Significant Left Main Disease Research Articles

Plaque composition and morphologic characteristics in significant left main bifurcation disease; virtual histology intravascular ultrasound study.

Although the left main coronary artery (LMCA) is clinically the most important site, little is known about the longitudinal plaque distribution and composition in the significant LMCA disease. Preprocedure virtual histology intravascular ultrasound data were analyzed in 120 patients with significant LMCA bifurcation lesions (angiographic diameter stenosis>50%) requiring revascularization. Plaque burden and percentage of necrotic core (%NC) at the minimal lumen area site and maximal %NC site were measured in four segments: proximal LMCA, distal LMCA, left anterior descending (LAD) ostium, and proximal LAD. Angiographically, a significant LMCA and ostial LAD stenosis were observed in 89.2 and 81.7% of patients, respectively. At the minimal lumen area site, the proximal LAD segment showed the smallest lumen [3.5 mm (2.5-4.7), P<0.001] and the greatest plaque burden [73.2% (63.0-79.3), P<0.001] compared with the other segments. Also, there was a significant downward trend in the number of IVUS-defined lesions toward the proximal LMCA (P=0.001). At the maximal %NC site, the proximal LAD segment carried the largest necrotic core [32.7% (25.7-40.1), P<0.001] and the most frequent virtual histology thin-cap fibroatheroma (67.6%, P<0.001) among the segments, followed by the proximal LMCA [30.3% (22.3-40.0) and 32.9%, respectively]. Most of the plaques carried, at least, one slice of fibroatheroma in every segment; thus, fibroatheroma distributed in a continuous pattern from the proximal LAD to the proximal LMCA. In the significant LMCA bifurcation disease, the proximal LAD segment was found to have the smallest lumen, the largest plaque burden, the highest virtual histology thin-cap fibroatheroma rate, and thus presented the most vulnerable characteristics by virtual histology intravascular ultrasound.

MY APPROACH to the patient diagnosed with significant left main disease: Use of FFR, IVUS, and OCT

MY APPROACH to the patient diagnosed with significant left main disease: Use of FFR, IVUS, and OCT

Tender Endothelium Syndrome: Combination of Hypotension, Bradycardia, Contrast Induced Chest Pain, and Microvascular Angina.

Hypotension, bradycardia, and contrast induced chest pain are potential complications of cardiac catheterization and coronary angiography. Catheter-induced coronary spasm has been occasionally demonstrated, but its relationship to spontaneous coronary spasm is unclear. We describe a 64-year-old female who underwent coronary artery bypass surgery in 1998 on the basis of an angiographic diagnosis of severe left main disease, who recently presented with increasingly frequent typical angina. Repeat coronary angiography was immediately complicated by severe chest pain, hypotension, and bradycardia but demonstrated only mild disease of the left main artery and entire coronary tree with complete occlusion of her prior grafts. This reaction was almost identical to that observed during her original coronary angiogram. We now believe her original angiogram was complicated by severe catheter-induced left main spasm, with the accompanying contrast reaction attributed to left main disease, and the occlusion of coronary grafts explained by the absence of significant left main disease. The combination of these symptoms has not been documented in the literature. In this instance, these manifestations erroneously led to coronary bypass surgery. It is unknown whether routine, systematic injection of intracoronary nitroglycerin prior to angiography might blunt the severity of such reactions.

Clinical impact of coronary protection during transcatheter aortic valve implantation: first reported series of patients.

Coronary protection with guidewires and an undeployed coronary balloon or stent positioned in the coronary artery is a pre-emptive technique to manage coronary obstruction during transcatheter aortic valve implantation (TAVI). We investigated the feasibility and safety of left main (LM) protection during TAVI. Twenty-five out of 623 patients who underwent TAVI at our institute were deemed to be at increased risk of LM compromise mainly due to a low LM ostium height, significant LM disease or a previous bioprosthetic valve. A pre-emptive LM protection technique was therefore used in these cases. Five patients (20%) had pre-TAVI significant non-revascularised LM stenosis, and four patients (16%) had a prior LM ostial stent without pre-TAVI in-stent restenosis. Twelve patients had extremely low LM height (mean height 6.7±2.4 mm; range 1.1-8.9 mm). Seven patients (25%) had valve-in-valve (VIV) procedures. LM compromise occurred in five out of 25 cases; all were treated successfully with emergency LM stenting. Nine patients underwent successful planned LM procedures following TAVI. The LM protection technique should be considered in patients deemed to be at increased risk of LM compromise. This was found to be helpful in the prompt diagnosis and treatment of LM compromise following TAVI.

