Rentrop Grade Research Articles

Relationship between quality of coronary collateral and myocardial viability in chronic total occlusion: a magnetic resonance study.

Revascularization of chronic total occlusion (CTO) is still debated regarding its indications and therapeutic benefits. Guidelines recommend patient selection based on ischemia detection and viability assessment. We aimed to investigate the relationship between the quality of coronary collaterals (CC), graded by Rentrop classification, and myocardial viability assessed by cardiovascular magnetic resonance (CMR). Unselected 100 consecutive patients with a single CTO were prospectively enrolled. CC of Rentrop grade two or three were considered as well-developed. Analyzing late gadolinium enhancement (LGE) images, CTO territories with mean segmental transmural scar extent < 50% were considered viable. Of the 100 patients (70 male, mean age 58.0 ± 6years), 73 patients (73%) had angiographically visible CC. Based on LGE, patients were classified into viable (n = 50) and non-viable (n = 50) groups. Significant differences between both groups existed regarding frequency of diabetes mellitus (p = 0.044), frequency of congestive heart failure (p = 0.032), presence of pathological Q in CTO territory (p = 0.039); and presence of well-developed CC (p < 0.001). Binary logistic regression and receiver operating characteristic curve showed that presence of well-developed CC could independently (OR 9.4, 95% CI: 2.6-33.6, p < 0.001) predict myocardial viability with a sensitivity and a specificity of 72% and 74%, respectively (AUC: 0.796, 95% CI: 0.708-0.884, P < 0.001). The presence of well-developed CC could independently predict with high accuracy myocardial viability assessed by LGE in territories subtended by CTO vessels. Therefore, search for viable myocardium using different imaging modalities, e.g. CMR, may be recommended in CTO patients with well-developed CC.

Prognostic implications of the rapid recruitment of coronary collaterals during ST elevation myocardial infarction (STEMI): a meta-analysis of over 14,000 patients.

Acute coronary collateralisation of an infarct-related arterial (IRA) territory may be identified during angiography for ST elevation myocardial infarction (STEMI). Whether the presence or absence of these collaterals affects outcomes remains uncertain. A search of EMBASE, MEDLINE and Cochrane Library, using the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines was conducted to identify studies which reported on the association between coronary collaterals and in-hospital and longer term mortality, left ventricular ejection fraction (LVEF), risk of repeat acute myocardial infarction (AMI) and repeat revascularisation. Patients with Rentrop grade 0 or 1 were defined as poor collaterals whilst those with Rentrop grade two or three were defined as those with robust collaterals. Studies were eligible if they included patients ≥ 18years of age who had immediate coronary angiography for STEMI. Included studies were observational which recorded the degree of collateral blood flow to the IRA. Two investigators reviewed all citations using a predefined protocol with final consensus for all studies, the data from which was then independently entered to ensure fidelity of results. Inverse variance random effects model for the meta-analysis along with risk of bias assessment was performed. 20 studies with a total of 14,608 patients were identified and included in the analysis. Patients with robust collaterals had lower mortality (OR 0.55, 95% CI 0.48-0.64), both in-hospital (OR 0.47, 95% CI 0.35-0.63) and longer term (OR 0.58, 95% CI 0.46-0.75). Patients with robust collaterals also had a higher mean LVEF (SMD 0.23, 95% CI 0.10-0.37). There was no difference in the rates of AMI or repeat revascularisation between patients with robust or poor collaterals. The presence of robust collaterals during STEMI is associated with reduced in-hospital and longer term mortality and improved left ventricular function. These findings have implications for prognostication and identifying patients who require close monitoring following STEMI.

In Acute ST-Segment Elevation Myocardial Infarction, Coronary Wedge Pressure Is Associated with Infarct Size and Reperfusion Injury as Evaluated by Cardiac Magnetic Resonance Imaging

