Proximal Left Anterior Descending Research Articles

Baseline Characteristics and Risk Profiles of Participants in the ISCHEMIA Randomized Clinical Trial

It is unknown whether coronary revascularization, when added to optimal medical therapy, improves prognosis in patients with stable ischemic heart disease (SIHD) at increased risk of cardiovascular events owing to moderate or severe ischemia. To describe baseline characteristics of participants enrolled and randomized in the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial and to evaluate whether qualification by stress imaging or nonimaging exercise tolerance test (ETT) influenced risk profiles. The ISCHEMIA trial recruited patients with SIHD with moderate or severe ischemia on stress testing. Blinded coronary computed tomography angiography was performed in most participants and reviewed by a core laboratory to exclude left main stenosis of at least 50% or no obstructive coronary artery disease (CAD) (<50% for imaging stress test and <70% for ETT). The study included 341 enrolling sites (320 randomizing) in 38 countries and patients with SIHD and moderate or severe ischemia on stress testing. Data presented were extracted on December 17, 2018. Enrolled, excluded, and randomized participants' baseline characteristics. No clinical outcomes are reported. A total of 8518 patients were enrolled, and 5179 were randomized. Common reasons for exclusion were core laboratory determination of insufficient ischemia, unprotected left main stenosis of at least 50%, or no stenosis that met study obstructive CAD criteria on study coronary computed tomography angiography. Randomized participants had a median age of 64 years, with 1168 women (22.6%), 1726 nonwhite participants (33.7%), 748 Hispanic participants (15.5%), 2122 with diabetes (41.0%), and 4643 with a history of angina (89.7%). Among the 3909 participants randomized after stress imaging, core laboratory assessment of ischemia severity (in 3901 participants) was severe in 1748 (44.8%), moderate in 1600 (41.0%), mild in 317 (8.1%) and none or uninterpretable in 236 (6.0%), Among the 1270 participants who were randomized after nonimaging ETT, core laboratory determination of ischemia severity (in 1266 participants) was severe (an eligibility criterion) in 1051 (83.0%), moderate in 101 (8.0%), mild in 34 (2.7%) and none or uninterpretable in 80 (6.3%). Among the 3912 of 5179 randomized participants who underwent coronary computed tomography angiography, 79.0% had multivessel CAD (n = 2679 of 3390) and 86.8% had left anterior descending (LAD) stenosis (n = 3190 of 3677) (proximal in 46.8% [n = 1749 of 3739]). Participants undergoing ETT had greater frequency of 3-vessel CAD, LAD, and proximal LAD stenosis than participants undergoing stress imaging. The ISCHEMIA trial randomized an SIHD population with moderate or severe ischemia on stress testing, of whom most had multivessel CAD. ClinicalTrials.gov Identifier: NCT01471522.

Longitudinal Tissue Velocity and Deformation Imaging in Patients with Significant Stenosis of Left Anterior Descending Artery

Introduction: Myocardial longitudinal tissue velocity imaging (TVI) and strain rate imaging (SRI) indices may have a role in the prediction of significant proximal stenosis of left anterior descending (LAD) by echocardiography. Materials And Methods: Total 20 patients with proximal LAD stenosis &gt;70% by angiography and ejection fraction ≥50%, without wall motion abnormality at resting echo (stenotic group) and 20 angiographically normal coronaries subjects with normal echocardiography (non-stenotic group) were included in the study. SRI and TVI were performed in nine segments of the LAD territory at rest. Parameters of interest included: peak systolic strain (ST, %), strain rate (SR, Second-1), and peak systolic velocity (Sm, cm/s). Results: Overal mean ST and SR showed a significant reduction in the stenotic group compared to non-stenotic group (P&lt;0.001), while the mean Sm had no significant difference. A segment-by-segment comparison revealed a reduction of ST in 4/9 (two apical and two anteroseptal) and SR in 5/9 (three apical, septal, and anteroseptal midportion) in the stenotic group (P&lt;0.05). Both ST and SR showed a significant reduction in three segments: anterior-apical, lateral-apical, and anteroseptal-midportion. When both ST and SR decreased in one segment, specificity and sensitivity for the diagnosis of proximal LAD stenosis was more than 80% and 55%, respectively, by Roc analysis. Conclusion: There is an overall reduction in the mean ST and SR in the segments of LAD territory with significant proximal stenosis and normal wall motion at rest and an acceptable specificity and sensitivity of SRI for the detection of stenosis in these segments.

