocardial bridging. DISCUSSION: In myocardial bridging, a coronary artery that normally runs on the epicardium, develops a transient intra-myocardial course. This section of the artery gets compressed during ventricular systole. Generally asymptomatic, bridging sometimes results in angina, arrhythmias myocardial ischemia. Most myocardial bridging has been found to occur in the middle portion of the LAD artery. However, on autopsy right coronary and left circumflex arteries have shown bridging at comparable rates. [3]. Proximal portion of the bridged segment is prone to accelerated atherosclerosis.Hypertrophic obstructive cardiomyopathy (HOCM) has shown increased association with myocardial bridging. Treatment is with beta blockers and non-dihydropyridine calcium channel blockers. Therapeutic benefit results from decreased chronotropy and inotropy. In cases refractory to medical management, surgical myotomy, coronary artery stenting or coronary artery bypass grafting (CABG) can be pursued. Our patient was started on aspirin, amlodipine, metoprolol, and rosuvastatin. His hospital course was uneventful and he was discharged on pharmacological therapy. CONCLUSIONS: Myocardial Bridging is being recognized increasingly as a cause of refractory angina. However, it is still not widely included as a differential diagnosis. Since the treatment is fairly specific, we wish to underscore the importance of recognizing myocardial bridging as an atypical cause of chest pain. Reference #1: C. de Zwaan, F.W. Bar, H.J. Wellens. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J, 103 (1982), pp. 730-736. Reference #2: C. de Zwaan, F.W. Bar, J.H. Janssen, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery. . Am Heart J, 117 (1989), pp. 657-665. Reference #3: Polacek P, Kralove H. Relation of myocardial bridges and loops on the coronary arteries to coronary occlusions. Am Heart J. 1961;61:44-52 DISCLOSURES: No relevant relationships by Paurush Ambesh, source=Web Response No relevant relationships by Stephan Kamholz, source=Web Response No relevant relationships by Dikshya Sharma, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response

Ten-year clinical outcome of patients treated with a drug-eluting stent in the proximal left anterior descending artery segment compared with patients stented in other non-left main coronary segments.

The aim of the study was to determine whether patients treated with drug-eluting stents in the proximal left anterior descending artery (LAD) carried a different long-term prognosis from patients treated in other coronary artery segments. Ten-year clinical outcome expressed as all-cause mortality and major adverse cardiac events (MACE: cardiac death, acute myocardial infarction, or target vessel revascularisation) was determined for 1,479 patients with a single non-left main coronary stenosis treated with a first-generation drug-eluting stent in the SORT OUT II trial. The outcome of patients treated with stents in the proximal LAD (n=365) was compared with that of patients treated in a non-proximal LAD segment (n=1,114). Follow-up was 99.3% complete. All-cause mortality was 24.9% in the proximal LAD group vs. 26.3% in the non-proximal LAD group (p=0.60). MACE occurred less frequently in the proximal LAD group, 24.6% vs. 31.0% with a hazard ratio of 0.77 (95% confidence interval [CI]: 0.61-0.97, p=0.024). After multivariate analysis which included baseline characteristics that were unevenly distributed between the groups, the hazard ratio for MACE was 0.82 (95% CI: 0.65-1.03, p=0.09). Patients treated with a drug-eluting stent in the proximal LAD have similar, if not better, long-term clinical outcome compared with patients stented in other coronary artery segments.

The de winter electrocardiogram pattern is a transient electrocardiographic phenomenon that presents at the early stage of ST-segment elevation myocardial infarction.

The de Winter electrocardiogram (EKG) pattern is a novel sign that indicates left anterior descending coronary artery (LAD) occlusion in patients with chest pain. This study aimed to assess the prevalence and clinical characteristics of patients with this pattern. The de Winter EKG pattern is an special anterior ST-segment elevation myocardial infarction (STEMI) equivalents without obvious ST-segment elevation. This retrospective study included all patients with anterior myocardial infarction admitted between January 2011 and December 2017. Patients were categorized into two groups: those with the de Winter EKG pattern and those with typical STEMI. Of 441 patients, 15 (3.4%) with anterior myocardial infarction had the de Winter EKG pattern. Similar to those with typical STEMI, the majority of patients with the de Winter EKG pattern had ST-segment elevation, pathologic Q wave, and absence of R wave at follow-up. The median time from recognition of this pattern until its evolution was 114 minutes. The ST-segment in leads V3R to V5R and leads V7 to V9 were normal or slightly depressed when a typical de Winter EKG pattern was noted in leads V1 to V6. The culprit lesion was mainly in the proximal LAD or the diagonal branch. Patients with this EKG pattern responded poorly to thrombolytic therapy. We believe that the de Winter EKG pattern may be a sign of ischemia and presents at the early stage of STEMI rather than being an independent pattern. In patients with this pattern, a percutaneous coronary intervention rather than follow-up and thrombolytic strategy should be performed.