Background. Coronary collateral flow influences patient prognosis in the setting of acute myocardial infarction. However, few data exist about the relation between coronary collaterals, infarct size, and reperfusion injury. The angiographic Rentrop score is prone to subjectivism and to the inherent limitations of angiographic images. Its prognostic value is controversial in the setting of acute myocardial infarction. The invasive measurement of coronary wedge pressure (CWP) represents an alternative to Rentrop score for the evaluation of coronary collateralization. Our study evaluates pre-revascularization CWP as a predictor of infarct size and reperfusion injury as evaluated by cardiac magnetic resonance imaging. Methods. Patients with acute ST-elevation myocardial infarction underwent preprocedural CWP measurement and primary percutaneous coronary intervention. Infarct size, microvascular obstruction, intramyocardial edema, and intramyocardial hemorrhage were evaluated by cardiac magnetic resonance imaging. Results. Mean CWP was inversely associated with infarct size p=0.01, microvascular obstruction p=0.02, intramyocardial edema p=0.05, and intramyocardial hemorrhage p=0.01. An excellent association was found between mean CWP and an infarct size ≥24% of left ventricular mass (AUC = 0.880, p=0.007), with an optimal cutoff value ≤24.5 mmHg. Both intramyocardial edema p=0.02 and hemorrhage p=0.03 had a larger extent in patients with coronary wedge pressure ≤24.5 mmHg. Rentrop grade &lt;2 was associated with larger infarct size p=0.03, but not with the extent of edema, microvascular obstruction, or intramyocardial hemorrhage. Conclusions. Pre-revascularization CWP was a predictor of infarct size and was significantly associated with a larger extent of intramyocardial edema and intramyocardial hemorrhage. Rentrop grade &lt;2 was associated with a larger infarct size, but had no influence on reperfusion injury. The clinical trial is registered with NCT03371784.

Circulating CD34+VEGFR-2+ endothelial progenitor cells correlate with revascularization-mediated long-term improvement of cardiac function in patients with coronary chronic total occlusions

BackgroundEndothelial progenitor cells (EPCs) participate in angiogenesis and neocollateralization. This study assessed if circulating EPCs can predict long-term improvement of global left ventricular systolic function in patients with coronary chronic total occlusions (CTOs) underwent successful percutaneous coronary intervention (PCI). MethodsIn this single-center, prospective, observational study, 115 consecutive patients with CTOs were evaluated by standard transthoracic echocardiography (ECHO) before and 9–12 months after PCI. Numbers of circulating putative EPCs were determined by flow cytometry analysis of mononuclear cells isolated from peripheral blood samples drawn before and 72 h after PCI. ResultsAt mean 11.3 ± 2.5 months post vs. before PCI (all P < .05): by SAQ-7 summary scores, angina frequency, physical limitation and quality of life scores were greater; by ECHO, LVEDd decreased and LVEF increased, which were more significant in patients with Rentrop grades 2/3 vs. 0/1. At 72 h post vs. before PCI, CD34+VEGFR-2+CD133− (0.82 ± 0.32 × 106/L vs. 1.00 ± 0.39 × 106/L, P = .003), CD34+VEGFR-2+CD133+ (0.24 ± 0.12 × 106/L vs. 0.27 ± 0.14 × 106/L, P = .028), and CD14+Tie2+VEGFR-2+ (6.60 ± 3.32 × 106/L vs. 7.82 ± 3.91 × 106/L, P = .006) cell numbers were lower. The baseline levels of CD34+VEGFR-2+cells (P = .001) and CD14+Tie2+VEGFR-2+cells (P < .001) were association with the grade of collateralization. In addition, the baseline and peri-procedural decrease of circulating CD34+VEGFR-2+ cells correlated with the increase of LVEF (P < .001, P < .001, respectively) and the decrease of LVEDd (P = .022, P = .029, respectively) at follow-up. ConclusionsIn this small study, the baseline levels of circulating CD34+VEGFR-2+ EPCs and its reduction after successful revascularization of CTOs correlated with long-term improvement in global LV systolic function.

Coronary collaterals and myocardial viability in patients with chronic total occlusions.

This study aimed to evaluate associations between coronary collaterals and myocardial viability as assessed by quantitative cardiac magnetic resonance (CMR) imaging in patients with a chronic coronary total occlusion (CTO). A total of 218 patients with a CTO who underwent CMR between 2013 and 2018 were included. A concomitant collateral connection (CC) score 2 and Rentrop grade 3 defined well-developed collaterals in 146 (67%) patients, whereas lower CC scores or Rentrop grades characterised poorly developed collaterals. Dysfunctional myocardium (<3 mm segmental wall thickening [SWT]) and ≤50% late gadolinium enhancement (LGE) defined viability. Extensive scar (LGE >50%) was observed in only 5% of CTO segments. In the CTO territory, SWT was greater (3.72±1.51 vs 3.05±1.60 mm, p<0.01) and the extent of scar was less (7.0 [0.1-16.7] vs 13.1% [2.8-22.2], p=0.048) in patients having well-developed versus poorly developed collaterals. Viability was more prevalent in CTO segments among patients with poorly developed versus well-developed collaterals (44% vs 30% of segments, p<0.01), predominantly due to a higher prevalence of dysfunctional myocardium (51% vs 34% of segments, p<0.01) in the poorly developed collateral group. The infarcted area in myocardium subtended by a CTO is generally limited. Well-developed collaterals are associated with less myocardial scar and enhanced preserved function. However, viability was regularly present in patients with poorly developed collaterals.