How should I treat a significant and inoperable left main coronary atherosclerotic disease (LMCAD) in the setting of a severely depressed left ventricular systolic function and severe aorto-iliac atherosclerotic disease?

How should I treat a significant and inoperable left main coronary atherosclerotic disease (LMCAD) in the setting of a severely depressed left ventricular systolic function and severe aorto-iliac atherosclerotic disease?

52 Percutaneous coronary intervention vs. coronary artery bypass graft surgery in left main coronary artery disease – clinical outcomes in the mid-west region

52 Percutaneous coronary intervention vs. coronary artery bypass graft surgery in left main coronary artery disease – clinical outcomes in the mid-west region

Comparison of Different Risk Factors and Coronary Angiographic Profile in Younger and Older Patients with Ischeamic Heart Disease

Background: Due to socio-economic improvement and changes in the life style, ischeamic heart disease is becoming a major burden to our health care system. In recent years, the incidence is increasing among younger age groups as well.Methods: A total of 120 patients with ischeamic heart disease admitted for coronary angiogram were included in the study and were divided into two groups. Among them, 60 younger patients were in Group-I (d” 40 years of age); 60 older patients in Group-II (&gt;40 years of age). We compared demographic profiles, different risk factors and angiographic profiles between two age groups.Results: Among the common risk factors, smoking (63.3% vs 40%, p=0.011) &amp; family history of ischeamic heart disease (21.7% vs 8.3%, p=0.040) were more common in younger group. Whereas, hypertension (41.7% vs 65.0%, p=0.010) and DM (18.3% vs 36.7%, p=0.024) were more common in older patients. Serum Homocysteine level was found significantly higher in younger patients (30.0% vs 13.3%, p=0.026). In group-I. coronary angiography revealed normal coronaries in 15 patients (25%), single vessel disease in 29 (48.3%) and multi-vessel disease in 16 patients (26.6%). Whereas, 40(66.6%) patients in group-II were found to have multi-vessel disease and 2 of them had significant left main coronary disease. However, young patients who had high serum homocysteine level showed more angiographic severity than older patients.Conclusion: There are significant differences in the clinical, biochemical and angiographic profile of young patients with ischeamic heart disease as compared to older patients. Young patients with ischeamic heart disease has got less angiographic severity, except in those with high serum homocysteine level.Cardiovasc. j. 2015; 8(1): 23-29

Stenting of Unprotected Left Main Coronary Artery Stenosis: Immediate out comes in NICVD our Initial Experience

This study aims to describe the initial experiences and immediate outcomes of percutaneous coronary intervention (PCI) in patients with significant left main coronary artery disease with normal LV function in National Institute of Cardiovascular Diseases (NICVD), Dhaka. Left main coronary artery disease is regarded as an absolute contraindication for coronary angioplasty. Recently several reports on protected or unprotected LMCA stenting or both suggested the possibility of percutaneous intervention for this prohibited area. The study was conducted in National Institute of Cardiovascular diseases &amp; Hospital, Dhaka, Bangladesh. Participants of the study were 100 patients with a diagnosis of critical left main coronary artery disease. Information was collected on their demographic characteristics and clinical history. Relevant physical examination and laboratory investigation were performed. Percutaneous transluminal coronary angioplasty (PTCA) with stent implantation were done in the left main coronary artery and other culprit vessel where required. They were followed up thoroughly during the hospital stay. The study subjects were from 35 to 70 years old. 70 male and 30 female were included in this study. According to the clinical history, 12 lead surface ECG reading and cardiac enzyme analysis 40% patient was diagnosed as unstable angina, 40% presented with chronic stable angina and rest of them presented with old myocardial infarction. Among the study population critically isolated LM disease were 30%, critical left main with other vessels disease were 70%. The pattern of LM disease involvement were osteal 40%, mid shaft 10%, distal bifurcation 30%, entire LM involving bifurcation 20%. Procedural success rate was 100%. No patient faced major advance cardiac events (MACE) during hospital stay. Stenting of unprotected LM coronary artery stenosis may be safe effective alternative to CABG in carefully selected patients with normal LV function. Further studies in larger population of this group are needed to assess late out comes.University Heart Journal Vol. 10, No. 1, January 2014; 7-12

