Significant Left Anterior Descending Research Articles

A Study of the Usefulness of Tissue Doppler Imaging for the Diagnosis of Coronary Artery Disease in Patients with Left Bundle Branch Block

Abstract Background: In patients with left bundle branch block (LBBB), the diagnosis of ischemia by noninvasive modalities is cumbersome. Most of them such as stress tests, nuclear imaging, and magnetic resonance imaging have limitations in the detection of ischemia in this subset. The postsystolic motion (PSM) during the isovolumetric relaxation period on tissue Doppler imaging (TDI) is a sensitive and specific marker of ischemia. We aimed to see whether the TDI parameters can detect coronary artery disease (CAD) in patients with LBBB. Materials and Methods: Patients with LBBB (n = 64) who underwent coronary angiography were divided into two groups. Group A (n = 30) included patients with left anterior descending (LAD) artery stenosis of ≥70%, and group B (n = 34) included patients without LAD stenosis. All patients underwent TDI and various myocardial tissue velocity parameters were analyzed to detect the presence of CAD. P < 0.05 was considered significant. Results: The TDI of the mid-interventricular septum showed a higher delayed amplitude of PSM (>100 ms after aortic valve closure), lower myocardial systolic (Sm), and early diastolic (Em) velocities, and a higher late diastolic (Am) velocity in group A when compared to group B (all were significant, P < 0.0001). Both the ratios Sm/PSM and Em/Am were significantly lower in group A compared to group B (P < 0.0001). On receiver operating characteristic curve analysis to predict the presence of significant LAD stenosis, the value of Sm/PSM ratio <0.8 showed the best combination of sensitivity (78%) and specificity (96%) with an area under the curve of 0.936. Conclusion: TDI, a noninvasive imaging modality, is reliable and effective in identifying myocardial ischemia in patients with LBBB.

Variation in Left Anterior Descending Coronary Artery Accumulated Dose Estimates during Breast Cancer Radiotherapy

Left anterior descending (LAD) coronary artery RT dose has been associated with the risk of coronary ischemic events in patients with breast cancer treated with radiotherapy (RT). However, consensus dose constraints commonly utilize mean heart dose, which has been shown to be an inadequate surrogate for LAD dose. Given the LAD is adjacent to the steep dose gradients of the left breast/chest wall, we hypothesize that variations in patient positioning or depth of breath hold may contribute to significant deviations in daily LAD dose exposure compared to predicted. Our objective was to investigate variations in accumulated LAD dose in patients with left-sided breast cancer treated with RT. Retrospective analysis of 10 consecutive patients with left-sided breast cancer treated between 2019-2022 with volumetric modulated arc therapy (VMAT) in the supine position. RT was delivered using daily cone beam computed tomography (CBCT) image guidance with deep-inspiratory breath hold technique and an optical surface monitoring system. Daily CBCT scans were individually registered to each planning CT based on daily positional changes. The LAD was manually segmented and transformed to each CBCT. Daily fractional dose was calculated (mean, volume receiving 15 Gy [V15 Gy], V30 Gy, and max) and summed to produce an accumulated dose which was compared to the predicted dose. Significant deviations in accumulated dose were defined as at least ±15% from predicted. The RT targets included breast/chest wall only (n = 1), supraclavicular nodes (n = 8), and/or internal mammary chain (n = 5). All plans were prescribed to 50 Gy in 25 fractions. The median predicted mean heart dose was 5.1 Gy. Overall, there were no significant differences between the median predicted vs. accumulated LAD doses: mean 10.4 vs. 10.2 Gy, V15 Gy 21% vs. 25%, V30 Gy 0% vs. 1%, max 24.5 vs 25.7 Gy (all p>.05). However, there was a subset of patients (n = 5, 50%) with significant deviations in accumulated vs. predicted dose (at least ±15%). For LAD mean, n = 2 had higher accumulated vs. predicted doses (16.6 vs. 11.6 Gy; 14.6 vs. 12.8 Gy), while n = 3 had lower (21.8 vs. 26.5 Gy; 2.7 vs. 4.2 Gy; 13.9 vs. 16.5 Gy). For LAD V15 Gy, n = 3 had higher accumulated vs. predicted doses (43 vs. 35%; 51% vs. 25%; 14% vs. 9%), while n = 2 had lower (49% vs. 61%; 37% vs. 56%). For LAD V30 Gy, n = 4 had higher accumulated vs. predicted doses (12% vs. 5%; 5% vs. 0%; 4% vs. 0%; 4% vs. 2%), while n = 1 had lower (32% vs. 44%). Daily setup differences, including the extent of inspiratory breath hold, may contribute to deviations in accumulated LAD dose (more than 15% of predicted) in approximately half of patients and were more pronounced in V15 and V30 Gy metrics. The potential for significant LAD dose uncertainty in a clinically meaningful subset of patients should be recognized and warrants further analysis in an expanded cohort.

