Severe Multivessel Disease Research Articles

Predicting severe multivessel coronary artery disease to guide access strategy in patients undergoing invasive coronary angiography.

Given radial artery conduits are increasingly utilized for coronary artery bypass grafting (CABG), avoiding transradial access (TRA) for invasive coronary angiography (ICA) may benefit patients who ultimately undergo CABG. We sought to predict the likelihood of severe multivessel disease (MVD) before ICA to guide this decision. This was a single-center study of 1485 patients with stable symptoms who underwent ICA. A model to predict severe MVD was developed. Relative importance analyses were performed to identify clinical characteristics most associated with the presence or absence of severe MVD. When predicting severe MVD, the model had a sensitivity of 70.3% and specificity of 71.8% (area under the curve = 0.7105). With a prevalence of 12.5% in our cohort, the model had a strong negative predictive value of 94.4%. Relative importance analyses showed factors most associated with the presence of severe MVD were a history of abnormal noninvasive tests, typical chest pain, aspirin use, insulin-dependent diabetes, increasing age, and a family history of coronary artery disease. Conversely, the absence of severe MVD was most associated with female sex, undergoing ICA as workup for either noncardiac or valve surgery, lung disease, atypical chest pain, and increased BMI. Clinical information available before ICA can risk stratify the likelihood of severe MVD and therefore aid in identifying patients that may need CABG and could stand to benefit from TRA avoidance. The potential benefits of maximizing radial artery conduit availability by avoiding TRA must be balanced against the risks of alternative access on an individual patient basis.

Abstract 16927: The Mother of All Pseudoaneurysms - A Rare Case

Introduction: Femoral artery pseudoaneurysms (FAP) are typically caused by percutaneous access during coronary and peripheral angiography. It occurs in 0.1 to 0.2% of diagnostic catheterization procedures and in 3.5% to 5.5% of interventional procedures. Cases of “Giant” femoral artery pseudoaneurysms have seldom documented in the past, however, our case is unique for two reasons:- Pseudoaneurysm presented 6 months after femoral arterial access, which is unusual.- This size of pseudo-aneurysm has yet to be documented. Case Description: 74-year-old male with history of diabetes mellitus type II and tobacco abuse presented with chest pain. He underwent cardiac catheterization via radial access, which confirmed severe multi-vessel disease with ejection fraction of 30%. Patient was started on goal-directed medical therapy with planned elective IABP-assisted coronary artery bypass grafting (CABG). On the day of surgery in anticipation of IABP, right femoral artery was accessed, however, intra-operative transesophageal echocardiography showed improvement of ejection fraction to 55%, which led to removal of the femoral sheath and application of a closure device. Six months later, patient presented with a large right groin mass. Computed tomography angiography confirmed a pseudoaneurysm anterior to the right common femoral artery, measuring 9.6 cm x 9.8 cm causing moderate stenosis of the superficial femoral artery. Peripheral arterial duplex ascertained the neck of pseudoaneurysm measuring 1.3 cm. Patient underwent emergent repair of the right femoral pseudoaneurysm, with thrombus removal. No further recurrence of pseudoaneurysm was noted. Discussion: Pseudoaneurysms may arise months after femoral arterial access. Any groin symptoms in patients who underwent percutaneous femoral arterial access warrant additional investigation. Further studies are needed to elucidate the factors that increase the risk of formation and rupture of pseudoaneurysms

Abstract 19084: The Deadly Squeeze - Coronary Vasospasm Complicated by Myocardial Infarction and Cardiac Arrest