Correlation of plasma vitamin D levels with coronary collateral circulation

Introduction: In patients with coronary chronic total occlusion (CTO), adequate coronary collateral circulation (CCC) supports myocardial tissue versus ischemia. Vitamin D deficiency is a risk factor for osteoporosis and other chronic diseases, including type 1 diabetes, hypertension, metabolic syndrome and ischemic heart disease. Objectives: In this study, we evaluated whether coronary CTO is associated with serum levels of vitamin D and CCC. Patients and Methods: Around 216 patients with coronary CTO at coronary angiography were incorporated in this investigation. Serum 25(OH)D level and low-density lipoprotein (LDL-C), triglyceride (TG), total cholesterol, fasting blood sugar (FBS), serum creatinine, high-density lipoprotein (HDL-C), were assessed before angiography. Patients were divided into a poor coronary collateral circulation group (Rentrop grades 0-1) or good coronary collateral circulation group (Rentrop grades 2-3). Results: A total of 216 patients (mean age 61.48±9.5 years) were included in this study. Regression analysis results displayed that serum 25(OH)D level had a significant correlation with CCC according to Rentrop scoring system (P&lt;0.0001). We also found that variables such as gender (P=0.05), HDL-C (P=0.01) and serum creatinine (P=0.05) were a predictor for CCC. This model described 33% of the CCC’s variance in the study patients. Besides, in the analysis of clinical levels of vitamin D, it can be stated that the probability of having a high degree of Rentrop criterion in the patients with adequate level of vitamin D is 24.5 times higher than the patients with vitamin D deficiency (P&lt;0.001). Conclusion: The results of this study emphasize the importance of informing patients with CTO commonly associated with serum vitamin D level.

The preservation effect of coronary collateral circulation on left ventricular function in chronic total occlusion and its association with the expression of vascular endothelial growth factor A.

Patients with coronary chronic total occlusion (CTO) typically have collateralization of the distal vessel, and these collaterals can contribute to the relief of ischemia and anginal symptoms and to the preservation of ventricular function. To investigate the preservation effect of coronary collateral circulation on left ventricular (LV) function in coronary CTO, and to explore the potential mechanism behind the development of coronary collateral circulation. A total of 102 consecutive patients with coronary CTO were divided into 2 groups: the left ventricular ejection fraction (LVEF)-preserved group (LVEF ≥ 50%; n = 46) and the LVEF-decreased group (LVEF < 50%; n = 56). Clinical, angiographic and laboratory data was collected for all patients. The association between LVEF and coronary collateral circulation in coronary CTO patients was analyzed with multivariate logistic regression analysis, and the serum levels of VEGF-A and the mRNA expression levels of the VEGF-A gene were compared between different grades of coronary collateral circulation. Multivariate analysis revealed that Rentrop grades 2-3 and coexisting collateral pathways were independent predictors of LVEF preservation in coronary CTO patients. Patients with Rentrop grades 2-3 had smaller left ventricular end diastolic diameters (LVDd) and left ventricular end systolic diameters (LVSd), and they had larger LVEFs than the patients with Rentrop grades 0-1. Patients with Rentrop grades 2-3 also had higher serum levels of VEGF-A and higher mRNA expression levels of the VEGF-A gene in their peripheral blood mononuclear cells (PBMCs) than patients with Rentrop grades 0-1. Patients with coexisting collateral pathways had higher serum levels of VEGF-A and higher mRNA expression levels of the VEGF-A gene in PBMCs than patients without coexisting collateral pathways. Coronary collateral circulation is significantly associated with LVEF preservation, and VEGF-A might promote the formation of coronary collateral circulation.