Impact of Preoperative Quantitative Flow Ratio of the Left Anterior Descending Artery on Internal Mammary Artery Graft Patency and Midterm Patient Outcomes After Coronary Artery Bypass Grafting.

Background In coronary artery bypass grafting, grafting a target vessel with nonsignificant stenosis increases the risk of graft failure. The present study aims to investigate the impact of preoperative quantitative flow ratio (QFR), a novel functional assessment of the coronary artery, on internal mammary artery graft failure rate and midterm patient outcomes. Methods and Results Between January 2016 and January 2020, we retrospectively included 419 patients who underwent coronary artery bypass grafting who had received preoperative angiography and postoperative coronary computed tomographic angiography in our center. QFR of the left anterior descending (LAD) artery was computed based on preoperative angiograms. The primary end point was the failure of the graft on the LAD artery assessed by coronary computed tomographic angiography at 1 year, and the secondary end point was major adverse cardiac and cerebrovascular events including death from any cause, myocardial infarction, stroke, or repeat revascularization. Grafts on functionally nonsignificant LAD arteries (QFR >0.80) had a significantly higher failure rate than those on functionally significant LAD arteries (31.4% versus 7.2%, P<0.001). QFR outperforms degree of stenosis in discriminating graft failure (C statistic, 0.76 versus 0.58). Clinical follow-up (3.6 years, interquartile range [3.3-4.1]) was accomplished in 405 patients, and the rate of major adverse cardiac and cerebrovascular events was significantly higher among patients with functionally nonsignificant LAD arteries (10.1% versus 4.2%; adjusted hazard ratio, 3.08 [95% CI, 1.18-8.06]; P=0.022). Conclusions In patients receiving internal mammary artery to LAD artery coronary artery bypass grafting, preoperative QFR of the LAD artery of >0.80 was associated with a higher graft failure rate at 1 year and worse patient outcomes at the 3.6-year follow-up.

Mysterious right ventricular function detection in isolated left anterior descending disease by speckle tracking imaging

Background and aim Early detection of impaired right ventricle (RV) would give significant data for management strategy and prognosis in patients with history of cardiac disease. Echocardiography machine is still the first and most widely used cardiac imaging modality in diagnosing heart disease and assessing systolic and diastolic function with high accuracy. The study aimed to assess mysterious RV function in significant isolated left anterior descending (LAD) disease by imaging with speckle tracking, strain, and strain rate. Patients and methods The present study was a comparative prospective study included 100 participants, 50 patients with significant LAD disease who were candidates for Percutaneous coronary intervention (PCI) (group I), and 50 persons as a control group (group II). All participants were exposed to full medical history, clinical examination, ECG, conventional echo, tissue Doppler, speckle tracking imaging. Results Global longitudinal free wall strain was statistically lower in patient than control group (−19.21±4.11 in patient group vs. −23.73±1.53 in control group, P&lt;0.001), and RV peak systolic strain rate was reduced in patient group than control group (−1.47±0.55 vs. −1.87±0.42, P&lt;0.001). Conclusion In isolated significant LAD disease RV function should be assessed even after opening of LAD by PCI. New echo modality like strain and strain rate are useful echo methods to detect mysterious RV function in patients with significant LAD disease.

