Routine Coronary Angiography Research Articles

Reference diameter and characteristics of the distal radial artery based on ultrasonographic assessment.

Background/AimsWhile distal radial artery (DRA) access is increasingly being used for diagnostic coronary angiography, limited information is available regarding DRA size. We aimed to determine the DRA reference diameters of Korean patients and identify the predictors of DRA diameter < 2.3 mm.MethodsThe outer bilateral DRA diameters were assessed using a linear ultrasound probe in 1,162 consecutive patients who underwent transthoracic echocardiography. The DRA diameter was measured by the perpendicular angle in the dorsum of the hand, and the average values were compared by sex. DRA diameter < 2.3 mm was defined as unsuitable for routine diagnostic coronary angiography using a 5 Fr introducer sheath.ResultsThe mean DRA diameters were 2.31 ± 0.43 mm (right) and 2.35 ± 0.45 mm (left). The DRA was smaller in women than men (right: 2.15 ± 0.38 mm vs. 2.43 ± 0.44 mm, p < 0.001; left: 2.18 ± 0.39 mm vs. 2.47 ± 0.45 mm, p < 0.001). The DRA diameter was approximately 20% smaller than the radial artery diameter. A total of 630 (54.2%) and 574 (49.4%) patients had DRA diameter < 2.3 mm in the right and left hands, respectively. Female sex, low body mass index (BMI), and low body surface area (BSA) were significant predictors of DRA diameter < 2.3 mm.ConclusionsWe provided reference DRA diameters for Korean patients. Approximately 50% of the studied patients had DRA diameter < 2.3 mm. Female sex, low BMI, and low BSA remained significant predictors of DRA diameter < 2.3 mm.

Feasibility of distal transradial access for coronary angiography and percutaneous coronary intervention: an observational and prospective study in a Latin-American Centre

Background Distal transradial access (dTRA) as a refinement of the conventional transradial access (TRA) has advantages in terms of risk of radial artery occlusion (RAO). In order to evaluate the real-world feasibility and safety of dTRA as the default access site for routine coronary angiography (CAG) and percutaneous coronary intervention (PCI) in a Latin-American centre, this prospective observational registry was conducted. Methods Consecutive patients with a prior assessment for CAG and/or PCI were enrolled in this single-centre prospective registry from October 2018 to March 2019. The primary endpoints were the success rate of CAG and PCI. Secondary endpoints included the success rate of puncture of the distal radial artery, complications at the puncture site and puncture time. Results The success rates of CAG and PCI were 100% (155/155) and 97% (69/71), respectively. Puncture time and fluoroscopic time were 52 ± 19 seconds and 16.3 ± 35.4 minutes, respectively. Haemostasis time was 142 ± 45 min. A total of 19 (12.5%) puncture site complications occurred, including 18 (11.6%) minor haematomas and one (0.6%) arterial perforation, in which the artery was patent at the one-month follow-up. Five patients complained of left thumb numbness at a one-month follow-up. No distal radial artery occlusion, pseudoaneurysm, or arteriovenous fistula occurred. Conclusions The success and complication rates of ldTRA support the feasibility and safety of this procedure using the appropriate materials in previously selected patients.

Prevalence and Angiographic Characteristics of Coronary Ectasia in Adults: A Retrospective Study in a Tertiary Cardiac Centre of Nepal