Trends in Outcomes of Revascularization for Left Main Coronary Disease or Three-Vessel Disease With the Routine Incorporation of Fractional Flow Reserve in Real Practice

Impact of fractional flow reserve guidance on revascularization strategies and outcomes for severe coronary artery disease was unclear. We evaluate changes in treatment strategy and clinical outcomes and to compare the effectiveness between percutaneous coronary intervention (PCI) with second-generation drug-eluting stents and coronary artery bypass graft surgery (CABG) in severe coronary artery disease patients before and after routine use of FFR. From January 2008 to December 2011, we enrolled 2,612 patients with significant left main coronary artery disease or 3-vessel disease. We obtained data of patients before (from January 2008 to December 2009) and after (January 2010 to December 2011) the routine use of FFR. We used propensity score matching to compare the rate of primary outcomes (death, myocardial infarction, stroke, or repeat revascularization [Major adverse cardiovascular and cerebral event; MACCE]) at 1year. Introduction of routine FFR use reduced the proportion of patients receiving CABG from 54% to 43% (p <0.001). The risk of MACCE before routine FFR use was significantly higher in the PCI group than the CABG group (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.09 to 3.03, p= 0.021), whereas that after routine FFR use was not significantly different between the groups (HR 1.22, 95% CI 0.59 to 2.52, p= 0.59). The risk of MACCE in patients receiving revascularization lowered after routine FFR use compared with that before (HR 0.57, 95% CI 0.38 to 0.85, p= 0.005). In conclusion, routine incorporation of FFR resulted in improved PCI outcomes, comparable with concurrent CABG in patients with severe coronary artery disease who received revascularization.

The Value of Angio CT Multislice for Pre-operative Assessment and Prediction of Post PCI Successful Intervention in Acute Coronary Syndromes Associated by Left Main Disease

Abstract Introduction: The location of culprit lesions on the left main is associated with an increased procedural risk in acute coronary syndromes. Our study aims to evaluate the utility of CT angiography determined Syntax score (CCTA) in comparison with the classical angiographic Syntax score for predicting the procedural success in percutaneous coronary interventions (PCI) of left main lesions. Methods: We included 23 patients presenting to the Cardiology Clinic with an acute coronary syndrome. All patients underwent coronary angiography ± angio CT multisclice for assessment of the target lesion, defined as a significant (&gt;50%) left main disease. Patient population consisted in: group 1 – 13 patients (56.52%), in whom revascularization indication was based on lesion severity assessment by CCTA score correlated with the angio Syntax score (SS), and group 2 – 10 patients (43.48%), in whom revascularization indication was based only on angio SS. According to the SS, the study population was divided into subgroup A – low SS (&lt;22), subgroup B – intermediate SS (23–32) and subgroup C –high SS (&gt;32). All patients were followed for 1 year. Results: Despite similar SS in both groups (35.38 in group 1 vs. 32.4 in group 2), the use of Angio CT multislice increased the rate of PCI indication – 76.92% PCI in group 1 versus 50% PCI in group 2. In patients with high SS, PCI rate was 66.66% in group 1 compared with 50% in group 2 (p&lt;0.05). High calcium score &gt;100 was recorded in 50% of patients in the low SS subgroup (&lt;22), 50% in the medium SS subgroup (23–32) and 22.22% in the high SS (&gt;33) subgroup. One-year follow-up showed an overall mortality of 8.69%, slightly higher in group 2 (10%), as compared to group 1 (mortality of 7.69%). Conclusions: Additional evaluation by angio CT of culprit left main stenoses in acute coronary syndromes provides more information about the complexity of atherosclerotic plaques in this location, and could be extremely useful in establishing the indication for PCI in high risk stenoses, showing a predictive significance for post-procedural 1 year follow up mortality.