Long Term Results of LAD Reconstruction with LIMA Patch in Patients with Multiple Significant LAD disease

Abstract Background Diffusely diseased left anterior descending (LAD) coronary artery with multiple significant stenoses is commonly encountered and is a surgically challenging condition. Aim This study aimed to evaluate the long-term patency of LAD reconstruction with a left internal mammary artery (LIMA) patch in patients with multiple significant LAD stenoses. Methods We enrolled 50 patients who presented with multi-vessel disease and multiple significant LAD stenoses between January 2012 and January 2022. The LAD was opened all the way through leaving the most proximal lesion until probe 1.5 can pass smoothly through the proximal and distal LAD. Then, the LIMA was widely opened, 1.3 times the LAD opening, and they were anastomosed in the usual way with long length anastomosis. All patients were discharged on a combination of aspirin and clopidogrel for the first year and then aspirin alone for life. Postoperatively, patients were followed-up using coronary CT angiography at 5- and 10-years intervals. Results The mean age of the studied patients was 59.08±2.06, and the highest percent (72%) were males. Hypertension, dyslipidemia, and diabetes mellitus comprised the common comorbidities (84%, 68%, and 54%, respectively). the mean ejection fraction was 49.29±3.5 and the mean EuroScore II was 1.02±0.37. The number of grafts was either 5 (8%), 4 (70%), or 3 (22%). Follow-up revealed LAD patency in all the assessed patients at 5 years (49, 98%) and 10-years (46, 92%), while we lost follow-up of 1 (2%) patient at 5 years and 4 (8%) patients at 10-years. Conclusion Reconstruction with LIMA patch was effective in maintaining long-term patency of LAD in patients with multiple significant LAD stenosis. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Unexpected Coronary Angiographic Findings in a Patient with Wellens' Sign

The abnormal electrocardiogram findings of Wellens' sign that occur in the context of unstable angina are typically associated with significant stenosis in the proximal left anterior descending (LAD) coronary artery. We report an unusual case of a patient who had unstable angina and Wellens' sign, without significant LAD stenosis.

Comparison of percutaneous coronary intervention using bioresorbable vascular scaffold and minimally invasive direct coronary artery bypass for left anterior descending artery disease: 3-year clinical outcomes

Aim. Evaluates 3-year clinical outcomes of percutaneous coronary intervention (PCI) with bioresorbable vascular scaffold (BVS) versus minimally invasive direct coronary artery bypass (MIDCAB) surgery for the treatment of left anterior descending (LAD) lesions.Methods. In this single-center study were included 130 patients with stable angina and significant (≥70%) LAD disease. Patients were randomly assigned in a 1:1 ratio to PCI with everolimus-eluting bioresorbable vascular scaffold (Absorb) (n = 65) or MIDCAB (n = 65). The primary end-point was major adverse cerebrocardiovascular events (MACCE) and secondary was. Primary and secondary endpoints were, respectively, major adverse cerebro-cardiovascular events (MACCE) and target vessel failure at 3-year.Results.The groups of patients were comparable for all baseline demographic, clinical and angiographic parameters. The primary composite endpoint of MACCE through 3 years occurred in 16.9% of BVS patients and 9.2% of MIDCAB patients (p = 0.19). But 3-year any revascularization rates were higher with BVS (13.8% vs. 3.1%; p = 0.027). TVF was favor of the MIDCAB group (12,3% vs. 3,1%, p = 0.04), mainly triggered by high subsequent need for revascularization of the targeted vessel in the BVS group (9.2% vs. 1.5%; p = 0.05).Conclusion. At 3-year follow-up, PCI by BVS and MIDCAB in in patients with isolated LAD lesions yielded similar long-term outcomes regarding the primary composite clinical endpoint. The bioresorbable scaffold was associated with a higher incidence of reinterventions, TVF and TVR than the MIDCAB through 3 years of follow-up.

Concurrent Carotid Endarterectomy and Off-Pump Coronary Artery Bypass Graft Surgery in Bangladesh: A Prospective Cohort Study