Background and Aims: Coronary artery Ectasia is a relatively uncommon problem encountered during coronary angiography with the prevalence ranging from 1.2% to 4.9%. Coronary artery Ectasia and aneurysm both denote an arterial segment the dimension of which is larger than normal arterial segment, both have diameter greater than 1.5 times of normal. The length of dilate segment is greater than its width in Ectasia while less in aneurysm. There is an overlap between risk factors of coronary artery Ectasia and atherosclerosis. The clinical relevance in general, and the appropriate medical management of coronary artery Ectasia specifically, is ill defined, as no randomised prospective studies exists. The study was conducted with an aim to estimate the prevalence of coronary artery Ectasia and aneurysm as well as to study the angiographic characteristics of coronary artery Ectasia and aneurysm undergoing in adult patients’ coronary angiography in tertiary cardiac centre of Nepal.&#x0D; Methods: A retrospective study was conducted in Shahid Gangalal national heart centre, Nepal analysing the angiographic records from cardiac catheterization lab. A total of 447 patients who underwent coronary angiography and meet the inclusion criteria from July, 2019 to December, 2019 were included in the study. Any angiographic evidence of coronary Ectasia and aneurysm, coronary artery involved and it’s extent were analysed and recorded in the proforma. In addition, any associated evidence of coronary artery disease was analysed and recorded in the proforma.&#x0D; Results: The findings of our study revealed the overall prevalence of coronary artery Ectasia (CAE) and Coronary artery Aneurysm as 2.6%. Coronary ectasia was most prevalent in left anterior descending (LAD) artery (83.3%), followed by RCA and left main in 66.7% and 16.7% respectively. In contrast, Coronary aneurysm was mostly seen in RCA (66.7%) followed by LCX (33.3%). In addition, the study also showed the frequency of localised Ectasia as 50 % and the association of significant coronary artery disease with coronary artery Ectasia in 66.67%.&#x0D; Conclusion: CAE and aneurysm are rare phenomenon encountered in routine coronary angiography, with LAD and RCA being most commonly involved in CAE and coronary aneurysm respectively. CAE and aneurysm have significant association with the coronary artery disease.

Routine Coronary Angiography in Adults Undergoing Percutaneous Atrial Septal Defect Closure: Implications for Practice Guidelines.

Secundum atrial septal defect (ASD) is a common adult congenital heart lesion for which percutaneous closure offers treatment in patients with suitable anatomy. We sought to determine the outcomes of coronary angiography in a population of adults >40 years of age who were undergoing percutaneous ASD closure. Patients >40 years of age who underwent ASD closure between 2009-2016 were included in this retrospective chart review. Coronary angiograms were reviewed by 2 independent reviewers to evaluate the presence and degree of coronary artery disease (CAD) and the resulting clinical sequelae. A total of 398 patients underwent ASD closure, and 300 had coronary angiography at the time of closure. Mild CAD (10%-39% vessel stenosis) was found in 33 patients (11.0%), moderate CAD (40%-69% vessel stenosis) in 23 patients (7.7%), and severe CAD (≥70% vessel stenosis) in 25 patients (8.3%). Of the 48 patients with moderate to severe CAD, 24 had proximal vessel disease and 21 had multivessel disease. Four patients (8.3%) with moderate to severe CAD subsequently underwent percutaneous interventions, 16 patients (33.3%) had medication changes, 16 patients (33.3%) had perfusion testing followed by medication changes, and 12 patients (25%) had no changes in their medical management. Given the prevalence of CAD in this population, routine coronary angiography at the time of ASD closure should be reserved for patients with an unfavorable cardiovascular risk profile, who have a higher likelihood of CAD. While patients with ASDs suffer from chest pain and dyspnea both before and after percutaneous closure, few have established CAD.

Uma rara combinação congênita

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

Feasibility of Distal Radial Access for Coronary Angiography and Percutaneous Coronary Intervention: A Single Center Experience