Coronary collaterals in patients with ST-elevation myocardial infarction presenting late after symptom onset

The role of coronary collaterals in ST-elevation myocardial infarction (STEMI) remains controversial. So far, studies examining the effect of collaterals on outcome mainly focused on patients presenting early after symptom onset. We sought to investigate the prognostic influence of coronary collateralization in patients presenting with prolonged ischemia late after symptom onset. The study is a subanalysis of a randomized trial addressing thrombus aspiration in STEMI patients presenting between 12 and 48h after symptom onset with a follow-up period of a minimum of 4years. A total of 95 patients with a Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 or 1 prior to percutaneous coronary intervention (PCI) were included in the analysis. Of these, 62 patients (65%) had none or poor coronary collateralization according to the Rentrop classification (Rentrop grade 0 or 1) compared to 33 (35%) with well-developed collateralization (Rentrop grade 2 or 3). In comparison, patients with well-developed collateralization had a smaller area of microvascular obstruction (2.1 ± 3.8 vs. 4.5 ± 4.9% of left ventriclular mass (%LV), p = 0.03) and infarct size (27.9 ± 11.7 vs. 34.8 ± 17.2% LV, p = 0.047) on magnetic resonance imaging. Further, mortality at 4-years follow-up was lower (6% Rentrop grade 2 or 3 vs. 25% Rentrop grade 0 or 1, p = 0.02). Poor collateralization was an independent predictor of long-term mortality on multivariate Cox regression analyses in addition to cardiogenic shock and unsuccessful PCI during the index procedure. Sufficient coronary collateralization has a positive impact on microvascular obstruction, infarct size and long-term mortality in STEMI patients presenting between 12 and 48h after symptom onset.

Effect of Recruitment of Acute Coronary Collaterals on In-Hospital Mortality and on Left Ventricular Function in Patients Presenting With ST Elevation Myocardial Infarction

Recruitment of the coronary collateral circulation is frequently observed during ST elevation myocardial infarction (STEMI) and is of uncertain significance. The aim of this study was to identify and determine the predictors and prognostic implications of the presence of robust collaterals during STEMI. All patients presenting to a large tertiary centre with a STEMI undergoing percutaneous coronary intervention from 2010 to 2018 were reviewed. Patients with poor collateral recruitment were defined as those with Rentrop grade 0 or 1 collaterals, whilst patients with robust collateral recruitment were defined as Rentrop grade 2 or 3. A total of 1,625 patients were included in the study, with 1,280 (78.8%) patients having poor collateral recruitment and 345 patients (21.2%) having robust collateral recruitment. Patients with robust collaterals were younger (63.1 vs 65.1 years, p < 0.05), had a longer ischemic time (628.5 minutes vs 433.1 minutes, p < 0.0001), and more likely to have a chronic total occlusion of a noninfarct related artery (10.4% vs 5.3%, p < 0.001). The presence of robust collaterals was associated with higher rates of normal or mildly impaired left ventricular function (83.5% vs 63.2%, p < 0.0001) and lower in-hospital mortality (2.1% vs 7.6%, p < 0.0001). After correcting for left ventricular function, collateral recruitment was not an independent predictor of mortality. In conclusion, in patients presenting with STEMI, the presence of robust coronary collaterals appears to be associated with improved left ventricular function. Further research is required to identify mechanisms of collateral maturation and recruitment.

Neutrophil-To-Lymphocyte Ratio Predicts Coronary Collateral Circulation in Multivessel Coronary Artery Disease

Background: Coronary collateral circulation (CCC) is an adaptive response to chronic myocardial ischemia. Patients with coronary stenosis develop varying degrees of collateral. Levels of inflammatory cells were suggested as potential determinants of collateral development. Neutrophil to lymphocyte (N/L) ratio has been proposed as a prognostic marker to determine systemic inflammatory response and the development of CCC. Our aim was to determine the relationship between N/L ratio and development of CCC in patients with coronary artery disease (CAD) with multivessel disease.Method:A total of 151 patients with multivessel disease were included in this study. Coronary collateral grades were classified according to Rentrop collateral grades as either poorly developed CCC (Rentrop grade 0-1) or well developed CCC (Rentrop grades 2-3). Factors significant at the p≤0.25 in the bivariate models were put into multiple logistic regressions. The receiver–operating characteristic (ROC) analysis were performed to determine the cutoff value of NLR in predicting poor CCC.Result: Of the 151 CAD patients in this study, 76 patients had poorly developed CCC and 75 patients had well developed CCC. Poorly developed CCC had significantly higher N/L ratio than well developed CCC (2.25±1.189 vs. 3.03±1.527, p &lt;0.001). Logistic regression analysis showed that N/L ratio (OR0.756; CI 95% 0.587 – 0.974, p 0.031) was independent predictor of poorly developed CCC. The ROC analysis provided a cut-off value of 1.99 (AUC 0.72, sensitivity 78.9%, specificity 52%) for N/L ratio to predict poorly developed CCC.Conclusion: Higher neutrophil to lymphocyte ratio was useful in predicting poor coronary collateral circulation in stable coronary heart disease with multivessel disease. Neutrophil to lymphocyte ratio &gt;1.99 was independently associated with impairment in coronary collateralization. This value had a sensitivity of 78.9% and specificity of 52%.