A patient of ischemic heart disease (IHD) with additional carotid artery stenosis (CAS) has been distinguished as a high risk group for both heart and cerebral inconveniences following surgical intervention. We aimed to review the outcome of concurrent carotid endarterectomy (CEA) and off-pump coronary bypass graft (OPCABG)in a patient undergoing surgical revascularization for IHD and CAS at our institute.In the vicinity of 2014 and 2016, fifteen patients experienced OPCABG and CEA associatively in a single Surgeon's Practice. Six (40%) patients had a history of myocardial infarction (MI), four (26.66%) had unstable angina (USAP), and three (20%) had USAP together with MI, though two (13.33%) were asymptomatic. Nine (60%) patients demonstrated no neurological manifestations, three (20%) had transient ischemic assaults (TIAs), two (13.33%) experienced stroke, and 1 (6.66%) experienced both. Majority 7 (46.66%) patients had 75-90% carotid artery stenosis and 6(40%) patients experienced right though 8 (53.33%) experienced left CEA and only 1 (6.66%) had bilateral CEA. Five (33.33%) patients were found left main disease (&gt;50% lesion) and 100% patients have had significant Left Anterior Descending (LAD) lesion in this study. Twelve (80%) patients show significant lesion in Right Coronary Artery (RCA) and ten (66.66%) patients had Obtuse marginal (OM) branch disease. CEA was performed before OPCABG in all cases. There were 15 patients (mean age 62.5±2.8 years; 80% were male), two (13.33%) had a perioperative stroke while one of them had TIAs (6.6%). Mean ICU stay was 36.6±4.5 h and patients were released in 10 days. There was no mortality in the early postoperative period and co-morbidity was less significant (6.6% myocardial ischemia, 13.33% atrial fibrillation, 6.66% TIA, 13.33% Stroke). There was 1 (6.66%) postoperative acute renal failure evidenced by raised serum creatinine level. Two (13.33%) patients showed respiratory complications; only 6.6% of them suffered from wound infection. A combined strategy by means of CEA with OPCABG is safe and savvy in view of the satisfactory consequences of morbidity and mortality rates and also short ICU and hospital stay status.Faridpur Med. Coll. J. Jan 2018;13(1): 2-7

Percutaneous coronary intervention with ABSORB biodegradable vascular scaffold in patients with left anterior descending artery disease

Aim. The article evaluates 30-day results of percutaneous coronary intervention (PCI) with ABSORB biodegradable vascular scaffold (BVS) implanted in the case of stenosis of the left anterior descending (LAD) coronary artery in patients with stable angina.Methods. 64 patients with significant (≥ 70%) LAD disease were included in the study. At 30 days, scaffold thrombosis and major adverse cardiovascular events (all-cause mortality, myocardial infarction, stroke, target vessel revascularization) were evaluated. The indicator of successful percutaneous coronary intervention (residual stenosis ≤20% in the presence of counterpulsation corresponding to TIMI 3rd Grade and in the absence of significant in-patient clinical complications) and successful intervention assessed by clinical criteria (successful percutaneous coronary intervention alongside with a decrease in objective and subjective symptoms of myocardial ischemia, or their complete disappearance) were also analyzed. Results. Mean age of patients was 61.6±8.5 years, with males accounting for 64%; 33% had earlier MI, 14% – diabetes mellitus. Mean left ventricular ejection fraction was 61.3±6.8%. Left anterior descending artery disease was presented in 89% of patients with SYNTAX Score 6.6±2.2. Mean number of implanted stents was 1.2±0.4, with mean length of the stented segment equal to18.7±1.8 mm and mean diameter 3.2±0.3 mm. At 30-day follow-up, the success of intervention assessed by clinical criteria amounted to 96.9% (n=62); that of myocardial infarction 3.1% (n=2); stent thrombosis 1.56% (n=1); repeated revascularization 1.56% (n=1); major adverse cardiovascular events (MACE) 3.1%.Conclusion. The implantation of everolimus-eluting BVS for LAD stenosis demonstrates satisfactory results at 30-day follow-up.Received 16 January 2017. Accepted 21 March 2017.Financing: The study did not have sponsorship.Conflict of interest: The authors declare no conflict of interest.