Objective: Asymptomatic radial artery occlusion remains the most common complication in transradial coronary interventional procedure. To prevent radial artery occlusion, distal transradial access (dTRA) has been suggested recently. In this article, we aim to describe our experience and to assess feasibility and safety of this new access site for routine coronary angiography (CAG) and percutaneous coronary intervention (PCI). Methods: We retrospective analyzed 1,063 consecutive patients who were assigned to undergo CAG or procedural PCI through dTRA between 1 January 2018 and 31 December 2019 at Affiliated Zhongshan Hospital of Dalian University. The size of radial sheath used was 5 or 6 French. The sheath was removed at procedure termination, and hemostasis was obtained by compression bandage with gauze. The success rate of dTRA access defined by successful radial artery cannulation on the first dTRA side attempted, the cause of access failure, the hemostasis duration, the incidence of post-catheterization radial artery occlusion, and the other access-related complications including hematoma of forearm and thumb numbness were assessed. Results: Radial artery cannulation via dTRA was successful in 953 of 1,063 patients with a success rate of 89.7%. Mean age of successful cases was 64.6 ± 11.2 years (26–94 years) with 339 (35.6%) women. A total of 363 (38.1%) cases were PCI. Among them, 95 cases (10%) underwent urgent PCI, including primary PCI in 64 patients with ST-segment elevation myocardial infarction and immediate PCI (<2 h from hospital admission) in 31 patients with very high-risk non-ST-segment elevation acute coronary syndrome. A total of 269 (28.2%) cases were via left dTRA. The 6 French sheath was used in 602 (63.2%) cases. Hemostasis was obtained within 2 h in 853 (89.5%) patients. There were 110 (10.3%) procedural failures: 59 (5.6%) cases of artery puncture failure, 49 (4.9%) cases of guide wire insertion failure, and 2 (0.2%) cases of sheath insertion failure. Complications potentially related to distal radial access included radial artery occlusion at the access site (13 cases, 1.4%), forearm radial artery occlusion (4 cases, 0.4%), hematoma of forearm (5 cases, 0.5%), and transient thumb numbness (2 cases, 0.2%). Conclusion: dTRA is a feasible and safe access and can be used as a rational alternative to traditional radial access for routine coronary interventional procedure.

CT-derived characterization of pericoronary, paracardial and epicardial adipose tissue and its association with myocardial ischemia as assessed by adenosine stress CMR perfusion imaging

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): German Heart Foundation e.V. Introduction Increased attenuation of pericoronary adipose tissue (PCAT) around the right coronary artery (RCA) is a new imaging biomarker to detect coronary inflammation derived from routine coronary CT angiography (CTA) and has been shown to be associated with cardiac mortality. Increased volume of epicardial adipose tissue (EAT) has been reported be associated with myocardial ischemia. Purpose We aimed to investigate a potential association between CTA-derived PCAT measures and myocardial ischemia as assessed by adenosine stress CMR perfusion imaging. Methods In this single-centre study 109 stable individuals (mean age of 62 ± 11 years, 77% males) with coronary artery disease underwent CTA followed by adenosine stress CMR perfusion imaging to detect myocardial ischemia. PCAT CT attenuation (HU) and PCAT volume (cm3) was measured around the RCA (10 to 50 mm from RCA ostium), the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) using semi-automated software. Per patient PCAT CT attenuation was calculated as followed: (PCAT attenuation of RCA + LAD + LCX)/3). Non-contrast CT data sets were used for coronary calcium scoring and the quantification of EAT (located between the myocardial surface and the pericardium) and paracardial adipose tissue (PAT; intrathoracic and outside of the pericardium). Results Between patients with evidence of significant myocardial ischemia as assessed by adenosine stress CMR perfusion imaging (n = 35) and patients without myocardial ischemia (n = 74) there was no significant difference in the CT attenuation of RCA (-85.3 HU vs. -85.7 HU, p = 0.87), LAD (-84.8 HU vs. -85.7 HU, p = 0.66) and LCX (-82.8 HU vs. -83.2 HU, p = 0.79) as well as in the per patient PCAT CT attenuation (-84.2 HU vs. -84.9 HU, p = 0.76). Neither did patients with myocardial ischemia within the RCA territory show increased RCA PCAT CT attenuation (-87.7 HU vs. -85.3 HU, p = 0.40); nor was such a relationship found for the territory of the LAD (-80.6 HU vs. 85.8 HU, p = 0.11) or LCX (-83.1 HU vs. -83.0 HU, p = 0.99). The CT attenuation of EAT (-77.9 vs. -78.7 HU, p = 0.65) and PAT (-89.9 HU vs. -90.0 HU, p = 0.93) did not differ between patients with myocardial ischemia compared to patients without myocardial ischemia. Between patients with myocardial ischemia and patients without myocardial ischemia there was no significant difference in the volumes of EAT (118.1 cm3 vs. 110.6 cm3, p = 0.55), PAT (279.5 cm3 vs. 240.9 cm3, p = 0.20) and the per patient PCAT volume (1021.9 mm3 vs. 1015.5 mm3, p = 0.90). In logistic regression analysis the volume and CT attenuation of the different intrathoracic fat compartments PCAT, EAT and PAT were not independently associated with the presence of myocardial ischemia (n.s.). Conclusions In this single-centre study CTA-derived quantified CT attenuation and volume of PCAT, EAT and PAT were not associated with myocardial ischemia as assessed by adenosine stress CMR perfusion imaging.