Abstract 422: Recognition of Pharyngeal Pain as an Angina Equivalent

A 64-year-old man presented to his physician with a 5-day history of throat pain and hoarseness. An initial diagnosis of pharyngitis was made, and the patient was sent home with a 7-day course of antibiotic therapy. He returned 6 days after his initial visit with persistent symptoms, which he now described as worsening on exertion such as when lifting weights. He was sent for a neck computed tomography to evaluate cervical soft tissues: No masses, enhancing lesions, lymphadenopathies, or imaging findings suggesting vocal cord paresis were noted. An ECG was ordered by the patient’s primary care physician and demonstrated new lateral T-wave inversions. The patient was also referred to ENT, and via direct laryngoscopy normal true vocal cords and questionable evidence of laryngopharyngeal reflux were visualized. He was then recommended to begin lifestyle modifications and start empiric treatment with omeprazole twice daily. Due to the ECG findings, an exercise stress test was ordered. During the exercise stress test, He developed throat tightness and the study was converted to a Lexiscan nuclear stress test. The stress test revealed inferior wall ischemia of moderate severity. Consequently, a coronary cath demonstrated quadruple vessel disease with 75% occlusion of left main, 70% stenosis of proximal LAD, 60% stenosis of the first diagonal, and total occlusion of the mid RCA. After undergoing quadruple coronary bypass surgery, the patient experienced a total resolution of his throat pain. Discussion: When approaching craniofacial pain elicited with exertion, it is essential for the clinician to consider ischemic heart disease as an etiology. Furthermore, the link of pain with physical activity and, additionally, pain relief with rest should drive the physician to consider cardiac ischemia. Isolated craniofacial pain or sole pharyngeal pain of cardiac origin are infrequent indicators of significant coronary artery disease. In a prospective multicenter study, only 6% of patients with confirmed ischemic cardiomyopathy presented with craniofacial pain as the only complaint. This case illustrates the importance of a thorough history and physical examination as well as a broad differential diagnosis when evaluating patients with throat pain and hoarseness.

Relief of vasospasm with fasudil after off-pump coronary artery bypass grafting: a case study

BackgroundCoronary vasospasm after coronary artery bypass grafting (CABG) is a rare but potentially lethal complication. It is often refractory to several vasodilators. We report a case of refractory coronary vasospasm relieved by fasudil injection.Case presentationA 74-year-old woman who had three instances of in-stent stenosis at the left anterior descending artery (LAD) was referred for CABG treatment. Preoperative coronary angiography showed 90% in-stent stenosis of the proximal LAD and 75% stenosis of the diagonal branch. We performed a left internal thoracic artery (LITA)-LAD bypass and a right internal thoracic artery (RITA) diagonal branch bypass. After anastomosis, transit time flow measurement revealed poor blood flow of LITA-LAD bypass even after re-anastomosis. We performed coronary angiography and detected a vasospasm in the native coronary arteries, which was not relieved using conventional vasodilators (calcium channel blockers, isosorbide dinitrate, and nicorandil) However, we were able to relieve the coronary vasospasm by administering fasudil (a Rho kinase inhibitor) injection without causing systemic hypotension.ConclusionsFasudil may be an important vasodilator, especially in cases of coronary vasospasm after CABG.