Evaluation of the Incidence of Major Adverse Cardiac and Cerebrovascular Events after Percutaneous Coronary Intervention or Coronary Artery Bypass Graft on Proximal Left Anterior Descending Artery with and without Other Coronary Arteries Involvement

: Background: Major Adverse Cardiac and Cerebrovascular Events (MACCE) include cardiac death, nonfatal Myocardial Infarction (MI), cerebrovascular events, and Target Vessel Revascularization (TVR) that may happen after Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Graft (CABG). Objectives: This study aimed to compare the incidence of MACCE between the patients who underwent PCI or CABG due to significant Left Anterior Descending (LAD) stenosis with and without other coronary arteries involvement. Patients and Methods: This randomized mixed cohort study was conducted on 400 patients with Coronary Artery Disease (CAD), 200 with proximal LAD stenosis and 200 with non-proximal LAD stenosis, selected through census. Half of each group underwent PCI and the rest underwent CABG. The participants were followed at fixed intervals after the procedure and the incidence of MACCE was documented in their checklists. Then, relative risk index was used to compare the two groups regarding the incidence of MACCE. Statistical analysis was done using the Stata software, version 11 and P Results: The study participants included 281 males and 119 females with the mean age of 61.36 ± 10.66 years. The results showed a significant difference between the two groups regarding the incidence of MACCE (31.58% vs. 3%, P = 0.001). However, no significant difference was found between the effects of PCI with drug eluting stent and CABG on proximal LAD (3.70% vs. 3%, P = 1.00). Conclusions: Considering the incidence of MACCE, CABG had no superiority over DES for proximal LAD stenosis.

ABSENCE OF SEPTAL Q WAVES: An Important Predictor of Significant Coronary Artery Disease and Mainly Proximal Stenosis of the Left Anterior Descending Artery.

Data concerning the correlation between the absence of septal q waves and significant stenosis of proximal left anterior descending (LAD) artery shows conflicting results. This retrospective study was conducted to show that absence of septal q waves in leads V5-V6 could be of value in predicting significant coronary artery disease (CAD) and mainly significant proximal LAD coronary artery stenosis. Our study included 500 consecutive patients who had coronary angiography, retrospectively chosen, excluding patients with acute coronary syndromes, and patients with abnormal ECGs (abnormal QRS duration, pathological q waves and hemiblocks). ECG and angiography films were reviewed. For the 2x2 tables analysis, a chi-square test was used. Of the 500 patients, 386 had significant CAD defined as 70% luminal stenosis, and 260 had no septal q wave. Of the 386 patients with significant CAD, 233 (60%) did not have septal q waves. Of 260 who did not have septal q wave, 192 (73%) had significant stenosis of proximal LAD. Statistical analysis shows that significant CAD correlates with the absence of septal q waves, with a sensitivity of 60% and a specificity of 76%, and that stenosis of proximal LAD could be predicted by absence of septal q waves in leads V5-V6 with a sensitivity of 83% and a specificity of 74%. The absence of septal q waves in leads V5-V6 on the ECG correlates with the presence of significant CAD and is of highly predictive value in those with significant stenosis of proximal LAD (p < 0.0001).

Coronary Extramural Haematoma Caused by Perforation during Left Main Coronary Artery Intervention

A year-old male patient with a background of quintuple coronary artery by-pass graft surgery 16 years ago presented to our department with symptoms consistent with unstable angina pectoris. Previous angiography performed in 2001 revealed occluded saphenous vein grafts to the left anterior descending (LAD), right coronary, obtuse The presence of pericardial effusion was immediately ruled out by echocardiography and because of absence of myocardial contrast staining heparin was not reversed. Subsequent intravascular ultrasound (IVUS) examination revealed a minimal lumen area of ≥11.00 mm2 throughout the stented segment despite stent underexpansion at marginal and first diagonal (DA) arteries, and patent left internal mammary artery (LIMA) graft to a second DA. At the same session he underwent percutaneous coronary intervention with bare metal stent implantation for significant mid to distal LAD artery disease. Since then, the patient was stable with Canadian angina class I. During this admission, his echocardiogram revealed an ejection fraction of 40%, akinesia of the inferior wall which was known to be predominantly infarcted and hypokinesia of the basal and mid anterior septum. Coronary angiography (Fig. 1) showed subocclusive calcified and angulated distal left main coronary artery (LMCA) disease, significant ostial LAD artery disease, collateralised occlusion of the distal LAD, left circumflex (LCx) and right coronary arteries, tight proximal disease of a first DA and patent LIMA graft to a second DA. Given these findings we proceeded with stent angioplasty to the LMCA-ostial LAD artery lesion. After a series of predilations with semicompliant balloons, a 4.0 mm × 24 mm drug-eluting stent was the LMCA opposite to the LCx artery ostium and at the LAD artery ostium. Cross-sections of IVUS at the site of perforation revealed an echo-dim pattern suggesting an extramural haematoma and local stent underexpansion with a compression effect by the haematoma whereas the site of blood entry into the adventitia was identified at the distal margin of the haematoma adjacent to a fibrocalcific plaque (Fig. 2). Given the adequate minimal lumen area further stent postdilation was not performed to avoid the risk of frank coronary perforation. The patient was maintained on dual antiplatelet therapy and discharged home after a two-day uneventful hospital course. He remained stable eight months post stenting with Canadian angina class I and no evidence of a cardiovascular event. Extramural haematoma that is accumulation of blood outside the arterial wall in the adventitia tissue is a rare complication of percutaneous coronary intervention and is thought to develop secondary to adventitial dissection implanted from the ostium of the LMCA across the stenosis into the LAD artery at 8 atms. Control angiography after [1–3]. It presents with an echo-dim pattern due to the dilution of the red blood cells and dissemination throughout