Myocardial bridging and endothelial dysfunction – Computational fluid dynamics study

Myocardial bridging (MB) is associated with endothelial dysfunction in patients with angina and non-obstructive coronary artery disease. This study aims to determine if there is a link between abnormal blood flow patterns and endothelial dysfunction in patients with MB. Ten patients with MB in their left anterior descending (LAD) artery were selected, 5 of whom had endothelial dysfunction and 5 had no endothelial dysfunction based on their response to acetylcholine. Similarly, 10 patients without MB in their LAD, 5 of whom had endothelial dysfunction and 5 of whom had no endothelial dysfunction, were studied as a control group. Transient computational fluid dynamics simulations were performed to derive wall shear stress (WSS) over the entire vessel including proximal, middle and distal segments. Patients with MB and endothelial dysfunction had lower WSS in the proximal LAD and greater WSS in the mid-LAD than patients with MB but without endothelial dysfunction. When comparing patients with endothelial dysfunction, those with MB had significantly lower shear stress in the proximal LAD (0.32 ± 0.14 Pa (with MB) vs 0.71 ± 0.38 Pa (without MB), p = 0.01) and greater shear stress in the mid-LAD (2.81 ± 1.20 Pa (with MB) vs 1.66 ± 0.31 Pa (without MB), p = 0.014) than patients without MB. Our findings demonstrated that the presence of MB significantly contributes to low WSS and endothelial dysfunction relationship.

The established electrocardiographic classification of anterior wall myocardial infarction misguides clinicians in terms of infarct location, extent and prognosis.

The currently used scheme for the classification of infarct location and extent in anterior myocardial infarction (MI) is intuitive rather than being evidence-based, and recent evidence suggests that it may be misleading both in anatomic and prognostic sense. Consecutive patients with the diagnosis of anterior MI were enrolled. All electrocardiograms (ECG) were first classified according to established scheme and then reassessed using newer criteria for angiographic site of occlusion. The site of left anterior descending (LAD) occlusion was determined using multiple angiographic views. Clinic, echocardiographic and angiographic outcomes were compared. A total of 379 anterior MI cases were enrolled, final study population consisted of 267 patients. The established scheme did not predict infarct size or adverse outcomes. Location of the myocardium subtended by the occluded coronary network did not match with the anatomic location as ECG classification implies. Many high-risk patients with proximal LAD were classified as "anteroseptal", whereas the majority of the patients labeled as "extensive anterior MI" had in fact distal occlusions. On the other hand, expert interpretation was fairly accurate in predicting adverse outcomes and the site of angiographic involvement. Classifying patients according to the established scheme neither gives prognostic information nor accurately localizes infarction. It should be regarded as obsolete and its use should be abandoned. Instead, the extent of infarction can be inferred from newer criteria provided by the angiographic correlation studies.

Guidewire Fracture, Entrapment in Proximal Left Anterior Descending and Successful Extraction with Snare Catheter

A 64 year old female patient with a history of dyslipidaemia presented with Canadian Cardiovascular Society class II angina and stage 1 positive treadmill stress test. Coronary angiogram revealed 20% stenosis in distal left main coronary artery (LMCA), two 95% stenosis in proximal left anterior descending artery (LAD) and non-significant disease in left circumflex and right coronary arteries. LAD lesion was crossed with Rinato guidewire and first diagonal branch (D1) crossed with BMW guidewire. Both proximal and distal LAD lesions were predilated and stented with 2.75 × 38 mm Xience prime (Everolimus Eluting) stent. After the stent implantation, jailed guidewire used to protect the diagonal branch could not be removed. Traction, pull and push, balloon reinflation and deflation, back-and-fourth vibration were attempted to no avail. Finally guidewire fracture occurred and eventually entrapment leaving a part in D1, LAD and LMCA. By using an endovascular snare system we were able to remove the fractured guidewire successfully. This case highlights that endovascular snare system can safely and effectively be used for extraction of fractured retained guidewires inside the coronary arteries which prevents impending surgical intervention.