Long-Term Prognostic Value of Coronary Computed Tomography Angiography in Asymptomatic Elderly Population Including Diabetic Patients

Objectives: There is still controversy about the long-term prognostic value of coronary computed tomography angiography (CCTA) for coronary heart disease (CHD) in asymptomatic individuals including diabetic patients. Also, long term CCTA’s role among elderly population has not been established. We investigated the long-term prognostic value of CCTA in asymptomatic elderly patients with or without diabetes. Methods: A community based-cohort study of 470 asymptomatic elderly individuals (mean age 75.1 ± 7.3 years) who underwent CCTA was conducted. Among them, there were 156 [33.2%] diabetic patients and 55 [11.7%] patients with HbA1c of more than 7% (HbA1c &amp;gt;7%). Major adverse cardiac events (MACE) defined as composite of cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization and coronary revascularization were measured. CCTA findings were categorized by various means including the presence of proximal LAD or left main disease (pLAD/LM). Coronary calcium score (CACS) and Framingham risk score (FRS) were adjusted for analysis. Results: There were 57 individuals (12.1%) with pLAD/LM finding for overall population and 8 (14.5%) for diabetic patients with HbA1c &amp;gt;7%. During median follow-up of 8.1 years (interquartile range: 7.7-8.2), MACE occurred in 28 (6%) subjects among overall population and 6 (10.9%) among diabetic patients with HbA1c &amp;gt;7%. Compared to individuals with negative pLAD/LM finding, positive group was significantly associated with MACE for overall population (HR 2.817 [95% CI 1.044-7.601], p = 0.041). Among diabetic patients with HbA1c &amp;gt;7%, there is more significant association between pLAD/LM finding and MACE (HR 6.525 [95% CI 1.147-37.121], p = 0.034). Conclusion: Among asymptomatic elderly population, CCTA showed considerable prognostic value additive on CACS and FRS over 8 years. And this result was more significant in elderly diabetic patients with poor glycemic control. Disclosure S. Moon: None. D. Lee: None. T. Oh: None. K. Kim: None. S. Choi: None. H. Jang: None. S. Lim: None.

Safety of FFR-guided revascularisation deferral in Anatomically prognostiC diseasE (FACE: CARDIOGROUP V STUDY): A prospective multicentre study

BackgroundFFR-guided coronary intervention is recommended for patients with intermediate stenoses. However, concerns exist with this approach in anatomically prognostic disease. MethodsIn this prospective, multicentre study, we consecutively enrolled patients found to have FFR negative lesions in anatomically significant sites: left main; proximal LAD; last remaining patent vessel; and multiple vessels with concomitant impaired left ventricular systolic function (EF < 40%). As per recommendation, revascularisation was deferred, and patients included into a registry.The primary endpoint was MACE (death, myocardial infarction and unplanned target lesion revascularization). Secondary endpoints were the above individual components.Subgroup analyses were performed for clinical presentation (stable vs. ACS), localization of lesion (ostial vs. non ostial) and renal function. ResultsThe registry included 292 patients with 297 deferred stenoses. After 1-year, the primary endpoint occurred in 5% of patients, mainly driven by TLR (2.7%). Cardiovascular death occurred in 0.8% and AMI in 0.8%. During a follow-up of 22.2 ± 11 months, MACE occurred in 11.6%. Cardiovascular death occurred in 1.8% and AMI in 2.1%. After multivariate analysis, impaired renal function (OR 1.99; CI 95% 1.74–5.41; p = 0.046) and ostial disease (OR 2.88; CI 95% 1.04–7.38; p = 0.041) were found to be predictors of MACE. Impaired renal function also predicted TLR (OR 2.43; CI 95% 1.17–5.02; p = 0.017). ConclusionFFR-guided revascularisation deferral is safe in the majority of anatomically prognostic disease. However, further evaluation is required in the risk stratification of those patients with ostial disease and renal disease. Registered on ClinicalTrials, NCT02590926.

INDICATIONS FOR MYOCARDIAL REVASCULARIZATION – ARE THEY USING EQUALLY FOR CHOOSING OF INVASIVE STRATEGY IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE?