Use of Strain Imaging to Predict Myocardial Function Recovery after Percutaneous Revascularization of Infarct Related Artery

Use of Strain Imaging to Predict Myocardial Function Recovery after Percutaneous Revascularization of Infarct Related Artery Background: Speckle tracking echocardiography is integrated into echocardiographic systems for automated evaluation of left ventricular (LV) function by means of Automated Function Imaging (AFI). This study aimed at evaluating role of strain imaging [AFI & Tissue Velocity Imaging (TVI)] in predicting post-percutaneous coronary intervention (PCI) LV function recovery. Methods: Fifty patients with anterior wall myocardial infarction & impaired LV ejection fraction (LVEF≤45%), were prospectively enrolled. All patients showed positive viability results concerning left anterior descending (LAD) artery territory using low-dose dobutamine stress echocardiography (LDSE) & significant LAD disease for PCI. All patients underwent strain maging using AFI & TVI; at rest, at peak dose of LDSE and 3 months after PCI.

The “widow maker” warning sign or Wellens’ syndrome: A case report

Wellens? syndrome, also known as LAD (left anterior descending) coronary T-wave syndrome, ?widow maker? or warning sign, is a potentially unrecognized critical proximal LAD stenosis with possible fatal consequences. It can be associated with extensive acute anterior wall myocardial infarction, with left ventricular dysfunction and a lethal outcome within a few days after the onset of symptoms. It usually consists of a typical ECG finding in the precordial leads that represents a significant proximal LAD stenosis in patients with unstable angina pectoris. Although this syndrome is not indicated for PCI (the patient is usually pain-free at the time of electrocardiography registration), it is necessary to recognize the characteristic pattern and perform an emergency coronary angiography and percutaneous or surgical revascularisation of the affected blood vessel. Here we present the case report of a 47 year-old woman without previous anamnesis of coronary disease. On admission to the Coronary Care Unit she was chest pain-free and had all the indicators of Wellens? syndrome.

Diagnostic and prognostic value of Doppler echocardiographic coronary flow reserve in the left anterior descending artery

BackgroundVasodilator stress echocardiography allows dual imaging of regional wall motion and coronary flow reserve (CFR) on left anterior descending (LAD) artery. Hypertension may affect CFR independently of obstructive coronary artery...

Usefulness of Coronary Flow Reserve Measured by Echocardiography to Improve the Identification of Significant Left Anterior Descending Coronary Artery Stenosis Assessed by Multidetector Computed Tomography