Introduction: Acute coronary syndrome (ACS) typically results from atherosclerotic plaque rupture. However, about 6% of ST elevation Myocardial Infarction (STEMI) patients have no obstructive disease. We present a case of STEMI, diagnosed with coronary vasospasm. Hypothesis: Methods: A 54-year-old female with alcohol abuse, smoking and uncontrolled hypertension presented after an out of hospital ventricular fibrillation cardiac arrest. EKG showed anterolateral ST elevation (STE). Left heart catheterization (LHC) showed moderate to severe multi-vessel disease without a definitive culprit lesion. STE resolved. Heart team approach for revascularization was contemplated. Echocardiogram showed systolic dysfunction with ejection fraction (EF) of 25%. Patient had another cardiac arrest and EKG showed recurrent anterolateral STE. Repeat LHC showed severe vasospasm of Left anterior descending (LAD) artery and diagonal branch, which improved with intracoronary (IC) nitroglycerin. Vasospasm was attributed to smoking and catecholamine excess from alcohol withdrawal. She was started on intravenous nitroglycerin and amlodipine. Her hospital course was complicated by high degree AV block requiring temporary pacer. She was eventually extubated with good neurological recovery and recovered systolic function (EF 60%). She was counselled on smoking and alcohol cessation and discharged home on isosorbide dinitrate and Amlodipine with planned surgical revascularization. Results: Coronary vasospasm (CVS) can occur both in normal and diseased coronaries. Risk factors include smoking, alcohol use and withdrawal, cocaine, mental stress, etc. Vasospasm may present as Prinzmetal’s angina, myocardial infarction, AV block, or fatal arrhythmias. IC nitroglycerine during LHC aids in diagnosis of CVS in setting of ACS. IVUS (Intravascular ultrasound) may help diagnose presence or absence of concomitant atherosclerotic disease. Provocative testing with IC ergonovine and acetylcholine may be considered in non-ACS setting. Conclusions: This case emphasizes the need to have a high index of suspicion for vasospasm to prevent associated complications and establish an accurate diagnosis and guide proper management of this potentially fatal disease.

Outcomes of coronary artery bypass grafting and percutaneous coronary intervention in high-risk non-ST-segment elevation acute coronary syndromes

Highlights. Despite high hospital mortality after coronary bypass grafting in patients with high-risk non–STsegment elevation acute coronary syndrome, surgical myocardial revascularization remains a preferable treatment modality since percutaneous coronary intervention in these patients is associated with high perioperative complications due to severely calcified coronary lesions.Background. The optimal revascularization strategy in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) remains the subject of many years of controversy. Coronary artery bypass grafting (CABG) improves the long-term prognosis through complete revascularization, however, percutaneous coronary intervention (PCI), due to its availability and low invasiveness, suggests an improvement in hospital outcomes.Aim. To compare hospital outcomes of CABG and PCI performed within 24 hours in high-risk NSTE-ACS patients.Methods. In the present study, the first group included 30 NSTE-ACS patients who underwent CABG in the first 24 hours (the CABG group), whereas 30 NSTE-ACS patients who underwent PCI were included in the second group (the PCI group).Results. The mean age was 64,4±7,3 years, it was comparable in both groups. The main clinical and anamnestic characteristics of patient in both groups were comparable as well. The severity of coronary atherosclerosis according to the Syntax score was 25,6±9,2 in the CABG group, and 21,7±5,7 in the PCI group (p = 0,054). After revascularization, the residual Syntax score did not differ between the groups (p = 0,42), indicating complete revascularization. Hospital mortality was relatively high in the CABG group (13,3%), while no such cases were noted in the PCI group. Most of the patients with adverse outcomes had a critical lesion of the left main coronary artery and a complicated postoperative course.Conclusion. The results of this study demonstrate promising outcome of CABG in patients with severe multivessel coronary disease at high risk of adverse events.

The South African Flag Sign: An Electrocardiographic Flag for All Coronary Territories?

The South African flag sign (SAFS) is an acute, dynamic electrocardiographic (ECG) finding typically associated with first diagonal (D1) artery occlusion. We report the case of a 47-year-old woman who exhibited this pattern but subsequently revealed the dreaded "widow-maker" lesion (100% occluded proximal left anterior descending [LAD] artery) and severe multivessel disease (90% stenosis of the posterior left ventricular [PLV] artery and 80% stenosis of the left circumflex artery [LCx]).