The Relationship Between Circulating Neuregulin-1 and Coronary Collateral Circulation in Patients with Coronary Artery Disease.

Coronary collateral circulation (CCC) plays a crucial role in myocardial blood supply, especially for ischemic myocardium. Previous study has shown that neuregulin-1 is a prominent angiogenic factor in diabetic cardiomyopathy, whereas the relationship between neuregulin-1 and CCC has not been investigated. Thus, we aimed to investigate relationship between circulating neuregulin-1 levels and CCC in stable coronary artery disease patients.Coronary artery disease patients with a stenosis of ≥ 90% as evidenced by coronary angiography were included in our study. According to the Rentrop-Cohen classification, coronary collateral degree was graded as 1 to 4. Patients with collateral degree grade 0 or 1 were enrolled in poor CCC group, whereas patients with grade 2 or 3 were enrolled in good CCC group.Plasma neuregulin-1 level was significantly increased in good collateral group and positively related to Rentrop grade (P < 0.01). Multivariate regression analysis and ROC (receiver operating characteristic curve) revealed that plasma neuregulin-1 could predict CCC status effectively.Increased plasma neuregulin-1 level was related to better CCC in patients with coronary artery disease. Neuregulin-1 was an independent and reliable predictor for good coronary collateral development and provided a potential therapeutic strategy to reduce myocardial ischemia injury.

Blood Group Types O and Non-O Are Associated With Coronary Collateral Circulation Development

Blood group types are associated with coronary artery disease. However, data are scarce about the impact of blood group types on coronary collateral circulation. In this study, we aimed to investigate the relationship between the blood group types and coronary collateral circulation. Two hundred and twelve patients who underwent coronary angiography in our department and had a stenosis of ≥ 90% in at least one major epicardial vessel were included in our study. Collateral degree was graded according to Rentrop-Cohen classification. After grading, patients were divided into poor coronary collateral circulation (Rentrop grade 0 and 1) and good coronary collateral circulation (Rentrop 2 and 3) groups. The ABO blood type of all participants was determined. The incidence rates of O blood group type were significantly higher in the good coronary collateral group compared to the poor collateral group (37.9% vs 17.1%, P < .001). The O type blood group was an independent predictor of good coronary collateral circulation (odds ratio = 1.83, 95% confidence interval = 1.56-6.18, P = .015). Coronary collateral circulation is associated with blood group types. The O blood group predicts good coronary collateral development among patients with coronary artery disease.

Lipoprotein(a) as a marker for predicting coronary collateral circulation in patients with acute myocardial infarction.

Aim: The aim of the present study was to examine the predictive value of lipoprotein(a) (Lp[a]) levels for coronary collateral circulation (CCC) in patients with acute myocardial infarction (AMI). Method & methods: A total of 409 consecutive patients with AMI were enrolled for this study. Patients were divided into two groups according to rentrop grades assessed by coronary angiography: bad (n=277) and good CCC group (n=132). Result: Patients with bad CCC had a higher level of Lp(a) than that with good CCC (median Lp[a] 219.1 vs 122.0mg/l). The area under the receiver-operating characteristic curves of Lp(a) in predicting bad CCC was 0.647 (95% CI: 0.592-0.702) with the cut-off value of 199.0mg/l. Conclusion: Our data firstly suggested that Lp(a) might be a useful marker for CCC after AMI.

Spontaneous coronary collateral recruitment in patients with recurrent ST elevation myocardial infarction (STEMI).