CT-derived characterization of pericoronary, paracardial and epicardial adipose tissue and its association with myocardial ischemia as assessed by adenosine stress CMR perfusion imaging

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Kaltenbach scholarship of the german heart foundation Background Increased attenuation of pericoronary adipose tissue (PCAT) around the right coronary artery (RCA) is a new imaging biomarker to detect coronary inflammation derived from routine coronary CT angiography (CTA) and has been shown to be associated with cardiac mortality. Increased volume of epicardial adipose tissue (EAT) has been reported be associated with myocardial ischemia. Purpose We aimed to investigate for the first time a potential association between CTA-derived PCAT measures and myocardial ischemia as assessed by adenosine stress CMR perfusion imaging. Methods In this single-centre study 109 stable individuals (mean age of 62 ± 11 years, 77% males) with coronary artery disease underwent CTA followed by adenosine stress CMR perfusion imaging to detect myocardial ischemia. PCAT CT attenuation (HU) and PCAT volume (cm³) was measured around the RCA (10 to 50 mm from RCA ostium), the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) using semi-automated software. Per patient PCAT CT attenuation was calculated as followed: (PCAT attenuation of RCA + LAD + LCX)/3). Non-contrast CT data sets were used for coronary calcium scoring and the quantification of EAT (located between the myocardial surface and the pericardium) and paracardial adipose tissue (PAT; intrathoracic and outside of the pericardium). Results Between patients with evidence of significant myocardial ischemia as assessed by adenosine stress CMR (n = 35) and patients without myocardial ischemia (n = 74) there was no significant difference in the PCAT CT attenuation of RCA (-85.3 vs. -85.7 HU, p = 0.87), LAD (-84.8 vs. -85.7 HU, p = 0.66) and LCX (-82.8 vs. -83.2 HU, p = 0.79) as well as in the per patient PCAT CT attenuation (-84.2 vs. -84.9 HU, p = 0.76). Neither did patients with myocardial ischemia within the RCA territory show increased RCA PCAT CT attenuation (-87.7 vs. -85.3 HU, p = 0.40); nor was such a relationship found for the territory of the LAD (-80.6 vs. 85.8 HU, p = 0.11) or LCX (-83.1 vs. -83.0 HU, p = 0.99). The CT attenuation of EAT (-77.9 vs. -78.7 HU, p = 0.65) and PAT (-89.9 vs. -90.0 HU, p = 0.93) did not differ significantly between patients with myocardial ischemia compared to patients without myocardial ischemia. Between patients with myocardial ischemia and patients without myocardial ischemia there was no significant difference in the volumes of EAT (118.1 vs. 110.6 cm³, p = 0.55), PAT (279.5 vs. 240.9 cm³, p = 0.20) and the per patient PCAT volume (1021.9 vs. 1015.5 cm³, p = 0.90). In logistic regression analysis the volume and CT attenuation of the different intrathoracic fat compartments PCAT, EAT and PAT were not independently associated with the presence of myocardial ischemia (n.s.). Conclusions In this single-centre study CTA-derived quantified CT attenuation and volume of PCAT, EAT and PAT were not associated with myocardial ischemia as assessed by adenosine stress CMR perfusion imaging.

Long-term outcomes of peripheral arterial disease patients with significant coronary artery disease undergoing percutaneous coronary intervention.