Treatment of three-vessel disease in light of the results of the FAME-3 study

Previous randomized clinical studies have shown the superiority of coronary artery bypass grafting over percutaneous coronary intervention in the treatment of severe multivessel disease mainly because of a reduced need for repeat revascularization but, in some, a mortality benefit and reduced rate of myocardial infarction were shown among those undergoing surgery. The late breaker multicentric, randomized FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation)-3 study, involving 1500 patients, sought to determine whether fractional flow reserve guided percutaneous coronary intervention with implantation of new-generation drug-eluting stents was non -inferior to present-day coronary bypass surgery with respect to the composite of all-cause death, myocardial infarction, stroke and repeat revascularization at one year. The authors who were particularly active in the FAME-3 trial describe the study setting, the characteristics of the patient population, the procedures, and the results. The FAME-3 study failed to show the non-inferiority of percutaneous coronary intervention to bypass surgery in the treatment of three vessel disease using the predetermined margin. The authors present a detailed analysis of the possible reasons and some important secondary results. These include a lack of significant difference between the two arms with respect to `hard end points' and the significantly higher perioperative morbidity of the surgical group. Albeit our clinical practice should be based on the analysis of the primary end point, informing patients and shared decision making must include these secondary results when individual revascularization strategies are planned.

Aortic Endarterectomy in Severe Multivessel Paravisceral and Limited Aortoiliac Occlusive Disease: A Lost Art with a Place in Modern Surgery

Historically the treatment of choice for aortoiliac occlusive disease, aortic endarterectomy (AE) is now rarely performed. However, in patients with severe multivessel atherosclerotic disease of the paravisceral aorta, and with severe disease limited to the infrarenal aortoiliac segment, AE provides an opportunity to restore in-line flow, either as a primary procedure or as a salvage procedure after prior endovascular attempts at revascularization have failed. We evaluated outcomes for patients at a single institution undergoing AE for disease involving multiple visceral vessels, or involving the infrarenal aorta and the iliac system.

Patients Receiving Extracranial to Intracranial Bypass for Atherosclerotic Vessel Occlusion Today Differ Significantly From the COSS Population

A retrospective, single-center study was performed in Berlin between January 2012 and December 2019. A total of 179 patients with atherosclerotic disease (51% with unilateral internal carotid artery [ICA] occlusion; 49% with multivessel disease) had undergone extracranial to intracranial bypass for symptoms that had occurred within the previous 4 months, including recurrent minor ischemic stroke or transient ischemic attack (TIA) in 136 patients (76%), single TIA or ischemic stroke in 36 patients (20%), and hemodynamic instability in 7 patients (4%). The overall perioperative stroke, surgical complication, and 1-year ischemic or TIA event rate was 4%, 6.5%, and 6%, respectively. Patients more recently referred for flow augmentation surgery appear to experience more severe symptoms and have more severe vessel occlusion patterns than did patients reported in the COSS (carotid occlusion surgery study). A new randomized controlled trial appears warranted, considering the poor prognosis of patients with an occluded ICA and associated severe multivessel atherosclerotic cerebrovascular disease.

