Severe Multivessel Coronary Artery Research Articles

Abstract 16128: The Winslow Pathway and Internal Mammary Artery Harvesting in Patients With Aortoiliac Occlusive Disease

Introduction We present a case where the left Internal Mammary Artery (IMA) was not a straightforward choice as the grafted vessel in a patient undergoing Coronary Artery Bypass Grafting (CABG). Case Presentation Patient was a 66 years old female with Hypertension, Hyperlipidemia, hypothyroidism, and tobacco use disorder. Evaluation for a motor vehicle accident secondary to a syncopal episode, and intermittent chest tightness over the past few months, showed ST depressions on ambulatory electrocardiographic monitoring, reversible ischemia in the anterior and apical walls on Exercise Stress Test and severe multivessel coronary artery disease involving the distal main left coronary artery and its branches on Coronary Angiography. CABG was advised. Preoperative peripheral angiogram showed bilateral common iliac artery occlusion, precluding IABP placement. Selective angiography of the left IMA showed the left IMA to be the major vessel supplying collateral circulation to the left iliac system. Patient subsequently underwent CABG with bilateral Saphenous Vein Harvest. Discussion IMA harvesting in patients with Aortoiliac Occlusive Disease (AOD) with prominent collaterals through the subclavian-IMA-inferior epigastric-external iliac pathway, AKA the Winslow Pathway (WP), can result in limb threatening ischemia, and elective IMA angiography and/or doppler flow evaluation before CABG can help identify this important collateral pathway. Alternative approaches in patients with AOD include simultaneous coronary and peripheral revascularization, completely avoiding IMA harvesting or in some cases, angioplasty, although there is no consensus thus far.

911 THE HYPERTROPHIC SEPTAL PERFORATING BRANCH MISINTERPRETED AS INTERVENTRICULAR DEFECT

Abstract Introduction the septal perforating arteries of the heart usually branch off from the anterior and inferior interventricular arteries and supply the interventricular septum and the conduction system therein. Aim we present the case of hypertrophic septal perforating branch in a 71-year-old man who experienced dyspnoea in which was initially misinterpreted as interventricular defect. Materials and methods transthoracic echocardiography without and with contrast, coronary angiography and angioTC with 3D reconstructions were performed. Results echocardiography showed dilative cardiopathy with EF 30%, akinesia of IVS, apical and inferior wall. Hypokinesia of the remaining walls. At color-Doppler: severe mitral regurgitation and moderate tricuspidal regurgitation. Coronary angiography showed severe multivessel atherosclerotic coronary artery disease. At the echocardiographic control was reported the presence of turbulent flows at the level of medio-basal segment of posterior IVS. Echo-power-Doppler showed no shunts. For persisting suspect of interventricular defect was performed contrast echocardiography that showed hypoperfusion of IVS after contrast infusion but no clear signs of interventricular shunts. To complete the diagnostic iter was performed finally CT-Scan of coronary arteries that reported a presence of hypertrophic septal perforating branch with long intramyocardial course in the interventricular septum, but was no detected interventricular defect. Conclusions Septal perforating arteries have a large variability in their anatomy. Particular clincal conditions such as chronic coronary syndromes could lead to a reactive hypertrophy. Is important recognise it due to its similarity with interventricular defect or myocardial bridging effect. A better understanding of these arteries will help physicians to enhance cardiac care for their patients.

1094 MULTIVESSEL CORONARY ARTERY SPASM TRIGGERED BY GANGLIONATED PLEXI STIMULATION DURING ATRIAL FIBRILLATION RADIOFREQUENCY CATHETER ABLATYION: A CASE REPORT

Abstract Background Atrial fibrillation is the most common sustained cardiac arrhythmia in adults and it is associated with a high burden of mortality and morbidity worldwide. Atrial fibrillation could be managed with rate-control or rhythm-control strategies. The latter is increasingly used to improve symptoms and prognosis in selected patients, especially after the development of catheter ablation. Although this technique is generally considered safe, it is not free from rare but life-threatening procedure-related adverse events. Among these, coronary artery spasm is an uncommon but potentially fatal complication that requires immediate diagnosis and treatment. Case summary We report a case of severe multivessel coronary artery spasm triggered by ganglionated plexi stimulation during pulmonary vein isolation with radiofrequency catheter ablation in a patient with persistent atrial fibrillation, promptly resolved after intracoronary nitrate administration. Discussion Although rare, coronary artery spasm is a serious complication of atrial fibrillation catheter ablation. Immediate invasive coronary angiography is key for both diagnosis confirmation and treatment of such dangerous condition. As the number of invasive procedures increases, it is important that both interventional and general cardiologists are aware of possible procedure-related adverse events.