Patients with peripheral arterial disease (PAD) have known to a high risk of cardiac mortality. However, the effectiveness of the routine evaluation of coronary arteries such as routine coronary angiography (CAG) in PAD patients receiving percutaneous transluminal angioplasty (PTA) is unclear. A total of 765 consecutive PAD patients underwent successful PTA and 674 patients (88.1%) underwent routine CAG. Coronary artery disease (CAD) was defined as angiographic stenosis ≥70%. Patients were divided into three groups; 1) routine CAG and a presence of CAD (n = 413 patients), 2) routine CAG and no CAD group (n = 261 patients), and 3) no CAG group (n = 91 patients). To adjust for any potential confounders that could cause bias, multivariable Cox-proportional hazards regression and propensity score matching (PSM) analysis was performed. Clinical outcomes were evaluated by Kaplan-Meier curved analysis at 5-year follow-up. In this study, the 5-year survival rate of patients with PAD who underwent PTA was 88.5%. Survival rates were similar among the CAD group, the no CAD group, and the no CAG group, respectively (87.7% vs. 90.4% vs. 86.8% P = 0.241). After PSM analysis between the CAD group and the no CAD group, during the 5-year clinical follow-up, there were no differences in the incidence of death, myocardial infarction, strokes, peripheral revascularization, or target extremity surgeries between the two groups except for repeat PCI, which was higher in the CAD group than the non-CAD group (9.3% vs. 0.8%, P<0.001). PAD patients with CAD were expected to have very poor long-term survival, but they are shown no different long-term prognosis such as mortality compared to PAD patients without CAD. These PAD patients with CAD had received PCI and/or optimal medication treatment after the CAG. Therefore a strategy of routine CAG and subsequent PCI, if required, appears to be a reasonable strategy for mortality risk reduction of PAD patients. Our results highlight the importance for evaluation for CAD in patients with PAD.

Kidney Transplant List Status and Outcomes in the ISCHEMIA-CKD Trial

BackgroundPatients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing. ObjectivesIn this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches–Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy. MethodsIn the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed. ResultsCompared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54–1.54) and 1.03 (95% CI: 0.78–1.37) for those listed and not listed, respectively (pinteraction= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55–1.46) in listed and 1.17 (95% CI: 0.89–1.53) in those not listed (pinteraction = 0.35). ConclusionsIn ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360)

High rate of critical coronary stenosis in comatose patients with Non-ST-elevation out-of-hospital cardiac arrest (NSTE-OHCA) undergoing therapeutic hypothermia-Experience from the HAnnover COoling REgistry (HACORE).

Myocardial infarction is the most frequent cause for out-of-hospital cardiac arrest (OHCA) in adults. Patients with ST-segment elevations (STE) following return of spontaneous circulation (ROSC) are regularly admitted to the catheterisation laboratory for urgent coronary angiography. Whether patients without obvious STE (NSTE) should receive coronary angiography as part of a standardised diagnostic work-up following OHCA is still debated. We analysed a cohort of 517 subsequent OHCA patients admitted at our institution who received a standardised diagnostic work-up including coronary angiography and therapeutic hypothermia. Patients were 63±14 years old, 76% were male. Overall, 180 (35%) had ST-elevation in the post-ROSC ECG, 317 (61%) had shockable rhythm (ventricular fibrillation or tachycardia) at first ECG. ROSC was achieved after 26±21 minutes. Critical coronary stenosis requiring PCI was present in 83% of shockable and 87% of non-shockable STE-OHCA and in 48% of shockable and 22% of non-shockable NSTE-OHCA patients. In-hospital survival was 61% in shockable and 55% in non-shockable STE-OHCA and 60% in shockable and 28% in non-shockable NSTE-OHCA. Standardised admission diagnostics in OHCA patients undergoing therapeutic hypothermia with a strict admission protocol incorporating ECG and coronary catheterisation shows a high rate of relevant coronary stenosis in STE-OHCA irrespective of the initial rhythm and in NSTE-OHCA with initial shockable rhythm. Based on the unfavourable outcome and low PCI rate observed in NSTE-OHCA patients with a primary non-shockable ECG rhythm it might be reasonable to restrict routine early coronary angiography to patients with primary shockable rhythms and/or ST-segment elevations after ROSC.