LET THE HEART BE YOUR GUIDE: A TALE OF SURGICAL COMPLICATION AND MEDICAL MANAGEMENT

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coronary guidewire entrapment and fragmentation during percutaneous coronary intervention is an infrequent complication with incidence between 0.1-0.2%. The retained fragment can lead to flow impediment, vessel thrombosis, distal embolism, and vessel perforation. Complications of guidewire retrieval include developing cardiac tamponade and requiring emergent cardiac surgery. We present a young male with severe multi-vessel disease and a rare procedural complication of coronary guidewire entrapment and fragmentation during percutaneous coronary intervention. CASE PRESENTATION: A 34-year old male with a past medical history for familial hyperlipidemia, hypertension, polysubstance abuse (opiate, benzodiazepine, tobacco, cocaine, alcohol, and marijuana), and hepatitis C presented with intermittent, substernal chest pain with radiation to the left arm. On presentation, patient was hypertensive, and his serum troponin-I peaked at 0.30 ng/mL. LDL was also markedly elevated at 234 mg/dL. His ECG revealed normal sinus rhythm with inferior Q-waves. Myocardial perfusion imaging revealed a medium area of moderate ischemia and infarction in the inferior wall with associated hypokinesis. He underwent coronary angiography which revealed an anomalous left circumflex originating from the right coronary cusp, diffuse right coronary artery disease, and a prior stent in the distal segment with a wire fragment entrapped between the previously deployed stent and the vessel wall. It was later found that this was a complication of his intervention 6 months prior where attempts to remove the wire percutaneously, as well as stenting the retained guidewire against the vessel wall, were all unsuccessful. Thus, the retained wire fragment was left at the stent site. Due to patient's young age and preference, a decision with cardiothoracic surgery was made for medical management to prevent morbidity associated with surgical correction. Patient was started on aggressive medical therapy, educated on substance abuse cessation, and scheduled for close follow-up. DISCUSSION: Risk factors for guidewire fragmentation and entrapment include extensive atherosclerosis of full-length coronary vessel, use of multiple guidewires, and tortuous lesions. Current therapeutic options for coronary guidewire entrapment include percutaneous management, surgical intervention, and conservative follow-up. The management of retained guidewires is not standardized. Percutaneous interventions for retrieval includes utilizing snares, filter wires, or forceps. Conservative management without intervention is indicated for retained guidewires located in small coronary branches with adequate post-occlusion blood flow. CONCLUSIONS: This case demonstrates tailoring therapy. Although, this complication is rare, medical management and lifestyle modification for retained guidewires represents an alternative option to percutaneous intervention. Reference #1: Al-Moghairi, A. and Al-Amri, H., 2013. Management of Retained Intervention Guide-wire: A Literature Review. Current Cardiology Reviews, 9(3), pp.260-266. Reference #2: Karabulut A, Daglar E, Cakmak M., Entrapment of hydrophilic coated coronary guidewire tips: which form of management is best? 2010. Cardiol J. 2010;17(1):104–108. Reference #3: Iturbe J., R. Abdel-karim A., Papayannis A., Mahmood, A., Rangan, B., Banerjee, S., Brilakis, E., 2023. Frequency, Treatment, and Consequences of Device Loss and Entrapment in Contemporary Percutaneous Coronary Interventions. Journal of Invasive Cardiology. 2012; 25(5): 215-221. DISCLOSURES: No relevant relationships by Christopher Bitetzakis, source=Web Response No relevant relationships by Arjun Khadilkar, source=Web Response No relevant relationships by Andrew Mehlman, source=Web Response No relevant relationships by Koushik Reddy, source=Web Response No relevant relationships by Christopher Schwartz, source=Web Response

Особенности перкутанного лечения пациентов с инфарктом миокарда без элевации сегмента ST, поступивших в стационар в разные сроки от начала заболевания

Цель работы – оценить влияние коронарной реваскуляризации (коронарного стентирования, КС) на выживаемость пациентов, перенесших инфаркт миокарда без элевации сегмента ST (non-ST-segment elevation myocardial infarction, NSTEMI), при выполнении вмешательства в разные сроки от начала заболевания.Материалы и методы. В исследование включен 101 пациент с NSTEMI. Ургентно (от 0 до 72 ч с момента развития заболевания) обследованы 29 больных. Остальные 72 пациента были госпитализированы в плановом порядке, а диагноз NSTEMI был установлен им в период от 4 до 180 суток до момента проведения коронаровентрикулографии или КС.Результаты и обсуждение. Пациенты после КС лучше переносили физическую нагрузку, у них реже возникали рецидивы стенокардии напряжения и инфаркт миокарда по сравнению с группой контроля, в которой реваскуляризацию не проводили. Общая выживаемость пациентов с NSTEMI за период наблюдения 48 мес была статистически значимо (р<0,0048) выше у больных, которым выполняли КС, чем в группе контроля: соответственно 95 и 80 %. Кумулятивная выживаемость без МАСЕ у ургентных и плановых больных в течение 48 мес наблюдения была статистически значимо (р=0,002) выше у пациентов, которым проводили КС: 78 % по сравнению с 50 % в группе контроля. Также кумулятивная выживаемость без MACE на протяжении 48 мес у пациентов, перенесших NSTEMI в сроки от 4 до 180 суток до госпитализации, которым было проведено КС в плановом порядке, была статистически значимо выше, чем в группе контроля (р<0,0036): соответственно 81 и 50 %. У пациентов после перкутанных вмешательств статистически значимо улучшалась функция левого желудочка, и через 48 мес наблюдения количество больных без нарушений сегментарной сократимости увеличилось с 82,4 до 92,4 %. Пациенты с NSTEMI, у которых была впервые выявлена дисгликемия (без диагностированного сахарного диабета), чаще имели тяжелое многососудистое поражение коронарных артерий по сравнению с больными с нормальным углеводным обменом.Выводы. Проведение КС у пациентов, перенесших NSTEMI, в разные сроки от начала заболевания, статистически значимо повышало как общую, так и кумулятивную выживаемость больных. При этом отмечено позитивное влияние КС на кумулятивную выживаемость без MACE не только в группе ургентных больных, но и у пациентов, перенесших NSTEMI в сроки от 4 до 180 суток до госпитализации.