Prevalence and Clinical Implication of Wellens' Sign in Patients With Non-ST-Segment Elevation Myocardial Infarction.

BackgroundSymmetrically inverted or biphasic T waves in anterior precordial leads, Wellens’ sign, have been shown to represent impending infarction of left anterior descending (LAD) territory among unstable angina patients in the studies published more than 3 decades ago, when non-ST-segment elevation myocardial infarction (NSTEMI) was not a recognized entity. The clinical implication of Wellens’ sign in the contemporary NSTEMI cohort has not been clarified.MethodsWe performed a retrospective analysis of all NSTEMI patients who underwent coronary angiography between January 2013 and June 2014. Wellens’ sign was defined as either symmetrically inverted T waves (≥ 0.10 mV) or biphasic T waves in both leads V2 and V3. Coronary angiograms were reviewed and culprit lesions were determined for each patient.ResultsA total of 274 patients were included in the final analysis, of whom 24 (8.8%) had Wellens’ sign. Among these 24 patients, 16 had a LAD culprit (eight proximal), two had a non-LAD culprit, and six had non-obstructive coronary artery disease. Patients with Wellens’ sign were more likely to have LAD culprit (66.7% vs. 19.6%, P < 0.001) and proximal LAD culprit (33.3% vs. 14.4%, P = 0.035) than those without it. Wellens’ sign had a sensitivity of 24.6% and a specificity of 96.2% to predict LAD culprit.ConclusionsOur study revealed that: 1) Wellens’ sign was seen in 8.8% of the patients with NSTEMI; 2) Two-thirds of patients with Wellens’ sign had LAD culprit and one-third had proximal LAD culprit; and 3) Sensitivity and specificity of Wellens’ sign to predict LAD culprit were 24.6% and 96.2%, respectively.

Percutaneous Coronary Intervention for High Takeoff Left Main Coronary Artery: A Case Report

AbstractPercutaneous coronary intervention (PCI) for high takeoff left main is challenging, as it poses difficulties with the engagement of the guiding catheter and establishment of backup support. This report examines the case of a 53-year-old woman with history of anterior wall myocardial infarction with a ventricular septal defect (VSD), who was treated with left anterior descending (LAD) angioplasty and VSD device closure done 4 years back, and now she presented with unstable angina. After successful engagement of 5F Tiger diagnostic catheter through a right radial artery, the angiography revealed an 80% stenosis of the proximal LAD and in-stent restenosis 70% of mid-LAD. The authors tried to engage the left coronary system through the right femoral artery with 6F Judkins left, 6F Amplatzer left, 6F EBU, and 6F XBU. They could not cannulate because of high takeoff left main, so they switched to right radial access. Then they engaged a 6F 3.5 EBU catheter. Due to the weak backup support of the guiding catheter, they used another wire to stabilize it and the stent was implanted successfully. This is one of the rare case reports of PCI for high takeoff left main.

Prevalence of junctional ST-depression with tall symmetrical T-waves in a pre-hospital field triage system for STEMI patients

IntroductionThe prevalence of the junctional ST-depression with tall symmetrical T-waves in a field triage system for ST-Elevation Myocardial Infarction (STEMI) is unknown. Material and methodsWe prospectively collected all transmitted 12-lead electrocardiograms (ECGs) from the STEMI field triage system in Amsterdam from 2011 to 2013. Electrocardiograms with junctional ST-depression with tall symmetrical T-waves were recognized and angiographic documentation and clinical follow up were collected. ResultsA total of 5588 patients with at least 1 transmitted field ECG were identified from the database. ST-elevation infarction was present on the field ECG in 1864 patients (33%) and 701 ECGs (12,5%) showed anterior infarction. In 11 patients, junctional ST-depression with tall symmetrical T-waves was identified (0,2% of total transmitted ECGs and 1,6% of anterior infarctions). The 11 angiograms invariably showed involvement of the proximal Left Anterior Descending (LAD) artery (segment 5,6 and 7). Mortality was 27% within the first week. ConclusionsAn ECG with junctional ST-depression with tall symmetrical T-waves is an infrequent finding. Because this pattern of STEMI equivalent is associated with LAD occlusions, it is important to recognize this pattern, so patients can be transported to the catheterization laboratory without delay.