Association of changes of pulse wave velocity and augmentation index after isometric handgrip exercise with coronary lesion extent and revascularization

BackgroundArterial stiffness is associated with myocardial ischemia and incident coronary artery disease (CAD), and indexes of arterial stiffness are usually increased in patients with CAD. However, these indexes are often increased in elderly without CAD. Arterial stiffness in patients with CAD may become more evident after isometric handgrip exercise which increases systolic pressure and ventricular afterload. We investigated the association of the change of stiffness indexes after isometric handgrip exercise with the lesion extent of CAD and the necessity for coronary revascularization.MethodsPatients who were scheduled a routine coronary angiography via a femoral artery were enrolled. Arterial waveforms were traced at aortic root and external iliac artery using coronary catheters at baseline and 3 min after handgrip exercise. Augmentation index (AIx) was measured on the recorded aortic pressure waveform, and pulse wave velocity (PWV) was calculated using the ECG-gated time difference of the upstroke of arterial waveforms and distance between aortic root and external iliac artery.ResultsTotal 37 patients were evaluated. Both PWV and AIx increased after handgrip exercise. ΔPWV was significantly correlated with ΔAIx (r = 0.344, P = 0.037). Patients were divided into higher and lower ΔPWV or ΔAIx groups based on the median values of 0.4 m/sec and 3.3%, respectively. Patients with higher PWV had more 2- or 3-vessel CAD (69% vs. 27%, P = 0.034), and underwent percutaneous coronary intervention (PCI) more frequently (84% vs. 50%, P = 0.038), but higher ΔAIx was not associated with either the lesion extent or PCI. Area under curve (AUC) of ΔPWV in association with PCI by C-statistics was 0.70 (95% confidence interval [CI] 0.51–0.88; P = 0.056). In multiple logistic regression analysis, ΔPWV was significantly associated with PCI (odds ratio 7.78; 95% CI 1.26–48.02; P = 0.027).ConclusionsHigher ΔPWV after isometric handgrip exercise was associated with the lesion extent of CAD and the necessity for coronary revascularization, but higher ΔAIx was not.

Contemporary management of calcified coronary lesions

### Learning objectives Management of patients with calcified coronary lesions represents one of the last unmet clinical needs in interventional cardiology. The age of patients referred for invasive coronary angiography...

Primary aldosteronism and coronary-pulmonary artery fistula: coincidence or causal link? A case report and literature review

Background: Primary aldosteronism (PA) is the most frequent form of potentially reversible hypertension and coronary-pulmonary fistulas are increasingly recognized during routine coronary angiography or multidetector computed tomography for analysis of chest pain in hypertensive patients. Aldosterone hypersecretion has been associated with endothelial proliferation and pathological remodeling of the heart and arteries, though coronary artery fistulas have never been reported in patients with PA. Case presentation: The authors report the first case of PA with dilated cardiomyopathy unusually associated with electrocardiographic changes after normalization of hypokalemia and with the finding of a coronary-pulmonary fistula during coronary angiography. The clinical presentation and our diagnosis and treatment decision-making in the COVID-19 era are discussed below. Conclusions: Our case suggests a potential link between hypertensive patients with coronary artery fistulas and PA.

Echocardiography Surveillance of Rejection after Heart Transplant without Endomyocardial Biopsy

Purpose Surveillance for acute rejection (AR) and cardiac allograft vasculopathy ( CAV) is essential for graft and patient survival. CAV can arise and progress without symptoms and subclinical AR can facilitate CAV .Standard surveillance of AR and CAV is based on routine endomyocardial biopsies (EMBs) and coronary angiographies (CA) at predefined intervals , 9 to 13 times during first post transplant year , there after 3-4 biopsy annually . These invasive screening tests are distressing ,costly and not without complications , yet they cannot identify all sub-clinical ARs . We adopted Biospy free Echocardiography surveillance for detection and treatment of Rejection . Methods From June 2016 till August 2020 , 12 heart transplant recipients,7 male and 5 female , were followed by Echocardiography with Doppler Tissue / strain imaging every 3 months or earlier if indicated. Routine Complete Blood Count , Renal &Liver Function test, Cyclosporine or Tacrolimus level also done .Eleven recipients are free of any rejection.Total Echo-surveillance follow up in study is > 510 months. Results Doppler tissue-imaging (DTI) and strain-imaging for myocardial wall motion and deformation analysis, allowed quantification of minor myocardial dysfunction for early detection of subclinical AR and CAV. Two patients had mild rejection Grade IIB were treated by increasing dose of steroid and raising level of Calcineurine inhibitor. One recipient found to have acute rejection on Echocardiography ,EMB, proved grade III rejection ,treated with Methyl prednisolone, Anti-thymic antibody Conclusion DTI and strain-imaging is an important tool enabling more efficient AR monitoring with fewer EMBs instead of routine EMB-screenings. Myocardial velocity and deformation imaging is also allows early detection of myocardial dysfunction induced by CAV, prognostic evaluation of CAV and timing of CAs aimed to reduce the number of routine CA-screenings. Donor specific antibody with protocol Echocardiography or same in symptomatic patients can yield good surveillance without endomyocardial biopsy.