An Adrenaline Rush: Management of Pheochromocytoma in Advanced Heart Failure

Background Pheochromocytoma is a rare neuroendocrine adrenal tumor characterized by overproduction of catecholamines by chromaffin cells. Clinical manifestations include paroxysms of severe hypertension, palpitations, diaphoresis and headaches. Tumor excision is curative but carries an elevated risk, as removal can lead to sudden fluctuations in catecholamine levels, resulting in life threatening arrhythmias, hemodynamic instability and death. We present a case of perioperative management of a pheochromocytoma in a patient with severe ischemic cardiomyopathy. Case A 47 year old man with hypertension presented with progressive dyspnea on exertion. An echocardiogram revealed a newly depressed ejection fraction of 10-15%. Subsequent coronary angiography demonstrated severe multivessel disease deemed not amenable to percutaneous or surgical intervention. Evaluation of his hemodynamics revealed RA12 RV 59/12 PAP 60/33/44 PCWP 25 MVO2 54% CO/CI 3.2/1.69. Routine CT chest and abdomen demonstrated an incidental 6 cm adrenal mass confirmed to be a pheochromocytoma by metaiodobenzylguanidine scan and urine metanephrines. His perioperative care was managed through a multidisciplinary approach with Advanced Heart Failure, Endocrinology, Oncology, and Surgery. Prior to excision, the patient underwent a 14 day load of phenoxybenzamine. A subclavian intra-aortic balloon pump and Swan Ganz catheter were placed preoperatively for continuous hemodynamic monitoring and support. He subsequently underwent laparoscopic removal without complications. His intra-aortic balloon pump was removed two days postoperatively with slow weaning of inotropic and vasoactive support. Phenoxybenzamine was ultimately discontinued, and he was initiated on goal directed neurohormonal blockade. He was discharged with close outpatient follow up. Discussion This case demonstrates successful management of a pheochromocytoma in a patient with ischemic cardiomyopathy in a decompensated low flow state utilizing preoperative mechanical circulatory support. Successful adrenalectomy was supported by an intra-aortic balloon pump and pre-treatment with alpha-blockade. Pertinent challenges in such cases include timing of surgery and use of temporary support devices. Previous data has been inconclusive regarding timing of excision and perioperative use of percutaneous circulatory support due to risks of anticoagulation. Our case highlights the use of this strategy in select high risk patients.

The significance of electrocardiographic changes without echocardiographic evidence of segmental wall motion abnormalities in patients undergoing dobutamine stress echocardiography

Ischemic ECG changes during dobutamine stress echocardiography (DSE) have been reported to have low sensitivity and specificity for detecting myocardial ischemia in the absence of wall motion abnormalities on echocardiography. We present a case of a renal transplant candidate with severe multivessel disease who had ST depressions without any wall motion abnormalities on DSE. Certain studies have shown the sensitivity of DSE is lower in patients with left ventricular hypertrophy and/or end stage renal disease, but the significance of ischemic ECG changes with no evidence of wall motion abnormalities in these patients has not been well studied.

Intelligent System for Personalized Training Coordination and Risk Management

Ischemic ECG changes during dobutamine stress echocardiography (DSE) have been reported to have low sensitivity and specificity for detecting myocardial ischemia in the absence of wall motion abnormalities on echocardiography. We present a case of a renal transplant candidate with severe multivessel disease who had ST depressions without any wall motion abnormalities on DSE. Certain studies have shown the sensitivity of DSE is lower in patients with left ventricular hypertrophy and/or end stage renal disease, but the significance of ischemic ECG changes with no evidence of wall motion abnormalities in these patients has not been well studied.