P234 A RARE CASE OF ACUTE RIGHT HEART FAILURE PRESENTED IN A CASE REPORT

Abstract Case Summary A 62–year–old male with multiple cardiovascular risk factors, presented at the ED with signs and symptoms of right heart failure, Doppler echocardiography showed a severe dilatation and dysfunction of the right ventricle and left ventricular diastolic dysfunction. After initial stabilization with diuretics and inotropes, the patient performed a coronary angiogram with evidence of severe multivessel coronary artery disease and combined pre–capillary and post–capillary pulmonary hypertension as shown by the right heart catheterization. After complete revascularization, the diastolic function of the left ventricle improved dramatically, and the right ventricle recovered completely. Discussion We presented a paradigmatical case of acute right heart failure secondary to left ventricular diastolic impairment in a patient affected by severe ischemic coronary artery disease. Several risk factors are associated with RVD in HFpEF: atrial fibrillation, male sex, chronic obstructive pulmonary disease. Diastolic performance of the LV is one of the main determinants of the right ventricular function, which, in turn, is proven to have prognostic implication in HFpEF. Nowadays, there is no evidence–based treatment for right heart failure secondary to decompensated HFpEF and therapy should be tailored to the individual patient’s response.

Combined Treatment With Carotid Endoarterectomy and Coronary Artery Bypass Grafting: A Single-Institutional Experience in 222 Patients.

Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting. We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our instituion. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels. The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the controlateral brain hemisphere. Two patients (.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke. Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits.

Heartlogic Heart Failure Index As Covid Index: Predicting Severity Of Covid-19 In Patients With Advanced Heart Failure

Heart Logic heart failure diagnostic is a personalized, remote heart failure diagnostic and monitoring system using multiple, novel physiologic sensors. It has been proven to have high sensitivity and low-alert burden that combines sensor data into one composite index that provides weeks of advance notice for detecting early signs of worsening heart failure. We present two cases, one with non-ischemic cardiomyopathy, the other with ischemic cardiomyopathy. In both cases, patients had reduced ejection fraction status post cardiac resynchronization therapy defibrillator who were monitored with Heart Logic heart failure diagnostics. In the first case, a rapid increase in sensors alarmed us for impending exacerbation of heart failure and retrospective analysis of differentials led us to diagnosis of COVID-19. The patient developed increase in respiratory rate, mean heart rate and S3 component of heart sound while decrease in thoracic impedance, ultimately with increased Index. Patient was admitted, intubated and successfully recovered. Heart Logic Index helped us making the diagnosis in early stage of COVID-19 and manage effectively. We present another case of ischemic cardiomyopathy with reduced ejection fraction awaiting heart transplant due to severe multi vessel coronary artery disease who tested positive for COVID-19 with milder symptoms. He was monitored prospectively to assess changes in Heart Failure Index which remained normal correlating with the milder symptoms from COVID-19 itself. All the indices including S1, S3, respiratory rate and mean heart rate remained normal. Patient recovered without any major residual effects from COVID 19. Hence, heartlogic index could serve as proactive alert tool like a “COVID index” to suspect, correlate with severity of symptoms and monitor the outcome in patients of heart failure diagnosed with COVID-19.

Variations in Coronary Revascularization Practices and Their Effect on Long-Term Outcomes.