The purpose was to reveal the value of separate indications for myocardial revascularization as well as their combinations for choosing invasive or conservative strategy of treatment in patients with stable coronary artery disease (CAD) during 2012–2015 years. Materials and methods . The retrospective data of 1196 patients (mean age: 52.5 ± 8.4 years; 77,0 % men) were analyzed, from the register of patients with stable CAD (2012–2015 years), who had separate indications for myocardial revascularization and their combination. Patients were divided into 2 groups: with an invasive (n = 481 patients without considering the revascularization method) and conservative (n = 715 patients) treatment strategy. Indications for revascularization are taken from the recommendations of the European Society of Cardiology 2014. Results. The most common indication for myocardial revascularization was the presence of any coronary stenosis in combination with the limiting angina in the context of optimal medication (88.1 % in the invasive treatment group, 94.3 % in the conservative therapy group, p 50 % + proximal stenosis LAD >50 %+ limiting angina pectoris occurred in 1.5 % of the patients in the invasive treatment group versus 3.8 % with the conservative strategy (p = 0.020). Proximal stenosis LAD >50 % was more common among operated patients (10.6 % vs 4.6 % in the conservative treatment group, p <0.001). Two- and three-vessel lesions + ejection fraction LV <40 % + limiting angina pectoris also occurred more frequently in the invasive treatment group (2.5 % vs 0.6 % in the conservative strategy group, p = 0.006).The remaining indications for myocardial revascularization and their combination were equally common in both groups. Conclusion. The presence of isolated proximal LAD stenosis or multivessel lesion with reduced left ventricular function accompanied with limiting angina was associated with the choice of invasive strategy in patients with stable CAD (data for 2012–2015 years). The lesion LM combined with proximal stenosis LAD and limiting angina pectoris and requiring coronary artery bypass grafting was associated with the choice of a conservative strategy. Almost half of the patients (48.6 %) had revascularization to improve the quality of life.

TCTAP C-223 Diffusely Calcified Long Lesion Treated Using Rotablation

### Patient Initials or Identifier Number WCN ### Relevant Clinical History and Physical Exam A 68 years old male patient was hospitalized for resting chest pain started 6 hours ago. He received proximal LAD and OM branch stenting 17 years ago in other hospital and proximal to mid-RCA and distal

Abstract 235: Revascularization Patterns of Systolic Heart Failure in a Large Urban County Hospital

Background: Coronary angiography is frequently performed after the initial diagnosis of heart failure to determine etiology and revascularization strategy. Current body of evidence suggests that surgical revascularization conveys a mortality benefit as compared to medical therapy alone, and the role of percutaneous coronary intervention (PCI) is not yet established. The aim of this study is to describe revascularization patterns among patients presenting with systolic heart failure who underwent diagnostic angiography at a large urban county hospital. Methods: We evaluated patients presenting to the emergency department with symptomatic heart failure with reduced ejection fraction (HFrEF) without acute coronary syndrome (n=150; average left ventricular ejection fraction of 25%) who underwent coronary angiography between January 2011 and January 2015. We defined surgical coronary artery disease (CAD) as: 1) three-vessel disease, 2) two-vessel disease including the proximal LAD artery, or 3) two-vessel disease including the left main coronary artery. Primary outcomes included intervention (PCI, CABG, or medical therapy [MT] alone) as well as referral for CABG. Results: Of patients presenting with HFrEF who underwent diagnostic angiography, 80% (n=120) of patients had obstructive CAD with 36% (n=43) of those patients having surgical CAD. Of those with surgical CAD, 74% (n=32) underwent PCI, 18% (n=8) underwent CABG and 7% (n=3) received MT alone. Of patients with 1-vessel CAD, or 2-vessel CAD without involvement of the proximal LAD artery or left main coronary artery, 81% (n=63) underwent PCI while 19% (n=14) received MT alone. Conclusion: Patients presenting with symptomatic HFrEF referred for cardiac catheterization have a high prevalence of obstructive CAD. Most patients with evidence of either surgical or non-surgical CAD during coronary angiography underwent revascularization, with PCI being the dominant revascularization method.

TCTAP C-140 Successful Retrieval of a Coronary Stent Entrapment at the Proximal LAD Stent Strut Which Protrude to Left Main

TCTAP C-140 Successful Retrieval of a Coronary Stent Entrapment at the Proximal LAD Stent Strut Which Protrude to Left Main

IMPACT OF SMALL DEVICE USE IN THE PROXIMAL LAD VERSUS OTHER CORONARY SEGMENTS ON LONG-TERM CLINICAL OUTCOMES: AN ADAPT-DES SUB-ANALYSIS

Proximal LAD (PLAD) vessel diameter is rarely <3 mm. We hypothesized that pts who undergo PCI with an undersized stent would have worse outcomes compared to an appropriately sized stent, and that the impact of undersized stents would be greatest in the PLAD. ADAPT-DES was a prospective, non-

AN ALTERNATIVE POST-ANTERIOR MYOCARDIAL INFARCTION MECHANICAL COMPLICATION

Ventricular Septal defect (VSD) and pseudoaneursym (PsA) post myocardial infarction (MI) require prompt intervention. A 63-year-old hypertensive, hyperlipidemic, female smoker presented with anterior ST-elevation MI (STEMI) and proximal LAD occlusion treated with a drug-eluting stent. Following