ALL’S WELL(EN) THAT ENDS WELL: A YOUNG LAD WITH WELLEN SYNDROME

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: Wellens’ syndrome is a preinfarction stage of coronary artery disease (CAD) that may progress to a major acute cardiac event in the near future if unrecognized or untreated, and can be detected most of the time by its unique pattern of electrocardiographic (ECG) changes in the context of unstable angina characterized by deep inverted T-waves or biphasic T-waves in the precordial leads, namely V2-V3. Human immunodeficiency virus (HIV) infection is known as an independent risk factor for cardiovascular disease. Here we report a case of a patient with history of congenital HIV who presented with chest pain and ECG changes consistent with those described in Wellens' syndrome. CASE PRESENTATION: A 24 year-old male with history of hypertension, HIV, and a family history of premature CAD, was referred from outside hospital for further evaluation and management of chest pain with elevated troponin. He was having new-onset intermittent, non-radiating, exertional, retrosternal pressure-like sensation for 4 days that is relieved with rest. At outside hospital, he was found to have mildly elevated troponin of 0.18 and thus was referred for further management. On presentation to Hartford Hospital, his vital signs were BP 187/123, HR 88, RR 18, SpO2 98% on room air, heart exam revealed normal s1 and s2 with no murmurs, lungs exam revealed good air entry with no crackles or wheezes, chest x ray was negative for acute cardiopulmonary disease, 3 sets of troponin were negative (<0.30 ng/ml), but ECG showed biphasic T-waves in V2-V4 with no ST elevations or Q waves. Given the history of HIV and his family history, CT angiogram coronaries was obtained, which showed proximal left anterior descending (LAD) artery stenosis. Thus coronary angiogram was pursued which revealed 95% proximal LAD occlusion which was treated with a drug-eluting stent, repeat ECG after the cardiac catheterization revealed resolution of the T-wave inversions in V2-V4. DISCUSSION: There are 2 types of Wellens' syndrome based on the ECG pattern; type A which is characterized by biphasic T-waves in V2–V3, and accounts for 25% of Wellens syndrome; and type B which is characterized by deep, symmetric T-wave inversions in V2–V3, and accounts for the remainder 75%, and occasionally those changes can involve leads V1, V4, V5 and V6. Additionally, other criteria have to be met including normal or slightly elevated serum cardiac markers, no loss of precordial R-wave progression, no pathological precordial Q waves, and history of angina. CONCLUSIONS: Patients with Wellens’ syndrome are at high risk of having acute myocardial infarction of the anterior wall. In addition, performing exercise stress test for these patients is contraindicated as it can trigger acute myocardial infarction. Thus, diagnosis of Wellens’ syndrome in patients with anginal pain is crucial and requires urgent percutaneous coronary intervention to prevent fatal sequelae. Reference #1: Tan B, Morales-Mangual C, Zhao D, Khan A, Chadow H. Wellens syndrome in HIV-infected patients: Two case reports. Patanè. S, ed. Medicine. 2017;96(24):e7152. Reference #2: Ashraf FWellens syndrome, a predictor of critical left anterior descending artery stenosis Postgraduate Medical Journal 2017;93:53. Reference #3: wellens syndrome: a life-saving diagnosis 10.1016/j.ajem.2010.10.014 DISCLOSURES: No relevant relationships by saif al-adwan, source=Web Response No relevant relationships by William Duvall, source=Web Response No relevant relationships by Anjana Easwar, source=Web Response No relevant relationships by Peter Montesano, source=Web Response No relevant relationships by Xuan Wang, source=Web Response

Short-term clinical outcomes and long-term survival of minimally invasive direct coronary artery bypass grafting.