BackgroundThe degree of hospital‐level variation in the ratio of percutaneous coronary interventions to coronary artery bypass grafting procedures (PCI:CABG) and the association of the PCI:CABG ratio with clinical outcome are unknown.Methods and ResultsIn a multicenter population‐based study conducted in Ontario, Canada, we identified 44 288 patients from 19 institutions who had nonemergent diagnostic angiograms indicating severe multivessel coronary artery disease (2013–2017) and underwent a coronary revascularization procedure within 90 days. Hospitals were divided into tertiles according to their adjusted PCI:CABG ratio into low (0.70–0.85, n=17 487), medium (1.01–1.17, n=15 275), and high (1.18–1.29, n=11 526) ratio institutions. Compared with low PCI:CABG ratio hospitals, hazard ratios (HRs) for major adverse cardiac and cerebrovascular events were higher at medium (HR, 1.19; 95% CI, 1.14–1.25) and high ratio (HR, 1.21; 95% CI, 1.15–1.27) hospitals during a median 3.3 (interquartile range 2.1–4.6) years follow‐up. When interventional cardiologists performed the diagnostic angiogram, the odds of the patient receiving PCI was higher (odds ratio, 1.37; 95% CI, 1.23–1.52) than when it was performed by noninterventional cardiologists, after accounting for patient characteristics. Having the diagnostic angiogram at an institution without cardiac surgical capabilities was independently associated with a higher risk of major adverse cardiac and cerebrovascular events (HR, 1.07; 95% CI, 1.02–1.11), death (HR, 1.09; 95% CI, 1.02–1.18), and myocardial infarction (HR, 1.10; 95% CI, 1.03–1.17).ConclusionsPatients undergoing diagnostic angiography in hospitals with higher PCI:CABG ratio had higher rates of adverse outcomes, including major adverse cardiac and cerebrovascular events, myocardial infarction, and repeat revascularization. Presence of on‐site cardiac surgery was associated with better survival and lower major adverse cardiac and cerebrovascular events.

Machine Learning for Multi-Vessel Coronary Artery Disease Prediction on Electrocardiogram Gated Single-Photon Emission Computed Tomography.

Background: Single-photon emission computed tomography (SPECT) encounters difficulties in diagnosing severe multi-vessel coronary artery disease (svMVD) because of balanced ischemia. We estimated the predictive value of electrocardiogram-gated SPECT for svMVD and improved it using machine learning (ML). Methods and results: We enrolled consecutive 335 patients (median age, 74 years; 255 men) who underwent adenosine stress-gated SPECT (99mTechnesium) and coronary angiography. svMVD was defined as three-vessel disease or left main tract stenosis. Predictive models were constructed using statistical and ML methods. Eighteen cases (5%) showed svMVD, and diabetes, summed stress score (SSS), and the max difference among segmental time of stroke volume per cardiac cycle (MDSV: a parameter of left ventricular [LV] end-systolic dyssynchrony) on adenosine stress were independent significant predictors. The area under the receiver operating characteristic curve (AUC) of SSS and MDSV on stress were 0.759 and 0.763, respectively. Conversely, the extra trees classifier and light gradient boosting machine had improved AUC values of 0.826 and 0.870, respectively, and the MDSV on stress and diabetes showed high feature values in the ML models. Conclusion: ML on SPECT helped to improve the diagnostic performance of svMVD and diabetes, and the parameters of LV dyssynchrony played essential roles in the ML predictive models.

Oxidative Stress and Inflammation Are Associated with Coexistent Severe Multivessel Coronary Artery Stenosis and Right Carotid Artery Severe Stenosis in Elderly Patients.

Oxidative stress and inflammatory response are the main pathogenic pathways in atherosclerosis stenosis. This study is aimed at evaluating the roles of oxidative stress and inflammatory response in coexistent right carotid artery severe stenosis and severe multivessel coronary artery stenosis in elderly patients. Circulating levels of total oxidant status (TOS), lipid hydroperoxide (LHP), 8-isoprostane (8-IP), malondialdehyde (MDA), monocyte chemotactic protein-4 (MCP-4), amyloid A (AA), high-sensitivity C-reactive protein (hs-CRP), and tumor necrosis factor-α (TNF-α) were measured by standardised laboratory test methods. Markers of oxidative stress and inflammatory response: levels of TOS, LHP, 8-IP, MDA, MCP-4, AA, hs-CRP, and TNF-α, were increased (P < 0.001) in elderly patient. These results suggested that oxidative stress and inflammatory response may be involved in carotid artery severe stenosis and severe multivessel coronary artery stenosis and measuring oxidative stress and inflammation biomarkers may also be a promising step in the development of an effective method for monitoring the severity of right carotid artery stenosis and multivessel coronary artery stenosis in elderly patients.