The spontaneous recruitment of acute coronary collaterals in the setting of an ST elevation myocardial infarction (STEMI) is seen frequently in those patients undergoing primary percutaneous coronary intervention (pPCI) and is associated with improved clinical outcomes. However, it is unknown whether in patients who present with a recurrent STEMI, the degree of collateral recruitment remains the same as in the index procedure. We reviewed all patients presenting to our tertiary centre with a STEMI undergoing primary or rescue percutaneous coronary intervention (PCI) from July 2010 until December 2018. We identified patients who presented with a recurrent STEMI following their index procedure. We defined patients with poor collateral recruitment as Rentrop grade 0 or 1, whilst patients with robust collateral recruitment as Rentrop grade 2 or 3. Of the 1795 patients who were identified, there were 27 cases in 25 patients who presented with a repeat STEMI following their index procedure. The median time between cases was 12.8days (IQR 2.3-589.5days). Compared to the index case, there was no statistically significant difference in the degree of collateral recruitment in recurrent presentations (Z = -0.378, p = 0.70). In those patients presenting more than 6months following the index procedure, the median time between cases was 654.5days (IQR 479.5-1151.9). There was no difference in the degree of collateral recruitment in recurrent presentations (Z = 0.000, p = 1.0). Cases which had poorer collateral recruitment in recurrent presentations were less likely to be current smokers (0% vs 50%, p < 0.001) and less likely to have diabetes (0% vs 27.3%, p < 0.05) The recruitment of spontaneous coronary collaterals remains constant in recurrent STEMI presentations suggesting an innate biological process rather than merely a manifestation of alteration of haemodynamic blood flow. Further investigations to identify these processes is required.

Effect of coronary collateral circulation on the prognosis of elderly patients with acute ST-segment elevation myocardial infarction treated with underwent primary percutaneous coronary intervention.

Investigate the effect of coronary collateral circulation (CCC) on the prognosis of elderly patients with acute ST-segment elevation myocardial infarction (STEMI) and acute total occlusion (ATO) of a single epicardial coronary artery.Three hundred forty-six advanced-age patients (age ≥60 years) with STEMI and ATO who underwent primary percutaneous coronary intervention (PCI) were enrolled in this study. According to the Rentrop grades, the patients were assigned to the poor CCC group (Rentrop grade 0–1) and good CCC group (Rentrop grade 2–3).Multivariate logistic regression analysis revealed that poor coronary collateral circulation was an independent factor for Killip class ≥2 (odds ratio [OR]: –1.559; 95% confidence interval [CI]: 1.346–2.378; P = .013), the use of an intra-aortic balloon pump (IABP) (OR: –1.302; 95% CI: 0.092–0.805; P = .019), and myocardial blush grade (MBG) 3 (OR: 1.516; 95% CI: 2.148–9.655; P < .001). We completed a 12-month follow-up, during which 52 patients (15.0%) were lost to follow-up and 19 patients (5.5%) died. Univariate analysis (Kaplan–Meier and log-rank tests) suggested that poor CCC had a significant effect on all-cause mortality (P = .046), while multivariate analysis (Cox regression analysis) indicated that CCC had no statistically significant effect on all-cause mortality (P = .089) after the exclusion of other confounding factors. After excluding the influence of other confounding factors, this study showed that the mortality rate increased by 26.9% within 1 year for every 1-hour increment of time of onset. The mortality rate in patients with Killip class ≥2 was 8.287 times higher than that in patients with Killip class 0 to 1. The mortality rate in patients over 75 years was 8.25 times higher than that in patients aged 60 to 75 years. The mortality rate in patients with myocardial blush grade 3 (MBG 3) was 5.7% higher than that in patients with MBG 0–2.The conditions of CCC in the acute phase had no significant direct effect on all-cause mortality in patients, but those with good CCC had a higher rate of MBG 3 after primary PCI and a lower rate of Killip ≥2.

Determinants of coronary collateral formation in patients with acute ST-elevation myocardial infarction and total occlusion of infarct-related artery

Background: The presence or absence of collateral circulation to the infarct-related artery territory significantly impacts the infarct size and resulting left ventricular function and hence the prognosis. However, the determinants of collateral formation have been poorly understood. Materials and Methods: The present single-center observational study examined 200 patients with acute ST-elevation myocardial infarction (STEMI), irrespective of the status of thrombolysis, undergoing coronary angiogram within 48 h showing complete occlusion of infarct-related coronary artery. Results: High-grade collaterals (Rentrop Grade 2 and 3) were seen in 17% of patients (n = 34). High-grade coronary collaterals were more often seen in patients belonging to the age group of 46–70 years compared to elderly individuals >70 years of age (38.2% vs. 2.9%,P Conclusions: The finding of high-grade coronary collaterals was seen more in patients who had angina prior to STEMI. High-grade collaterals were significantly more in middle-aged individuals compared to the elderly. Diabetes mellitus and smoking status were negative predictors of high-grade collaterals.