Minimally invasive direct coronary artery bypass (MIDCAB) grafting is regarded as an alternative to conventional coronary artery bypass grafting (CABG) through full sternotomy, particularly for patients with isolated proximal left anterior descending (LAD) artery stenosis deemed unsuitable for percutaneous coronary intervention. However, the technically demanding nature of the procedure and lack of long-term published outcomes have precluded its universal adoption. We report the comparative short-term outcomes and long-term survival of MIDCAB and conventional CABG through full sternotomy for grafting of isolated LAD. From February 1996 to October 2017, a total of 668 patients underwent MIDCAB (n=508) and full sternotomy (n=160) CABG for isolated proximal LAD stenosis. Their data were prospectively entered into the institutional cardiac surgery database (Patients Analysis & Tracking System; Dendrite Clinical Systems, Ltd, Oxford, England, United Kingdom) and analyzed retrospectively. Information on patient deaths was obtained from the institutional database and the National General Register Office for all patients. The two groups were comparable with respect to preoperative demographics and risk profile. MIDCAB was associated with longer operative time (177±32 versus 141±12 min; P=0.003). The two groups did not significantly differ with regard to other complications including operative mortality. At a mean follow-up of 12.95±0.47 years, survival was also similar. This large single centre study with longest follow-up validates the status of MIDCAB as an effective strategy for grafting of LAD. However, it fails to show superiority of the minimally invasive approach compared to conventional CABG through full sternotomy.

Dosimetric evaluation of right coronary artery in radiotherapy for breast cancer

Comparison with control groups of untreated patients suggests that right-breast-cancer patients who receive radiotherapy have a higher rate of heart disease. Dose constraint for heart has been established to minimize radiotherapy-induced cardiotoxicity during left breast cancer treatment. Additionally, it is suggested to minimize the dosage on left anterior descending (LAD) artery. Right coronary artery (RCA), is the second largest artery, after left main coronary artery, supplying the heart. A dose evaluation study is not present for RCA; the proximal part of which is included in the irradiation field during breast cancer treatment of right breast. To investigate the presence of a correlation, doses resulting from right and left breast radiotherapy on proximal RCA (pRCA), LAD, and heart are evaluated in this study. Forty breast cancer patients who went under breast-conserving surgery are the subject of this study. Four groups were established; right breast, right breast and internal mammary (IM), left breast and left breast, and IM. pRCA, LAD, and heart volumes were contoured for each group on the planning tomographies. Resultant doses of tangential fields planning on these volumes were compared using dose-volume histograms. Mean and maximum doses of pRCA were statistically compared between groups. The highest mean and maximum point doses (192 to 284 cGy) were found in the right breast + IM group (p < 0.05). The mean and maximum doses only in the right breast and left breast + IM group did not differ statistically. However, the mean and maximum pRCA doses in these 2 groups were higher than only the left breast group (p < 0.05). pRCA receives high doses during radiotherapy of right and left breast especially if IM is included. This may predispose to coronary artery disease.

A volumetric intracoronary ultrasonographic study of coronary bifurcation lesions.

To evaluate the plaque distribution and composition pattern in the left main coronary artery (LMCA) disease using intracoronary ultrasound. Intravascular ultrasound data of 50 patients from the January 2010 to December 2015 with significant LMCA bifurcation lesions, with angiographic diameter stenosis >50%, and requiring revascularization, were evaluated. Plaque burden and percentage of necrotic core (% NC) at the minimal lumen area site and maximal % NC site were measured in different segments. The segments that were included in the study are as follows: segment 1: proximal LMCA, segment 2: left anterior descending (LAD) ostium, segment 3: left circumflex branch (LCX) ostium, segment 4: proximal LAD, segment 5: proximal LCX. According to its relationship with the bifurcation ridge, the blood vessel wall was divided into the contralateral bifurcation ridge blood vessel wall and bifurcation ridge blood vessel wall. Plaque burden results showed that the plaque eccentricity index of segment 2 and segment 3 was significantly higher than that of the other segments at sites of the minimal lumen area and maximal % NC with a statistically significant difference (p<0.05). Plaque eccentricity index of contralateral bifurcation ridge was significantly higher than that of the bifurcation ridge, and the difference was statistically significant (p<0.05). Analysis of plaque composition showed the fibrous tissue percentage of segment 2 and segment 3 was significantly higher than the other segments that at the sites of minimal lumen area and the maximal % NC site. The fibrous percentage of the contralateral bifurcation ridge was significantly lower than that of the bifurcation ridge. Intravascular ultrasound is an effective way for detecting the distribution and composition of the atherosclerotic plaque at the left main coronary artery bifurcation and is of great significance to adjuvant interventional therapy.