AVOIDING ANCHORING BIAS: DIAGNOSIS OF AL-AMYLOIDOSIS IN WORSENING HEART FAILURE AFTER CORONARY ARTERY BYPASS GRAFTING

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Amyloidosis is a systemic disease caused by deposition of misfolded protein in various tissues and organs. Early recognition of amyloidosis is necessary as cardiac dysfunction is the major determinant of survival(1). The diagnosis is often delayed given the non-specific symptoms at onset. Prognosis in amyloidosis is primarily dependent on the degree of cardiac involvement and, in AL amyloidosis, on circulating light-chain levels(2). CASE PRESENTATION: The patient is a 68-year-old male referred to our institution for assessment of worsening heart failure (HF). Four months prior, he began to experience exertional dyspnea along with jaw pain. Subsequent evaluation included lab work, chest X-ray and electrocardiogram demonstrating troponin elevation, pulmonary edema and complete heart block respectively. An echocardiogram(ECHO) demonstrated a severely reduced ejection fraction(EF). Temporary pacemaker was placed and a subsequent angiogram showed severe multi-vessel coronary artery disease(CAD). He underwent coronary artery bypass graft surgery. Post-operatively EF improved to 45%. Implantable loop recorder was placed due to concerns for post-operative atrial fibrillation. Three months later, he experienced a syncopal event attributed to ventricular tachycardia, and CRT-D was placed. ECHO revealed reduction of his EF (30%) with moderate concentric left ventricular hypertrophy(LVH). A repeat angiogram demonstrated patency of his bypass grafts. After referral to our institution, a repeat ECHO demonstrated findings concerning amyloidosis. Protein electrophoresis revealed monoclonal IgG gammopathy, and fat pad aspirate confirmed the diagnosis of AL amyloidosis. DISCUSSION: Although CAD is the most common cause of HF with reduced EF, other etiologies must be considered when symptoms cannot be explained solely by ischemia. Cardiac amyloidosis was suspected based on a constellation of clinical symptoms as well as suggestive ECHO findings(Biventricular concentric hypertrophy, restrictive filling pattern, Bull's eye appearance on LV strain). The diagnosis should be suspected in patients with HF who have unexplained LVH with no prior history of hypertension(3). Patients also present with syncopal events caused by conduction blocks, bradyarrhythmia, or in the case of our patient, ventricular tachyarrhythmias. Early diagnosis is important given the emerging therapies that can halt cardiac damage, potentially reducing the risk of mortality and allowing amyloid clearance and improved cardiac function. CONCLUSIONS: Anchoring bias is the tendency to stick with initial impressions even as new information becomes available. Clinicians must avoid this and consider alternative diagnoses when patients do not experience the anticipated outcome to a particular treatment. REFERENCE #1: 1. Fontana M. Banypersad SM. Treibel TA, et al. Differential myocyte responses in patients with cardiac transthyretin amyloidosis and light-chain amyloidosis: a cardiac MR imaging study. Radiology. 2015;277:388–97 REFERENCE #2: 2. Kumar S, Dispenzieri A, Lacy MQ, et al. Revised prognostic staging system for light chain amyloidosis incorporating cardiac biomarkers and serum free light chain measurements. J Clin Oncol 2012;30:989-95 REFERENCE #3: 3. Gertz MA. Comenzo R. Falk RH, et al. Definition of organ involvement and treatment response in immunoglobulin light chain amyloidosis (AL): a consensus opinion from the 10th International Symposium on Amyloid and Amyloidosis, Tours, France, 18-22 April 2004. Am J Hematol. 2005;79:319–28 DISCLOSURES: no disclosure on file for Brian Hardaway; No relevant relationships by Michael Liu, source=Web Response No relevant relationships by Amith Reddy Seri, source=Web Response

Results of treatment of myocardial infarction with ST-segment elevation using early and delayed coronary interventions in different age groups

The aim of the study was to assess the treatment results in patients with anterior STEMI using primary PCI in different patient age groups, including those at late hospitalization, taking into account the initial mortality risk (MR). The study included 804 patients with anterior STEMI, aged 28 to 91 years, who were admitted to N. V. Sklifosovsky Research Institute for Emergency Medicine in the period from 2008 to 2017: 583 of them had the primary PCI performed either within the first 12 hours from the disease onset (311 patients) or at late hospitalization: after 12–72 hours (272 patients); and 221 patients treated without PCI. The distribution of patients by age: under 65 years old, 65–75 years old, and over 75 years old was 340, 139, and 104 in the PCI group, and 126, 47, and 48 in the group without PCI, respectively. In 26 death cases after PCI and in 39 of died without interventions, the state of the coronary bed, the affected area, and the immediate cause of death were determined. We have found that in the absence of reperfusion therapy (RT) in STEMI, the initially high baseline MR assessed by TIMI Risk Score corresponds to high mortality. It affects people of predominantly elderly and, especially, senile age, who more often have a proximal lesion of the main coronary arteries, which causes an extensive area of infarction with the development of fatal complications. The use of primary PCIs, including those at late hospitalization, prevents the progression of acute heart failure, the formation of LV aneurysms, and reduces the deaths rate. In different periods of time, the mortality rate with the use of primary PCI, including the delayed ones, fluctuates; it can rise with a significantly increasing number of the hospitalized at senile age. An increase in mortality is associated with complications, including those arising during procedures in severe multivessel coronary artery disease, which is more common in this patient population. Achieving angiographic success even in the absence of ECG signs of reperfusion can significantly reduce mortality in all age groups. High MR is an optimal indication for using delayed procedures. An urgent use of primary PCIs, including those at late hospitalization, allows the optimization of the STEMI treatment, and the achievement of the maximum reduction in mortality.