What does one need to survive with Anomalous origin of left coronary artery from pulmonary trunk (ALCAPA) beyond infancy.

A 53-year old man presented with sustained monomorphic ventricular tachycardia which was restored with 200 joules of direct current cardioversion. Complete haemogram, liver, and kidney function tests, and serum electrolytes were within normal limit. His past history was insignificant except exertional dyspnoea NYHA class-I for last one year. Transrthoracic echocardiography revealed dilated left ventricle and atrium with severe systolic dysfunction (EF=28%). There was continous flow entering the pulmonary trunk. Origin of right coronary artery was dilated and left coronary artery was originating from main pulmonary artery suggestive of anomalous origin of left coronary artery from pulmonary trunk (ALCAPA). Coronary angiogram showed dilated and tortuous right coronary artery (RCA) with absence of a left coronary ostium in aortic sinus. During the delayed filling phase, abundant intercoronary anastomoses (Rentrop grade 3) were seen, communicating with left coronary artery which was later opacifying the main pulmonary artery thus establishing diagnosis of ALCAPA. Multidetector computed tomography angiography confirmed its diagnosis. Implantable cardioverter defibrillator was implanted. ALCAPA is a rare congenital cardiovascular anomaly which occurs 1 in 300,000 live births with rare survival to adulthood as 90% succumbs by third decade.Those with this syndrome who manages to survive beyond childhood are often incapacitated by myocardial ischemia, arrhythmias and severe ischemic cardiomyopathy. Survival beyond fourth or fifth decade with ALCAPA without surgical intervention is exceedingly rare as low pulmonary artery pressure results in coronary steal phenomenon. Rarely some remain asymptomatic until adulthood due to superdominant RCA, although they generally become symptomatic in early adulthood due to fixed myocardial ischemia and coronary steal phenomenon. In utero, as the systemic and pulmonary arterial pressures are equal, there is anterograde flow in both the left and the right coronary. In the neonatal period as the pulmonary artery pressure falls and ductus arteriosus closes, the flow in the left coronary artery reverses. The more collateral channels exist between RCA and anomalous left coronary system (ALCA), the longer the patient may survive. Another contributing factor may be the area supplied by the ALCA as the smaller the area supplied by the ALCA, the less extensive the myocardial ischemia is likely to be. In few adult cases, RCA supplies not only the posterior wall of the left ventricle but also its lateral wall. May be this reduction in the area of the myocardium supplied by the ALCA would favour survival. However, even extensive collateral circulation may not totally prevent ischemic damage though can delay it as low pulmonary artery pressure may still result in coronary steal phenomenon, which may cause sudden deaths. We believe right coronary artery may have “supernormal” flow reserve to account for his survival. Surgical correction such as direct transfer of the left coronary artery from pulmonary artery (like in arterial switch operation), Takeuchi repair (creating aorto-pulmonary window), and bypass graft when these two are not possible, it is one of the coronary anomalies not compatible to life. In our case, it was decided not to intervene surgically as risk of cardiac surgery was outweighing the benefit.

Serum Sphingosine 1 Phosphate Levels in Patients with and without Coronary Collateral Circulation.

Sphingosine 1 phosphate, an active sphingolipid metabolite, functions in both healthy and diseased cardiovascular systems. It has been reported to play a role in angiogenesis and arteriogenesis in various tissues, which are the proposed mechanisms for the development of coronary collateral circulation. To the best of our knowledge, no data exist regarding serum sphingosine 1 phosphate levels and the presence of coronary collateral circulation in the literature. Thus this study aimed to investigate serum sphingosine 1 phosphate levels in patients with and without coronary collateral circulation. A total of 140 patients were included (70 with coronary collateral circulation and 70 with normal coronary arteries and stable coronary artery disease without collaterals). Rentrop collateral grade and the number of coronary arteries with collateral circulation were recorded. Serum sphingosine 1 phosphate levels were higher in the collateral group than in the control group [186.6 (142.3-243.5) μg/l vs. 128.5 (105.0-161.6) μg/l, p < 0.001]. Multivariate logistic regression analysis revealed that the presence of multivessel disease, high serum sphingosine 1 phosphate levels and previous history of P2Y12 use were independent predictors of coronary collateral circulation. Median sphingosine 1 phosphate levels in different Rentrop grades in the collateral group were similar, and there was no significant difference in median serum sphingosine 1 phosphate level with a higher number of coronary arteries with collateral circulation. Our findings demonstrated higher levels of sphingosine 1 phosphate in the patients with coronary collateral circulation.