Comparison of Fractional Flow Reserve-Guided Revascularization Strategies in Isolated Proximal Left Anterior Descending Coronary Artery Disease

The data about FFR-guided revascularization in isolated proximal LAD disease are limited and studies comparing long-term outcomes of FFR-guided PCI versus FFR-guided CABG in single-vessel proximal LAD disease are lacking. We aimed to assess the 4-year long-term safety and effectiveness of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) and FFR-guided coronary artery bypass graft surgery (CABG) for the treatment of proximal left anterior descending (LAD) lesions. The study included 129 patients with functionally significant (FFR ≤ 0.80) isolated proximal LAD stenosis (PCI, 88 patients vs. CABG, 41). Clinical endpoints were assessed by Kaplan-Meier method and compared by the log-rank test. At a mean follow-up time of 47 ± 12 months, a higher incidence of myocardial infarction in the PCI group (PCI: 32% vs. CABG: 15%; p = 0.003) and a higher incidence of stroke in the CABG group (CABG: 3 (7%) vs. PCI 0 (0%); p = 0.031) were observed. However, there were no significant differences in the primary composite endpoint, death and target vessel revascularization between PCI and CABG groups. The PCI and CABG in isolated proximal LAD lesions yielded similar long-term outcomes regarding the primary composite clinical endpoints. However, stroke was more frequent in the CABG group than in the PCI group.

Long-Term Mortality Following Percutaneous Coronary Intervention to the Proximal Left Anterior Descending Artery: A Multi-Centre Australian Registry Review

Long-Term Mortality Following Percutaneous Coronary Intervention to the Proximal Left Anterior Descending Artery: A Multi-Centre Australian Registry Review

TCTAP C-288 Drug-coated Balloon Angioplasty for Proximal Left Anterior Descending Artery Lesion: Lumen Enlargement and Plaque Modification After 5 Months Follow-up

### Patient initials or identifier number YJ ### Relevant clinical history and physical exam Age: 35, Sex: male Chief Complaint: effort chest pain for 1 year, more severe 2 months. Present Illness: 1 years ago, after working the patient always felt chest pain, more severe in the left side,

Long-Term Outcomes of Stenting the Proximal Left Anterior Descending Artery in the PROTECT Trial

ObjectivesThis study sought to compare the outcomes of patients undergoing drug-eluting stent implantation according to lesion location within or outside the proximal left anterior descending (LAD) artery. BackgroundProximal LAD artery involvement is considered uniquely in revascularization guidelines. The impact of LAD lesion location on long-term outcomes after revascularization is poorly understood in context of current percutaneous coronary intervention and medical therapy. MethodsAmong 8,709 patients enrolled in PROTECT (Patient Related Outcomes with Endeavor Versus Cypher Stenting Trial), a multicenter percutaneous coronary intervention trial, we compared the outcomes of 2,534 patients (29.1%) (3,871 lesions [31.5%]) with stents implanted in the proximal LAD to 6,172 patients (70.9%) (8,419 lesions [68.5%]) with stents implanted outside the proximal LAD. ResultsAt the 4-year follow-up, death rates were the same (5.8% vs. 5.8%; p > 0.999), but more myocardial infarctions occurred in the proximal LAD group (6.2% vs. 4.9%; p = 0.015). The rate of clinically driven target vessel failure (TVF) (14.8% vs. 13.5%; p = 0.109), major adverse cardiac event(s) (MACE) (15.0% vs. 13.7%; hazard ratio: 1.1; 95% confidence interval: 0.97 to 1.31; p = 0.139), and stent thrombosis (2.1% vs. 2.0%; p = 0.800) were similar. Drug-eluting stent type had no interaction with MACE or TVF. In multivariate analysis, the proximal LAD was a predictor of myocardial infarction (p = 0.038) but not of TVF (p = 0.149) or MACE (p = 0.069). ConclusionsIn this study of contemporary percutaneous coronary intervention, proximal LAD location was associated with higher rates of myocardial infarction during the long-term follow-up, but there were no differences in stent thrombosis, death, TVF, or overall MACE. This finding may suggest that, in the drug-eluting stent era, proximal LAD no longer confers a different prognosis than other lesion sites. (Randomized Study Comparing Endeavor With Cypher Stents [PROTECT]; NCT00476957)