Diabetes mellitus and heart failure: insights from a toxic relationship

Diabetes mellitus and heart failure: insights from a toxic relationship

Unstable angina in the era of high-sensitivity troponin testing: a genuine entity and a cautionary tale

High-sensitivity cardiac troponin assays have emerged as a powerful tool in the management of patients presenting acutely to hospital with suspected cardiac chest pain. Recent guidelines emphasize the reassurance offered by low troponin concentrations early after admission. We describe a patient with known coronary artery disease, who presented with a classical history of recurrent myocardial ischaemia. High-sensitivity cardiac Troponin-I concentrations remained in the low-normal sex-specific reference range, despite serial testing on the day of admission, and despite recurrent pain with dynamic ECG changes. Urgent coronary angiography confirmed severe multi-vessel disease. He required an intra-aortic balloon pump within 24 h due to clinical instability, and had urgent coronary artery bypass surgery a few days later. This case confirms that "unstable angina" remains a genuine entity. It highlights the hazards of over-reliance on any single test and serves as a reminder of the importance of integrating tests with clinical assessment.

ST elevation myocardial infarction equivalent - De Winter T-wave electrocardiography pattern

Introduction. Rapid diagnosis of acute myocardial infarction is essential for proper treatment and reduction of patient mortality. Electrocardiography plays an important role in its diagnosis. Acute myocardial infarction with ST segment elevation requires urgent reperfusion therapy, that is, primary percutaneous coronary revascularization. A small number of patients with acute myocardial infarction have ST segment depression in one or more leads, whereas ST segment elevation in augmented vector right the electrocardiogram is characteristic for a myocardial infarction without ST elevation, but the clinical course and the severity of disease correspond to the anterior myocardial infarction with ST segment elevation. De Winter T-wave electrocardiography. One of these forms is known as de Winter T-wave pattern, characterized by ST segment depression at the J-point (> 1 mm) in the precordial leads, the absence of ST segment elevation in the precordial leads, high peaked and symmetrical T-waves in the precordial leads and, in most cases, mild ST segment elevation (0.5 mm to 1 mm) in the augmented vector right. These patients have occlusion of the left main coronary artery, occlusion of the proximal segment of the anterior descending artery, or a severe multivessel coronary disease. Patients with this electrocardiographic pattern, which is equivalent to acute myocardial infarction with ST segment elevation, require consideration of emergency reperfusion therapy due to high mortality, compared to other patients with acute myocardial infarction without ST elevation. Primary percutaneous intervention is recommended, or if there is no catheterization laboratory nearby, fibrinolytic therapy may be considered. Because of the lack of clear recommendations, treatment decisions are made individually, from case to case. Conclusion. We need large pro?spective studies with this specific electrocardiographic pattern to provide quick recognition and proper treatment of the anterior myocardial infarction with ST elevation.

Association of endotheline receptor gene rs1878406 polymorphism with severe multi-vessel coronary disease

To assess the association of single nucleotide polymorphisms (SNPs) of endotheline receptor gene with the severity of coronary heart disease (CHD). A total of 553 CHD patients, including 324 patients with mult-vessel disease based on result of selected coronary angiography, and 553 age- and sex-frequency matched controls were selected. Clinical data were collected. Genotypes of rs501120, rs899997, rs1878406 and rs7173743 were determined with TaqMan-MGB probes. The distribution of genotypes of the 4 SNPs showed no significant difference between the two groups. However, the frequency of A allele of rs501120 and T allele of rs1878406 were significantly higher in the CHD group compared with the control group (P< 0.05). For rs7173743 and rs899997, no significant difference was detected between the two groups. After adjusting for conventional risk factors by logistic regression analysis, the results suggested that the distribution of rs1878406 TT+TC genotype in severe multi-vessel disease group is significantly higher than that in the control group (OR=1.43, 95% CI: 1.05-2.07, P=0.033). The above results suggested that the rs1878406 polymorphism of endotheline receptor gene may serve as a genetic marker for severe multi-vessel disease in CHD among ethnic Han Chinese.

The Systematic Evaluation of Identifying the Infarct Related Artery Utilizing Cardiac Magnetic Resonance in Patients Presenting with ST-Elevation Myocardial Infarction.