In a Heartbeat: An Assessment of Dynamic Dose Variation to Cardiac Structures Using Dual Source Computed Tomography

To assess radiation dose variation to the left anterior descending artery (LAD), left main coronary artery (LMCA), left ventricle (LV), and whole heart (WH) during the cardiac cycle using dual source computed tomography (DSCT). The present prospective study included patients with left-side breast cancer planned to undergo tangential radiation therapy. An electrocardiogram-synchronized contrast-injected DSCT scan was obtained with the patient in the treatment position, in deep-inspiration breath-hold, using retrospective sequential acquisition. The WH, LV, LMCA, and proximal, middle, and distal LAD segments were contoured on each phase of the cardiac cycle. The maximum, minimum, and mean Hausdorff distance between each structure and the tangential fields was assessed in ventricular systole and diastole. Four-dimensional dose-volume histograms were used to compare the systolic and diastolic dosimetric data. Ten patients were enrolled. The average maximum, minimum, and mean Hausdorff distance variation from systole to diastole was ≤4mm for the LV and LMCA and ≤3mm for the WH and LAD segments. WH maximum dose and volume receiving 5Gy were decreased in systole compared with diastole (42.9Gy versus 44.5Gy, P=.03, and 21.7cm3 versus 27.7cm3, P=.01), but the mean dose remained similar throughout the cycle. The maximum and mean dose to the distal LAD was 21.2Gy versus 26.6Gy(P=.005) and 8.6Gy versus 13.2Gy(P=.006) in systole versus diastole, respectively. The maximum and mean dose to the middle LAD was 18.4Gy versus 25.1Gy(P=.005) and 8.5Gy versus 10.2Gy in systole versus diastole (P=.005). The maximum dose to the LV was lower in systole than in diastole (21.5Gy vs 26.7Gy; P=.005). In addition to deep-inspiration breath-hold, systolic irradiation is associated with a reduction in dose to the LAD, LV, and WH. In addition to its potential use in radiation planning for cardiac gating, DSCT imaging can be used to help define a planning organ at risk volume for clinically important cardiac substructures.

Midterm Follow-up of Coronary Artery Bypass Grafting with 64-Slice Multi-detector Computed Tomography: Identification of Risk Factors Affecting Graft Patency.

To identify the risk factors that are associated with the midterm coronary artery bypass grafting (CABG) functionality by assessing patency of left internal mammary artery (LIMA) graft and saphenous vein (SV) graft with 64-slice multi-detector computed tomography (64-MDCT).Methods Patients who underwent CABG operation and postoperative 64-MDCT follow-up examinations from August 2012 to December 2015 were included. The graft patent status was classified into patent and poor patent according to MDCT findings predominantly on 3D reconstructed images by two radiologists. The clinical data and imaging findings of the patients were collected and compared between the patent group and poor patent group. Univariate analysis and the multivariate logistic regression analysis were performed to identify the risk factors that affect graft patency.Results Among 341 patients in the study, there were 330 LIMA grafts [326 anastomosed to the left anterior descending artery (LAD), 4 to right coronary artery (RCA)] and 564 SV grafts (SVG) [100 anastomosed to the diagonal branch (D), 226 to the obtuse marginal branch (OM), and 238 to the RCA territory]. The approximal vessel stenosis exceeding 90% occurred in 268 of 292 patent LIMA grafts, and in 1 of 34 poor patent grafts (χ 2=167, P<0.001). The patency rate was higher when SVG was anastomosed to OM (85.4%) or RCA territory (81.9%) than to D (69.0%) (χ 2=15.471, P=0.004). The proximal target vessel stenosis < 90% (OR= 0.015, 95% CI: 0.01-0.14, P=0.000) was independently associated with the closure risk of LIMA grafts, the dyslipidemia (OR= 1.52, 95% CI: 1.0-2.5, P=0.048), history of diabetes (OR = 1.28, 95% CI : 0.90-2.26, P=0.045) and typical angina symptoms (OR=1.81, 95% CI :1.33-4.15, P=0.003) were independently associated with the closure risk of SVG. Conclusions The proximal LAD stenosis less than 90% was adversely associated with graft patency in LIMA recipients; dyslipidemia, diabetes and angina symptoms were associated with the midterm failure in SVG recipients. The choice of the target anastomosis sites may affect the patency of SVG.