A Case of Primary Hyperaldosteronism Presenting as Hemorrhagic Stroke

Background: Primary aldosteronism (PA) is the most common form of secondary hypertension. Patients with PA are more likely to suffer from end-organ damage compared to matched controls with essential hypertension. We present a case of PA identified in a patient who presented with hypertensive emergency and hemorrhagic stroke. Clinical Case: A 52-year-old man with hypertension and chronic kidney disease presented with sudden onset left-sided weakness. He had a ten year history of hypertension and was taking carvedilol, losartan, and hydralazine prior to presentation. On arrival, his blood pressure was 263/142 mmHg. He had 3/5 grade weakness in the left upper and lower extremities. Laboratory analysis showed a potassium level of 2.8 mmol/L (n = 3.5–5 mmol/L) and a bicarbonate level of 33 mmol/L (n = 21–29 mmol/L). Screening labs for PA were drawn after potassium repletion. CT Head without contrast revealed an acute 2.5-centimeter intracerebral hemorrhage of the right basal ganglia. He was admitted to the intensive care unit and was started on a nicardipine drip with an improvement of blood pressure. His weakness improved and he was discharged home on carvedilol, hydralazine, nifedipine, and losartan.Screening for PA revealed a plasma aldosterone concentration (PAC) of 22.8 ng/dL (n < 16 ng/dL) and a plasma renin activity (PRA) of 0.1 ng/ml/hr (n = 0.2–1.6 ng/ml/hr). The PAC/PRA ratio was therefore extremely elevated at 228. The presence of spontaneous hypokalemia, very low renin, and PAC >20 ng/dL confirmed the diagnosis of primary aldosteronism. He underwent an adrenal MRI which revealed two left adrenal nodules, the largest measuring 10 mm, and a 7.3 mm right adrenal nodule, consistent with bilateral adrenal adenomas. The patient did not desire surgery, therefore adrenal vein sampling was deferred. His hypertension improved with the addition of a mineralocorticoid receptor antagonist. Eight weeks after his stroke the patient was readmitted due to chest pain. He was found to have severe multi-vessel coronary artery disease and underwent a four vessel coronary artery bypass. Conclusion: Patients with PA have higher rates of adverse cardiovascular events compared to age-, sex-, and blood pressure-matched controls with essential hypertension. Studies demonstrate that aldosterone excess has blood pressure independent proinflammatory and profibrotic effects on the vessel wall which leads to endothelial dysfunction and thus accelerated atherosclerosis. Appropriate treatment can eliminate the excess cardiovascular risk associated with PA. This case highlights the importance of including PA in the differential diagnosis of secondary hypertension, particularly among patients presenting with spontaneous hypokalemia, severe uncontrolled hypertension and early onset cardiovascular or cerebrovascular disease.

Severe multivessel coronary artery spasm detected by computed tomography: a case report.