Chronic kidney disease in patients with significant left main coronary artery disease qualified for coronary artery bypass graft operation.

According to the guidelines and experts’ opinion, chronic kidney disease can be diagnosed when estimated glomerular filtration rate (eGFR) is lower than 60 ml/min/1.73 m2 and such a filtration rate lasts for more than 3 months. Impaired kidney function accelerates the progress of atherosclerosis, significantly increases the risk of adverse cardiovascular events and worsens prognosis in patients with cardiac diseases. This risk increases in patients with slightly decreased renal function but increases drastically in patients on regular dialysis [1–3].

Demographic profile, clinical characteristics and outcomes of patients undergoing coronary artery bypass grafting—retrospective analysis of 4,024 patients

Large databases give an insight into patient characteristics and outcomes of patients undergoing coronary artery bypass grafting (CABG) in western populations. However, there is paucity of data in Indian population. This study was designed to understand the clinical characteristics and short-term outcomes of patients undergoing CABG at our institute. All the patients who underwent isolated CABG from January of 2001 to December of 2011 were included in the study. Those who underwent re-operative CABG and concomitant valve surgery were excluded. A total of 4,024 patients underwent CABG during the 11-year period. Mean age of patient population was 57 ± 9.6 years. The incidence of female patients undergoing surgery was 12.6 %. Diabetes mellitus was present in 58.4 % of patients. A total of 1,972 (49 %) patients had prior myocardial infarction. Thirty percent of patients had anterior and anterolateral wall infarction. Nineteen percent of patients had inferior wall infarction; 10.6 % had ischemic cardiomyopathy. Incidence of significant left main disease was 10.9 %. Majority of patients (66.4 %) presented with triple vessel disease. Ninety patients (2. 23 %) died in the early post-operative period. Post-operative stroke rate was 0.15 %. Acute renal failure requiring dialysis and mediastinitis occurred in 0.5 and 0.75 % of patients, respectively. Compared to Western population, this cohort of patients who underwent coronary artery bypass grafting had higher incidence of diabetes mellitus and ischemic cardiomyopathy and low incidence of significant left main disease. Post-operative stroke rate was significantly lower compared to 1–2 % stroke rate reported in western population.

Left main disease progression following left branch vessel percutaneous intervention in patients who are referred for coronary artery bypass grafting.

We studied patients presenting for coronary artery bypass grafting (CABG) with significant left main coronary artery disease (LMD) despite previously documented minimal or no LMD at percutaneous coronary intervention (PCI) for left-sided branch coronary artery disease. Patients undergoing CABG for LMD with previous PCI were separated into fast or slow stenosis progression using percent change in LMD from first PCI to CABG divided by time (progression velocity). Outcomes and Kaplan-Meier survival were compared between the two groups. Between September 1997 and June 2010, 4837 patients underwent CABG with 1235 of them having previous PCI of which 118 had LMD and previous left-sided branch PCI. Using median progression velocity fast and slow progression groups were identified (0.53 ± 0.18 and 4.5 ± 4.8%/month, p < 0.001). Mean follow-up was 4.9 ± 3.6 years and 6.9 ± 3.9 years, respectively. Fast progression patients were younger (p = 0.042), with higher baseline LMD at PCI (16.4% vs. 9% stenosis, p = 0.025), and a mean of 2.5 years to LMD compared to 10.6 years for the slow group (p < 0.001). There was no difference between the groups in number or type of PCI and number or type of vessel intervened. Kaplan-Meier survival was similar at one, three, and five years. Fast LMD progression patients were younger and made up 4.7% (59/1235) of patients undergoing CABG with a history of PCI. Rapid progression was not related to number, type of PCI, or branch vessel intervened.