Multidetector computed tomography (MDCT) detects coronary artery disease. However, an overestimation of coronary artery stenosis and artifacts can prevent accurate identification of significant coronary narrowing. The combination of MDCT with coronary flow reserve (CFR), the hyperemic/baseline peak flow velocity ratio, measured by transthoracic Doppler echocardiography might be helpful. We studied 144 consecutive patients with CFR and quantitative coronary angiography, obtained using both MDCT and invasive coronary angiography (reference method). It was hypothesized that the CFR might provide an incremental value to MDCT in detecting significant (> or =70%) left anterior descending (LAD) coronary artery stenosis. A CFR cutoff of <2 was used to discriminate significant stenosis. CFR was feasible in 141 (98%) of 144 patients, and MDCT was feasible in 131 (91%) of 144 patients (p <0.02). In a univariate model, the prediction of significant LAD stenosis was slightly, but significantly (p <0.0001), better with CFR (sensitivity 90%, specificity 96%, positive predictive value 84%, negative predictive value 97%, and diagnostic accuracy 94%, chi-square = 97.5) than with MDCT (sensitivity 80%, specificity 93%, positive predictive value 71%, negative predictive value 95%, diagnostic accuracy 90%, chi-square = 63.2). When the findings from transthoracic Doppler echocardiography and MDCT agreed, the diagnostic accuracy increased (96%; chi-square = 86.1, p <0.0001). In a multivariate prediction of significant LAD stenosis using a logistic neural network, CFR overshadowed MDCT, and the area under the receiver operating curve was 0.99. Of the 13 patients missed by MDCT, the diagnostic accuracy of transthoracic Doppler echocardiography to predict significant LAD stenosis was 100%. Thus, CFR could improve the diagnostic accuracy of MDCT to detect significant LAD stenosis.

Randomized Comparison of Minimally Invasive Direct Coronary Artery Bypass Surgery Versus Sirolimus-Eluting Stenting in Isolated Proximal Left Anterior Descending Coronary Artery Stenosis

The purpose of this randomized study was to compare sirolimus-eluting stenting (SES) with minimally invasive direct coronary artery bypass (MIDCAB) surgery for patients with isolated proximal left anterior descending (LAD) coronary artery disease. Bare-metal stenting is inferior to MIDCAB surgery in patients with isolated proximal LAD lesions due to a higher reintervention rate with similar results for mortality and reinfarction. SES are effective in restenosis reduction. A total of 130 patients with significant proximal LAD coronary artery disease were randomized to either SES (n = 65) or MIDCAB surgery (n = 65). The primary clinical end point was noninferiority in freedom from major adverse cardiac events (MACE), such as cardiac death, myocardial infarction, and the need for target vessel revascularization within 12 months. Follow-up was completed for all patients. MACE occurred in 7.7% of patients after stenting, as compared with 7.7% after surgery (p = 0.03 for noninferiority). The individual components of the combined end point revealed mixed results. Although noninferiority was revealed for the difference in death and myocardial infarction (1.5% vs. 7.7%, noninferiority p < 0.001), noninferiority was not established for the difference in target vessel revascularization (6.2% vs. 0%, noninferiority p = 0.21). Clinical symptoms improved significantly in both treatment groups in comparison with baseline, and the percentage of patients free from angina after 12 months was 81% versus 74% (p = 0.49). In isolated proximal LAD disease, SES is noninferior to MIDCAB surgery at 12-month follow-up with respect to MACE at a similar relief in clinical symptoms.

Three-dimensional analysis of vulnerable segments in the left anterior descending artery

Analysis of conventional angiograms has suggested that specific anatomic parameters of particular segments of a coronary artery render them prone to vulnerable plaque development, plaque rupture, and consequent thrombosis. This study aimed at performing a three-dimensional analysis of recanalized left anterior descending (LAD) coronary arteries in patients who had suffered an anterior ST-elevation myocardial infarction (STEMI). Coronary angiograms of 76 consecutive patients with an anterior STEMI and a recanalized LAD were reconstructed in the three-dimensional space, and compared with angiograms of 76 patients with stable coronary artery disease (SCAD) and significant LAD stenosis. In both groups the majority of lesions occurred between 20 and 40 mm (P=0.745), but the number of lesions beyond 60 mm from the ostium was significantly higher in SCAD compared with STEMI (P=0.045). Culprit lesions were statistically significantly longer in patients with STEMI compared with SCAD (18.3+/-7.5 vs. 12.7+/-6.2 mm, P<0.001). Cut-off point analysis indicated a lesion length of >or=12.5 mm as discriminating threshold between SCAD and STEMI (sensitivity 79% and specificity 63%). Bifurcation branches on the culprit lesion were seen in 79% of the patients with STEMI and 58% of those with SCAD (P=0.026). Lesion angulation was significantly sharper in STEMI compared with SCAD patients in diastole (155+/-15 vs. 160+/-14 degrees, P=0.037). Multiple logistic regression model including these parameters had a high discriminating ability with c-statistic 0.78 (95% confidence intervals: 0.71-0.86), sensitivity 72.4%, and specificity 75%. Specific anatomic characteristics of LAD segments predispose to development of plaque rupture and thrombosis.