Is Donor-Derived Cell Free DNA a Useful Biomarker of Cardiac Allograft Vasculopathy? (FreeDNA-CAV Study)

<h3>Purpose</h3> To evaluate the performance of Donor-derived Cell Free DNA (ddcf-DNA) as a biomarker of cardiac allograft vasculopathy (CAV) in a cohort of heart transplant (HT) recipients undergoing routine coronary angiography. <h3>Methods</h3> We prospectively obtained ddcf-DNA levels in all patients who underwent routine coronary angiography > 1 year after HT in our center between Jan 2019 and Sept 2020. Patients with concomitant acute rejection (n=10), circulating HLA-antibodies (n=1) or multiorgan transplant (n=8) were excluded. Ddcf-DNA levels were correlated with CAV degree (ISHLT 2010 classification). <h3>Results</h3> We included 82 HT recipients, median age 56 years (IQR 49.3-66), 68% men, a median of 10 years (IQR 4.2-17.7) after transplant. Coronary angiogram revealed CAV0 in 68%, CAV1 in 13%, CAV2 in 5% and CAV3 in 13%. Median ddcf-DNA values in each group are shown in Figure 1A. Ddcf-DNA levels did not differ significantly between patients with and without CAV (Table 1 and Figure 1B). No significant differences were found between patients with "stable CAV" (no new significant coronary lesions since previous angiogram, n=67) and "progressive CAV" (those with new coronary stenosis, n=15), median values were 0.8% (IQR 0.26-2.0) and 0.87% (IQR 0.12-4.2) respectively, p=0.635 (Figure 1C). No correlation was found between ddcf-DNA and troponin I (ρ=0.086, p=0.568) or NTproBNP levels (ρ=-0.137, p=0.238). <h3>Conclusion</h3> In this preliminary experience, ddcf-DNA level did not seem to correlate with CAV presence, severity or progression. We hope that ongoing recruiting will help to establish a definitive conclusion in this topic.

The Influence of Obesity on Perioperative Course in High-Risk Patients with Coronary Artery Disease in Cardiac Surgery

The aim. To analyze the influence of obesity on the perioperative course in high-risk patients with coronary artery disease (CAD) in cardiac surgery.&#x0D; Material and methods. Retrospective analysis of 354 randomly selected high-risk patients with CAD (ES II &gt; 5%) who underwent surgical intervention and were discharged from the Institute in the period from 2009 to 2019. All the patients underwent routine clinical tests, ECG, echocardiography, coronary angiography and surgical revascularization of the myocardium with correction of concomitant cardiac pathology. Among the patients of the experimental group, 194 (54.8%) had CAD, 132 (37.2%) had postinfarction left ventricular aneurysm, 12 (3.3%) suffered from ischemic mitral regurgitation, 16 (4.5%) patients had CAD and aortic valve disease.&#x0D; Results. Among high-risk patients with CAD, 287 (81.07%) had BMI &gt; 25 kg/m2. Carbohydrate metabolism disorders were found in 208 (72.4%) overweight patients. Type 2 diabetes mellitus (DM) was diagnosed in 78 (27.1%) patients, glucose intolerance was found in 130 (45.2%) cases. Risk stratification according to the ES II scale showed maximum risk (9.8%) in patients with normal body weight and the lowest risk (5.23%) in those with grade III obesity: however, the scale does not take into account anthropometric data. With the increase in body weight, the average number of grafts decreased (3.1 at a BMI of 25-35 kg/m2, 2.6 at a BMI &gt; 40 kg/m2) and the use of internal thoracic arteries increased: 53.7% in patients with normal weight, 66.6% in those with grade III obesity. The level of blood transfusions was the highest (55.2%) in patients with normal weight, and in those with grade III obesity no blood transfusions were performed. Postoperative atrial fibrillation occurred in 14 (20.8%) patients with BMI up to 25 kg/m2, in 30 (28.03%) with BMI 30-29.9 kg/m2 and in 8 (34.7%) patients with grade II obesity. Regardless of body weight, there was a trend towards increase in glucose levels on the first postoperative day with subnormalization until discharge. Acute kidney injury was detected in 3 (4.4%) patients with normal weight, 3 (1.94%) overweight patients, 3 (2.8%) patients with grade I obesity and 1 (33.3%) patient with morbid obesity.&#x0D; Conclusions. Timely preventive measures can help to avoid serious complications even in high-risk patients with obesity. Despite the fact that overweight patients have more severe perioperative period, experience of our Institute allows to operate and treat high-risk patients successfully regardless of their body weight.