BackgroundVentricular arrhythmia and sudden cardiac arrest caused by multivessel coronary artery spasm (CAS) is rare. Although coronary angiography (CAG) with provocation testing is the diagnostic gold standard in current vasospastic angina guidelines, it can cause severe procedure-related complications. Here, we report a novel technique involving dual-acquisition coronary computed tomography angiography (CCTA) to detect multivessel CAS in a patient who survived out-of-hospital cardiac arrest (OHCA).Case summaryA 58-year-old healthy Korean male survived OHCA caused by ventricular fibrillation (VF), experiencing seven episodes of defibrillation and cardiopulmonary resuscitation, and was referred to the Emergency Room. Vital signs were stable and physical examination, electrocardiogram, chest, and brain CT did not show any abnormal findings, except elevated hs-Troponin I levels (0.1146 ng/mL). Echocardiogram revealed a regional wall motion abnormality in the inferior wall, with a low normal left ventricular ejection fraction (50%). A multivessel CAS (both left and right) was detected using a dual-acquisition CCTA technique (presence and absence of intravenous nitrate). During CAG with the 2nd injection of ergonovine, a prolonged and refractory total occlusion in the proximal-ostial right coronary artery was completely relieved after a seven-cycle intracoronary injection regimen of nitroglycerine. The patient was discharged with the recommendation of smoking and alcohol cessation. Nitrate and calcium channel blockers were also prescribed. The patient had no further events at 3 months of follow-up after discharge.DiscussionDual-acquisition CCTA is a promising tool to detect multivessel CAS.

IMPROVED ACUTE ST-SEGMENT ELEVATION DUE TO AIR EMBOLISM AFTER CORONARY ARTERY BYPASS GRAFT PROCEDURE

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Air embolism is often an iatrogenic complication during coronary artery bypass grafting (CABG) surgery.1 Although infrequent as a complication of CABG surgery it is generally attributed to air introduced into the coronary arteries during the procedure.2 We report a case of ST-segment elevation after triple CABG surgery secondary to the introduction of air into the coronary arteries. CASE PRESENTATION: A 62-year-old male presents to the emergency department with mid-sternal chest pain, radiating to the left arm, his symptoms were associated with diaphoresis and palpitations. Initial Electrocardiogram (ECG) showed lateral ST-segment depressions, the initial troponin was elevated at 0.32 ng/ml (0.015-0.045 ng/ml). Patient underwent a left heart catheterization, which showed severe multi-vessel coronary artery disease. The decision was made to proceed with CABG. CT surgery was consulted and he underwent triple CABG with left internal mammary artery grafting to the anterior descending coronary artery, saphenous venous grafting to obtuse marginal 1 branch and saphenous venous grafting to the posterolateral branch of the right coronary artery. The anastomosis was completed with successful filling of the grafts. The aortic cross-clamp was removed, and the patient was allowed adequately to reperfuse and rewarm. Shortly after that, the patient developed ST-segment elevation in lead II, III, and aVF, along with ST depressions in lead I, aVL, V1, V2. Flow in the grafts were checked and they remained patent. Air embolization of the coronary arteries was suspected. Transthoracic echocardiogram (ECHO) demonstrated ventricular function impairment. Extended reperfusion was performed to force air from the coronaries out. The ECG showed resolution of ST-segment elevations and repeat ECHO showed improved ventricular function. The patient was monitored in the cardiovascular intensive care unit and was discharged home after four days of routine Post-CABG care. DISCUSSION: Air embolization of the coronary arteries may result as a complication of CABG as well as cardiac catheterization, leading to disruption of coronary perfusion.1 There may also be elevations of cardiac enzymes and hemodynamic instability. An extended reperfusion period with increased perfusion pressures usually causes the passing of bubbles through the coronary artery system, during the surgery.3,4 Late embolizations require urgent re-catheterization. 4 CONCLUSIONS: In conclusion, this case illustrates ST-segment elevation on ECG from an air embolism during CABG surgery. Early diagnosis and prompt treatment of this rare iatrogenic complication are crucial to prevent life-threatening cardiac complications. Reference #1: 1. Engelmann U, Minden H, Stock UA, Kühnel R, Albes JM. Late air embolism with interventional removal after isolated coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2006;131(6):1403-1404.doi:10.1016/j.jtcvs.2006.01.046 2. Khan M, Schmidt DH, Bajwa T, Shalev Y. Coronary air embolism: Incidence, severity, and suggested approaches to treatment. Cathet Cardiovasc Diagn. 1995;36(4):313-318. doi:10.1002/ccd.1810360406 3. Solodky A, Birnbaum Y, Assali A, Gal T Ben. Coronary Air Embolism Treated by Bubble Aspiration. 2000;454(October 1999):452-454. 4. Patterson MS, Kiemeneij F. Coronary air embolism treated with aspiration catheter. Heart. 2005;91(5):1-2. doi:10.1136/hrt.2005.060129 Reference #2: Figure 1. Initial Electrocardiogram. Figure 2. Post CABG Electrocardiogram. Figure 3. Electrocardiogram at discharge. DISCLOSURES: No relevant relationships by Ahmad ababneh, source=Web Response No relevant relationships by Shubham Adroja, source=Web Response No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by Ahmad JABRI, source=Web Response

DNA methylation patterns from peripheral blood separate coronary artery disease patients with and without heart failure.