MINIMALLY INVASIVE CABG REDUCES TARGET VESSEL REVASCULARIZATIONS IN COMPARISON TO PCI WITHOUT INCREASED MAJOR ADVERSE EVENTS: A META-ANALYSIS OF RANDOMIZED TRIALS

Background: The trials comparing Minimally Invasive Direct Coronary Artery Bypass Graft (MIDCABG) with Percutaneous Coronary Intervention (PCI) for proximal Left Anterior Descending Artery (LAD) stenosis show conflicting results. Methods: The PubMed, EMBASE, and Cochrane Central Register of

What is the commonest site of coronary artery involvement in diabetic patients with coronary artery disease?

Introduction Diabetes is a complex metabolic disease with different targets of vascular endothelial injury. This study concentrates on locating the common areas of insult in the coronary vascular tree among diabetic patients. Objectives To evaluate the frequent sites of coronary artery involvement in diabetic patients and to compare with non-diabetic patients with Coronary Artery Disease (CAD). Methods Retrospective observational study was conducted on all patients with coronary angiographic evaluation for CAD at Cardiology Unit, Kandy. Results Among 1531 patients reviewed, 37.5% were diabetics (69% males) with a mean age of 56.76±8.5 years. Among them 54.3% had hypertension and 13.3% had dyslipidaemia. Single vessel disease (SVD) was the commonest (30.3%) pattern, whereas 27.6% had dual vessel disease and 26.9% had triple vessel disease. There were 35.6% with significant (stenosis >70%) proximal Left Anterior Descending (LAD) lesions, 17.4% with proximal Left Circumflex (LCX) lesions and 26.7% with proximal Right Coronary Artery (RCA) lesions. There were 13.4%, 13.5% and 10% with distal LAD, LCX and RCA involvement respectively. There were 56.5% with at least one proximal vessel involvement and 35.8% with at least one distal vessel involvement. There were 35.4% and 25.4% with significant diagonal and obtuse marginal vessel involvement respectively, among diabetics. There was a significant involvement of diagonal and obtuse marginal branches in diabetics compared to non-diabetics (p=0.001). Conclusion Single vessel disease and proximal LAD involvement were the commonest patterns observed among diabetic patients and they showed significant involvement of diagonal and obtuse marginal arteries compared to non-diabetic patients.

Stent Fracture and Coronary Aneurysm with a Sirolimus-Eluting Stent

A 75-year-old male presented to the Emergency Department with chest pain and anterior ST segment elevation. He had previously had a left anterior descending (LAD) stent (CYPHER™ sirolimus-eluting) implanted in 2006 for angina. Coronary angiography revealed stent fracture with thrombosis, displacement of the distal half of the stent, and a coronary aneurysm between fractured segments. Stent fracture in first-generation drug-eluting stents (DES) is an uncommon but recognised complication of DES implantation. Most cases are minor, but aneurysm formation at the site of fracture is rare. Image A demonstrates the stent in the LAD with the proximal (red arrow) and distal (yellow arrow) portions angulated relative to each other; the coronary wire is in the proximal LAD. Image B shows the coronary aneurysm (blue arrow) with TIMI 0 flow in the LAD distal to the aneurysm; the coronary wire is seen in a septal branch. The vessel was unable to be revascularised.

Anomalous Origin of the Right Coronary Artery from Proximal Left Anterior Descending Artery: A Case Report

Anomalous Origin of the Right Coronary Artery from Proximal Left Anterior Descending Artery: A Case Report