Pharmacoinvasive Strategy Versus Lysis and Risk Stratification Strategy in Treatment of Stemi Patients

Stemi is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic (ECG) ST elevation and subsequent release of biomarkers of myocardial necrosis.Was to detect efficacy and predictors of outcomes of pharmacoinvasive treatment strategy in STEMI patients over reperfusion with thrombolysis only in areas with non-PCI capable centers as in most of hospitals in middle east. A time limited prospective interventional study started in November 2016 till November 2018. Patients divided into two groups, first group 300 patients treated with Lysis full dose TNK followed by risk stratification, the other 300 will go through pharmacoinvasive strategy as stream study by doing routine coronary angiography 3 to 24 hours after successful lysis, if lysis failed in both groups’ patient will go directly to rescue PCI. Successful lysis is defined as > 50% regression of ST segment elevation with pain relief. Lysis associated with more myocardial damage, more Troponin release and less preservation of myocardial contractility function measured by Echo by EF. Pharmacoinvasive strategy significantly reduce risk of reinfarction, need for CABG, PCI, arrhythmia, preservation of EF and at least is as effective as 1ry PCI.

Status of coronary disease and results from early endovascular aneurysm repair after preventive percutaneous coronary revascularization.

The incidence of coronary artery disease (CAD) is high in patients with an aortic aneurysm but preoperative routine coronary angiography and preventive coronary revascularization are not recommended to reduce cardiac events in patients with severe CAD. This study evaluated the safeness and efficacy of preventive percutaneous coronary intervention (PCI) in patients with severe CAD scheduled for endovascular aneurysm repair (EVAR). All patients with descending thoracic aneurysm (DTA) or abdominal aortic aneurysm (AAA) scheduled for EVAR underwent preliminary coronary angiography. Based on coronary angiography results, 917 patients (40.7%) had significant CAD and were treated by percutaneous coronary intervention (PCI; CAD group) and 1337 patients (59.3%) were without or with mild/moderate CAD and were considered as controls (no-CAD group). To evaluate the safeness and efficacy of preventive PCI in patients with severe CAD undergoing EVAR, groups were compared for hospital and 12-monthcardiac adverse events. CAD was present in 1210 patients (53.6%): significant in 917 patients (38%) and mild to moderate in 293 patients (5.3%). Hospital and 12-monthcardiac events occurred in 15 (1.6%) and 13 (1.4%) CAD group patients and in 9 (0.7%) and 8 (0.4%) no-CAD group patients (p = .05 and p = .08), respectively. Hospital and 12-monthcardiac deaths occurred in 3 (0.3%) and 2 (0.2%) CAD group patients and in 3 (0.2%) and 2 (0.2%) no-CAD group patients (p = .9 and p = .9), respectively. The strategy to treat severe CAD preoperatively by PCI and early subsequent EVAR brings a similar outcome to that in patients without or with mild/moderate CAD.

Invasive Assessment of INOCA: Safety and Clinical Utility in an Australian Cohort

Microvascular and/or vasospastic angina are relevant causes of ischaemia in patients without obstructive CAD (INOCA). These may be overlooked during routine coronary angiography. Local prevalence data in NSW Australia is not known. Our aim was to evaluate prevalence of INOCA endotypes and safety of an Interventional Diagnostic Procedure (IDP) after angiography.