BackgroundIdentification of the infarct-related artery (IRA) in patients with STEMI using coronary angiography (CA) is often based on the ECG and can be challenging in patients with severe multi-vessel disease. The current study aimed to determine how often percutaneous intervention (PCI) is performed in a coronary artery different from the artery supplying the territory of acute infarction on cardiac magnetic resonance imaging (CMR).MethodsWe evaluated 113 patients from the Reduction of infarct Expansion and Ventricular remodeling with Erythropoetin After Large myocardial infarction (REVEAL) trial, who underwent CMR within 4±2 days of revascularization. Blinded reviewers interpreted CA to determine the IRA and CMR to determine the location of infarction on a 17-segment model. In patients with multiple infarcts on CMR, acuity was determined with T2-weighted imaging and/or evidence of microvascular obstruction.ResultsA total of 5 (4%) patients were found to have a mismatch between the IRA identified on CMR and CA. In 4/5 cases, there were multiple infarcts noted on CMR. Thirteen patients (11.5%) had multiple infarcts in separate territories on CMR with 4 patients (3.5%) having multiple acute infarcts and 9 patients (8%) having both acute and chronic infarcts.ConclusionsIn this select population of patients, the identification of the IRA by CA was incorrect in 4% of patients presenting with STEMI. Four patients with a mismatch had an acute infarction in more than one coronary artery territory on CMR. The role of CMR in patients presenting with STEMI with multi-vessel disease on CA deserves further investigation.

ANALYSIS OF LONG TERM RESULTS OF MYOCARDIAL REVASCULARIZATION IN PATIENTS WITH STABLE ISCHEMIC HEART DISEASE WITH A HIGH LEVEL OF TREATMENT ADHERENCE

Aim. To compare long term results of different methods of myocardial revascularization in patients with stable ischemic heart disease. Material and methods . In the study, 352 patients included, with stable ischemic heart disease: mean age 57,6±7,7 y.o. underwent coronary bypass operation (CBG) — group 1 (n=183) and percutaneous coronary interventions (PCI) — group 2 (n=169) with drug eluting stents implantation (1st generation — Taxus, Cypher), with high treatment adherence — medication treatment in postsurgery period. Each group was selected to 2 subgroups: 1 subgroup with 1-2 vessel disease, 2 subgroup with main left coronary artery stem disease and/or severe multivessel disease. Primary endpoints: all-cause mortality, cardiac mortality, non-fatal myocardial infarction, non-fatal stroke. Secondary endpoint: repeated revascularization or appearance of indications to it. Mean time of follow up after CBG was 37,9±6 months. Results . In long term period there were no differences in survival between groups CBG and PCI neither in 1-2-vessel lesion (95,5% vs. 96,8%), nor with stem stenosis or multivessel disease — 95,6% vs 94,1%. Also, there were differences in survival rate depending on the grade of patient comorbidity, regardless revascularization method. There were no differences in groups 1 and 2 in cardiac mortality, nonfatal events. Emerging of indications for repeated myocardial revasculariztion was significantly higher in subgroups with multivessel disease: free from revascularizations, respectively, 97,1% vs 88,0%, in CBG and PCI (p=0,34). Conclusion . Long term survival after PCI with drug eluting stents of 1st generation in comparison to CBG, does not show significant differences in patients with different severity of coronary arteries lesion and high adherence to treatment. However there is dependence on comorbidity evel. Repeated revascularization of myocardium is needed more oftenly after endovascular interventions in stem lesion and/or multivessel disease.

Coronary artery bypass grafting in octogenarians: only when percutaneous coronary intervention is not feasible?

The aim of this study was to review recent literature reporting the results of coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients older than 80 years. The review of recent studies on octogenarians demonstrates a surgical CABG advantage in the case of patients with increasing baseline coronary risk, such as severe multivessel disease, chronic total occlusions, and left ventricular dysfunction. PCI seems to be more appropriate for less severe degree and distribution of coronary lesions, and for subgroups of patients with higher surgical risk, such as acute coronary syndromes, reoperations, malignancy, dementia, poor mobility, frailty, and serious comorbidities contraindicating extracorporeal circulation. It is not the case that CABG is indicated only when there are contraindications to PCI. CABG confers more benefit than PCI in patients with increasing baseline cardiac risk, in the absence of serious systemic diseases that can reasonably reduce their life expectancy.CABG and PCI, with proper selection, should be considered complementary rather than competitive procedures in the therapy of octogenarians affected by coronary artery disease.