AimsNatriuretic peptides are useful for diagnosis and prognostication of heart failure of any cause. Now, research aims to discover novel biomarkers that will more specifically define the heart failure phenotype. DNA methylation plays a critical role in the development of cardiovascular disease with the potential to predict fundamental pathogenic processes. There is a lack of data relating DNA methylation in heart failure that specifically focuses on patients with severe multi‐vessel coronary artery disease. To begin to address this, we conducted a pilot study uniquely exploring the utility of powerful whole‐genome methyl‐binding domain‐capture sequencing in a cohort of cardiac surgery patients, matched for the severity of their coronary artery disease, aiming to identify candidate peripheral blood DNA methylation markers of ischaemic cardiomyopathy and heart failure.Methods and resultsWe recruited a cohort of 20 male patients presenting for coronary artery bypass graft surgery with phenotypic extremes of heart failure but who otherwise share a similar coronary ischaemic burden, age, sex, and ethnicity. Methylation profiling in patient blood samples was performed using methyl‐binding domain‐capture sequencing. Differentially methylated regions were validated using targeted bisulfite sequencing. Gene set enrichment analysis was performed to identify differences in methylation at or near gene promoters in certain known Reactome pathways. We detected 567 188 methylation peaks of which our general linear model identified 68 significantly differentially methylated regions in heart failure with a false discovery rate <0.05. Of these regions, 48 occurred within gene bodies and 25 were located near enhancer elements, some within coding genes and some in non‐coding genes. Gene set enrichment analyses identified 103 significantly enriched gene sets (false discovery rate <0.05) in heart failure. Validation analysis of regions with the strongest differential methylation data was performed for two genes: HDAC9 and the uncharacterized miRNA gene MIR3675. Genes of particular interest as novel candidate markers of the heart failure phenotype with reduced methylation were HDAC9, JARID2, and GREM1 and with increased methylation PDSS2.ConclusionsWe demonstrate the utility of methyl‐binding domain‐capture sequencing to evaluate peripheral blood DNA methylation markers in a cohort of cardiac surgical patients with severe multi‐vessel coronary artery disease and phenotypic extremes of heart failure. The differential methylation status of specific coding genes identified are candidates for larger longitudinal studies. We have further demonstrated the value and feasibility of examining DNA methylation during the perioperative period to highlight biological pathways and processes contributing to complex phenotypes.

UTILIZATION OF HEMODYNAMIC SUPPORT DEVICES IN HIGH-RISK PCI: EXPERIENCE FROM A HIGH VOLUME CENTER

High-risk candidates for percutaneous coronary intervention (PCI) include patients with severe multi-vessel coronary artery disease (CAD), unprotected left main (LM) coronary artery stenosis, or last remaining patent conduit with a stenosis, especially in patients with a left ventricular ejection

Diffuse ST-segment depression despite prior coronary bypass grafting: An electrocardiographic-angiographic correlation

The standard 12‑lead electrocardiogram (ECG) has become a mainstay diagnostic tool in patients suspected to have myocardial ischemia. The identification of hallmark electrocardiographic abnormalities, such as ST-segment deviation or serial T wave changes, not only helps identify the presence of myocardial ischemia but also may help localize myocardial territories with an ongoing injury. Widespread ST-segment depression is commonly attributed to diffuse subendocardial ischemia precipitated by severe multivessel or left main coronary artery disease. However, among patients with prior coronary revascularization, clear electrocardiographic-angiographic relationships responsible for widespread ST-segment depressions have not been well defined. We report a case in which diffuse ST-segment depression emerged from a patient with prior coronary artery bypass grafting. In this report, we examine the patient's presenting ECG pattern as to (1) establish causal inferences which align with the distribution of myocardial ischemia supported by angiography and (2) provide an accompanying analysis of the relevant scientific literature.