Abstract 4705: Detection of Significant Left Anterior Descending Coronary Artery Disease in Pacemaker Dependent Patients Utilizing Real Time Perfusion Imaging During Dobutamine Stress Echocardiography

Non-invasive methods of detecting left anterior descending (LAD) coronary artery disease (CAD) in patients who are pacemaker dependent (PD) are limited because of right ventricular (RV)-pacing induced left ventricular wall thickening (WT) abnormalities involving the septum and apex. Real time perfusion echocardiography (RTPE) analyzes myocardial blood flow (MBF) changes with high resolution (&lt;2 mm) during intravenous (IV) infusions of ultrasound contrast, and can potentially identify whether significant LAD is present in PD patients during dobutamine stress (DS). 54 consecutive PD patients who were being evaluated for CAD using DS echocardiography with RTPE were identified. Dobutamine was infused to 30 u/kg/min, but had to be combined with incremental RV pacing to achieve 85% predicted maximum heart rate. Perfusion and WT in the septum and apex were assessed at rest and at peak DS. MBF in the LAD territory was considered abnormal if a &gt;4 second delay in contrast replenishment occurred during a continuous 3% Definity infusion at rest, or &gt;2 second delay at peak DS. Quantitative coronary angiography (QCA) was performed to assess for significant CAD (&gt;50% diameter stenosis considered significant). Outcomes were analyzed by examining coronary events (death, non-fatal myocardial infarction, or need for coronary revascularization) at a median follow-up of 20 months post DS. WT abnormalities in the septum and apex due to RV pacing were noted in 43 of the patients (80%), while the remaining patients exhibited normal WT. Of those with pacing-induced WT abnormalities, 25 (58%) had a MBF abnormality at peak stress, while 18 (42%) had normal myocardial contrast enhancement. Overall, the positive predictive value (PPV) of abnormal MBF by RTPE for the detection of LAD CAD in PD patients was 85%. Patients with a MBF abnormality in the LAD territory by RTPE had a coronary event rate of 17 % at follow up, while patients with normal MBF responses during DS had no events at follow up (negative predictive value 100%). RTPE is helpful in detecting CAD in the LAD territory of patients who are PD. A normal MBF response predicts an excellent cardiac outcome, irrespective of WT responses.

Transthoracic Doppler Echocardiographic Coronary Flow Imaging in Identification of Left Anterior Descending Coronary Artery Stenosis in Patients with Left Bundle Branch Block

Conventional noninvasive methods have well-known limitations for the detection of coronary artery disease (CAD) in patients with left bundle branch block (LBBB). However, advancements in Doppler echocardiography permit transthoracic imaging of coronary flow velocities (CFV) and measurement of coronary flow reserve (CFR). Our aim was to evaluate the diagnostic value of transthoracic CFR measurements for detection of significant left anterior descending (LAD) stenosis in patients with LBBB and compare it to that of myocardial perfusion scintigraphy (MPS). Simultaneous transthoracic CFR measurements and MPS were analyzed in 44 consecutive patients with suspected CAD and permanent LBBB. Typical diastolic predominant phasic CFV Doppler spectra of distal LAD were obtained at rest and during a two-step (0.56-0.84 mg/kg) dipyridamole infusion protocol. CFR was defined as the ratio of peak hyperemic velocities to the baseline values. A reversible perfusion defect at LAD territory was accepted as a positive scintigraphy finding for significant LAD stenosis. A coronary angiography was performed within 5 days of the CFR studies. The hyperemic diastolic peak velocity (44 +/- 9 cm/sec vs 62 +/- 2 cm/sec; P=0.01) and diastolic CFR (1.38 +/- 0.17 vs 1.93 +/- 0.3; P=0.001) were significantly lower in patients with LAD stenosis compared to those without LAD stenosis. The diastolic CFR values of <1.6 yielded a sensitivity of 100% and a specificity of 94% in the identification of significant LAD stenosis. In comparison, MPS detected LAD stenosis with a sensitivity of 100% and a specificity of 29%. CFR measurement by transthoracic Doppler echocardiography is an accurate method that may improve noninvasive identification of LAD stenosis in patients with LBBB.