FEASIBILITY OF ACHIEVING AND MAINTAINING MODERATE THERAPEUTIC HYPOTHERMIA (31 DEGREES CELSIUS) IN POST-CARDIAC ARREST PATIENTS

adjudicators blinded to the angiogram results. RESULTS: 528 cardiac catheterizations were performed on PM patients presenting with ACS. After excluding patients without ventricular pacing on the ECG, 157 cases were included. Of the 157 cases, 16 (10.2%) met at least one SC (10 cases had > 5 mm of discordant ST elevation; 6 cases had > 1 mm of ST depression in leads V1, V2, or V3) while 147 did not meet any SC criteria. Baseline clinical characteristics were similar between the groups except for an increased prevalence of peripheral vascular disease in the SC group (53.9% vs. 17.5%; p1⁄40.002). The proportion of patients with positive troponin levels was similar between the groups. Patients meeting SC had a greater incidence of significant left main (LM) coronary disease at the time of cardiac catheterization (31.3% vs. 12.1%; p1⁄40.04; see Figure). There were no significant differences in revascularization strategy (medical therapy vs. PCI vs. CABG) between the groups. CONCLUSION: Among paced patients presenting with ACS, only a small proportion of patients met SC. However, a greater proportion of patients who met SC were found to have significant LM disease at the time of cardiac catheterization compared to those patients who did not meet SC.

ONE YEAR Results OF THE SEVOFLURANE IN ACUTE MI (SIAMI) TRIAL

adjudicators blinded to the angiogram results. RESULTS: 528 cardiac catheterizations were performed on PM patients presenting with ACS. After excluding patients without ventricular pacing on the ECG, 157 cases were included. Of the 157 cases, 16 (10.2%) met at least one SC (10 cases had > 5 mm of discordant ST elevation; 6 cases had > 1 mm of ST depression in leads V1, V2, or V3) while 147 did not meet any SC criteria. Baseline clinical characteristics were similar between the groups except for an increased prevalence of peripheral vascular disease in the SC group (53.9% vs. 17.5%; p1⁄40.002). The proportion of patients with positive troponin levels was similar between the groups. Patients meeting SC had a greater incidence of significant left main (LM) coronary disease at the time of cardiac catheterization (31.3% vs. 12.1%; p1⁄40.04; see Figure). There were no significant differences in revascularization strategy (medical therapy vs. PCI vs. CABG) between the groups. CONCLUSION: Among paced patients presenting with ACS, only a small proportion of patients met SC. However, a greater proportion of patients who met SC were found to have significant LM disease at the time of cardiac catheterization compared to those patients who did not meet SC.

ELECTROCARDIOGRAPHIC DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION IN PACED RHYTHMS: UTILITY OF THE SGARBOSSA CRITERIA

ELECTROCARDIOGRAPHIC DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION IN PACED RHYTHMS: UTILITY OF THE SGARBOSSA CRITERIA

OCT during left main bifurcation PCI

80 years old male was admitted with recent history of acute coronary syndrome. Coronary angiogram showed minimal distal left main disease with significant ostial left anterior descending artery (LAD) lesion (Fig. 1A & Video 1). Optical coherence tomogram (OCT) guided percutaneous intervention (PCI) to Left main and LAD was planned using Provisional T stenting strategy. OCT evaluation showed minimal disease in distal left main (E). Ostial LAD showed thin cap fibro-atheroma with multiple calcified plaques (Fig. 1B, C & D). There was no significant calcium requiring de-bulking. Left circumflex artery (LCX) ostium showed minimal disease. After pre-dilatation and stenting of LAD lesion, there was significant plaque shift into the LCX (Fig. 1F & Video 2). Hence it was converted to two stent strategy and bifurcation stenting of LAD/LCX was done using T and protrusion technique (Fig. 1G, H & Video 3). Post stenting, left main bifurcation was assessed by OCT which showed good apposition of the stents in both LAD and LCX (Fig. 1I). Compared to IVUS OCT with lower penetration has limitations in large vessels like the left main, but its higher resolution helped in identifying a clear landing zone in the left main and a TCFA involving ostial LAD which predicted the plaque shift. Fig. 1 A: CAG in AP cranial view showing tight Ostial LAD lesion without any significant Ostial LCX disease. B: Longitudinal OCT image run from LAD to Left main (orientation-from left to right its distal to proximal) C: Cross-sectional OCT image from mid LAD ... Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.ihj.2014.08.009. The following are the supplementary data related to this article: Video 1: Initial CAG showing critical Ostial LAD disease without any significant left main or LCX disease. Click here to view.(1.1M, mp4) Video 2: After pre-dilation there was significant plaque shift into the LCX ostium. Click here to view.(1.0M, mp4) Video 3: Final angiogram after successful bifurcation PCI to LAD/LCX with two stents using TAP technique. Click here to view.(1.2M, mp4)