The value of three-dimensional speckle tracking echocardiography in detecting severe multi-vessel coronary artery stenosis

Objective To evaluate the diagnosis value of three-dimensional speckle tracking echocardiography (3D-STE) in severe multi-vessel coronary stenosis at resting state. Methods Ninety-one patients with chest tightness, chest pain, other related clinical symptoms, and suspected coronary heart disease were enrolled and underwent coronary angiography (CAG), two and three-dimensional echocardiography(2D-STE, 3D-STE). According to CAG results, the patients were divided into 3 groups: severe multi-vessel stenosis group (n=38), severe single-vessel stenosis group (n=22), and control group (n=31). All patients underwent two and three-dimensional echocardiography.3D-STE was applied to obtain left ventricular global longitudinal strain (3D GLS), global circumferential strain (3D GCS), global area strain (3D GAS) and global radial strain(3D GRS). Receiver operating curve analysis was conduct to evaluate the diagnosis value of 3D-STE in severe multi-vessel coronary stenosis at resting state. Results 3D GLS, 3D GCS, 3D GAS and 3D GRS were decreased in the severe multi-vessel group and single-vessel stenosis group compared to those in the control group(P<0.05); and greater decreases was observed in the severe multi-vessel stenosis group(P<0.001). Furthermore, 3D GLS and 3D GAS in the severe multi-vessel stenosis group were lower than those in severe single-vessel stenosis group(P<0.05). ROC curve showed that the cutoff value for 3D GLS was ≤-11% with a measurement sensitivity of 84.2% and cutoff value for 3D GAS was ≤-20% with a measurement specificity of 79.3%. A joint diagnostic test showed that the sensitivity was increased when 3D GLS was combined with at least one other parameters. Conclusions 3D-STE shows a great diagnostic potential when applied to detect severe multi-vessel coronary stenosis. Moreover, GLS and GAS may act as more valuable indicators. Key words: Echocardiography; Coronary stenosis; Ventricular function, left; Global strain

Outcome after revascularisation of acute myocardial infarction with cardiogenic shock on extracorporeal life support

The aim of the study was to identify independent correlates of survival in patients undergoing PCI for refractory cardiogenic shock due to myocardial infarction (RCS-MI) with the need for extracorporeal life support (ECLS). This observational single tertiary centre study enrolled 106 consecutive patients (52.7±10.4 years) with ECLS placed before or after the PCI. Half of the patients had triple vessel disease and PCI was attempted whenever possible (74.5%). The 30-day mortality rate was 63.2%. Left main culprit vessel disease (19% of patients) (adj. HR [95% CI]: 2.31 [1.27-4.18], p=0.006) and sepsis-related organ failure assessment ≥13 (adj. HR 2.17 [1.25-3.75], p=0.005) were independently associated with 30-day mortality. The use of intra-aortic balloon pump (IABP) combined with ECLS was an independent protective factor (adj. HR 0.48 [0.28-0.80], p=0.006). Neither complete (p=0.66) nor successful (p=0.69) myocardial revascularisation was associated with 30-day survival. RCS in MI patients often reveals a severe multivessel coronary artery disease with no impact of early percutaneous coronary revascularisation on clinical outcome. The survival advantage of IABP when combined with ECLS further suggests that achieving an early effective haemodynamic support should be the major goal in this young patient population.

Real-time three-dimensional echocardiography of left atrial volume and function in patients with severe multi-vessel coronary artery disease.

To evaluate the changes in left atrial (LA) volume and function in patients with severe multi-vessel coronary artery disease (CAD) by real-time three-dimensional echocardiography (RT-3DE). One hundred and eight subjects were stratified based on coronary angiography (CAG) imaging, comprising 48 patients with severe multi-vessel CAD, 31 patients with severe single-vessel CAD, and 29 controls. RT-3DE was performed in all groups. LA volume parameters were measured. LA ejection fractions (EF) and LA function index (LAFI) were also calculated. There were no significant differences between the single-vessel CAD group and the control group, while LA passive emptying fraction (LAVpEF) was significantly reduced in the single-vessel CAD group. In the multi-vessel CAD group, LAVpEF and LAFI were lower, while LA presystolic volume (LAVpre) was prominently higher as compared with the other groups, and LA active emptying volume (LAVa) was higher than that in the control group (p<0.05). Receiver-operating characteristic (ROC) analysis showed that the area under the curve (AUC) of LAVpEF was the largest parameter; the optimal cut-off value, AUC, sensitivity, and specificity were 0.50, 0.864, 93.7, and 72.4%, respectively. Specifically, conduit function reflects the early changes in LA function, and CAD damage is aggravated with increasing coronary lesions, whereas the booster pump function of severe multi-vessel CAD can increase in compensation. We speculate that LAVpEF may be the most ideal threshold for detecting and differentiating severe CAD patients from controls.