Triglyceride to HDL-cholesterol ratio as an independent risk factor for the poor development of coronary collateral circulation in elderly patients with ST-segment elevation myocardial infarction and acute total occlusion.

To determine the prognostic role of triglyceride (TG) to high-density lipoprotein cholesterol (HDL) ratio for poorly developed coronary collateral circulation (CCC) in elderly patients with ST-segment elevation myocardial infarction (STEMI) and acute total occlusion (ATO).As a retrospective case–control study, elderly patients (age ≥60 years) with both STEMI and ATO (n = 346) were classified as having either poorly- or well-developed CCC (Rentrop grades 0–1 and 2–3, respectively). The ratio of TG/HDL was calculated according to the detected levels of TG and HDL. The difference of TG/HDL ratio in those 2 groups was compared by Student t test, and multivariate logistic regression analysis indicating occurrence of poorly developed CCC was performed. Receiver operator characteristic curve (ROC) analysis of TG/HDL ratio which determine the optimal cut-off value of TG/HDL ratio was applied.The TG/HDL ratio was significantly higher in patients with poorly developed CCC than in those with well-developed CCC (2.88 ± 2.52 vs 1.81 ± 1.18, P < .001). In multivariate logistic regression analysis, higher TG/HDL ratio (OR 1.789, 95% CI 1 . 346–2.378, P < .001) and the presence of left circumflex branch of coronary artery (LCX) occlusion (OR6.235, 95% CI 2.220–17.510, P = .001) were emerged as independent positive predictors of poor development of CCC, whereas presence of right coronary artery (RCA) occlusion (OR 0.474, 95% CI 0.265–0.850, P = .002) and onset time (OR 0.693, 95% CI 0.620–0.775, P < .001) were found as negative indicators. The optimal cut-off value of TG/HDL ratio was found as 1.58 in ROC analysis, which yielded an area under the curve value of 0.716 (95% CI 0.654–0.778, P < .001) and demonstrated a sensitivity of 80.9% and a specificity of 59.3% for prediction of poorly developed CCC.TG/HDL ratio is an independent risk factor for predicting poor development of CCC in elderly patients with STEMI and ATO.

The relationship of plasma miR-503 and coronary collateral circulation in patients with coronary artery disease

ObjectiveAlthough angiogenesis plays an important role in coronary collateral circulation (CCC) formation and there are many determinants of coronary angiogenesis, they cannot fully explain the mechanism of CCC formation or as potent biomarker for CCC status. Therefore, there is of great clinical significance to identify the novel molecules associated with CCC. Previously, miR-503 exerts anti-angiogenesis effect via inhibition of VEGF-A and its expression is associated with many angiogenesis-related factors. Thus, we aimed to investigate the relationship of plasma miR-503 with CCC formation as well as its predictive power for CCC status in patients with coronary artery disease. MethodsAmong patients who underwent coronary angiography with coronary artery disease and a stenosis of ≥90% were included in our study. Collateral degree was graded according to Rentrop Cohen classification. The patients were divided to good CCC group (grade 2 or 3) and poor CCC group (grade 0 or 1) according to Rentrop grade. We investigated the plasma levels of miR-503 and VEGF-A by ELISA or q RT-PCR, respectively. In addition, we assayed the correlations of plasma miR-503 with VEGF-A or Rentrop grade using the spearman correlation test and its predictive power by receiver operating characteristic (ROC) and binary logistical regression analysis. ResultsOur data showed that plasma VEGF-A was significantly higher in good CCC group than that in poor group. Plasma miR-503 was lower in CAD patients with good CCC or poor CCC compared with control subjects and lowest in good CCC group. In addition, miR-503 negatively correlated with VEGF-A and Rentrop grade, respectively. Moreover, miR-503 displayed more potent predictive power for CCC status than VEGF-A, but its sensitivity and specificity for CCC status were only 72.4 or 60.9%, respectively. ConclusionsLower plasma miR-503 level was related to better CCC formation, accompanied by up-regulation of VEGF-A. In addition, miR-503 displayed potent predictive power for CCC status, but its sensitivity and specificity were not high enough, indicating that miR-503 might be as an additional prognosis biomarker for CCC.