Prevalence, location, and extent of significant coronary artery disease in patients with normal myocardial perfusion imaging

BackgroundFalse-negative myocardial perfusion imaging (MPI) can by due to left main (LM) or three-vessel disease causing “balanced ischemia”. However, so far prevalence of LM or three-vessel-disease in patients with normal MPI is unclear. We assessed prevalence, location, and extent of significant coronary artery disease (CAD) in patients with normal MPI. MethodsBetween 2006 and 2010, 256 patients with normal MPI who had invasive angiography because of persisting or worsening of the same initial symptoms were studied. Significant CAD was defined as stenosis > 70% or LM > 50%. ResultsA total of 93 patients (36%) had significant CAD. Significant CAD was observed more frequently in males, higher age and those with typical angina complaints. Significant LM disease was present in 7%, three-vessel disease in 10%, two-vessel disease in 22%, and single vessel disease (not left main) in 61%. In those with single vessel disease, the location was the LAD in 40%, the RCA in 30%, and the LCX in 30%. ConclusionsIn selected patients with normal MPI, one-third had significant CAD. The majority of these patients had single vessel disease (not left main). LM or three vessel disease, causing “balanced ischemia”, is a less common cause of false-negative MPI.

Long-Term Prognostic Factors in Patients with Significant Left Main Coronary Artery Disease

Introduction and Objectives: The natural history of patients with left main coronary artery disease (LMCAD) is largely unknown. Our objective was to analyse the predictors of long-term mortality in these patients, both those that have had surgery and those that have not undergone surgery for various reasons, in a cohort treated at a university hospital. Methods: The study included patients with significant LMCAD diagnosed through consecutive coronary angiograms from 2001 to 2009. Clinical variables, the reasons for cardiac catheterisation, therapeutic decisions and clinical evolution in long-term follow-up were analysed. Results: Of the 163 patients included in the analysis, a total of 109 (66.9%) underwent revascularisation, while the remaining 54 (33.1%) received other medical treatment. We analysed the clinical events that took place with a mean follow-up period of 54 months (IQR: 25-95). The non-revascularised group had a lower survival rate than the revascularised group in unadjusted analysis (logrank test 0.005). Age (OR 1.04, CI 1.02-1.07, p = 0.001), ventricular dysfunction (OR 2.87, CI95% 1.71-4.81, p 0.0001), clinical instability (OR 2.11, CI95% 1.08 to 4.13, p = 0.028) and above 70% severity of LMCAD (OR 1.78, CI 1.09 to 2.91, p = 0.021) were independent predictors of mortality for the entire cohort, but revascularisation was not. Conclusions: Revascularisation is associated with improved survival in patients with LMCAD, but only age, ventricular dysfunction, clinical instability and the severity of the lesion are independent predictors of long-term mortality in the unselected population.

A case of left main coronary artery disease in a young female with aorto arteritis

Aorto arteritis involving coronary lesions is very rare. Coronary lesions, mostly involved are in the form of stenosis or occlusion. It usually involves 9–11% of cases, with coronary ostial site, being the most common site for the involvement up to 73%. The disease is commonly involved in young Asian women with unknown aetiology. In this case, we present a young woman, who has high suspicion of aorto arteritis with significant left main coronary artery disease and right coronary involvement. The culprit lesions were stented with drug eluting stents (Promus Element). But during her 7th month of post angioplasty, patient was readmitted with acute coronary syndrome- Exertional Angina. Her Computerised Tomography – Coronary angiogram showing significant in stent disease in stented ostioproximal segments of Right coronary artery and Left main coronary artery. So patient has been posted for coronary artery bypass graft surgery. The patient has improved symptomatically during her post operative stay and was discharged in haemodynamically stable condition.