Proximal LAD Stenosis Research Articles

Comprehensive Risk Assessment of LAD Disease Progression in CCTA: The CLAP Score Study

Background: a wider left main bifurcation angle (LMBA) has been linked to severe plaque development in the proximal left anterior descending artery (LAD). This study aimed to identify predictors of severe proximal LAD stenosis and major adverse cardiovascular events (MACE) using coronary computed tomography angiography (CCTA). Methods: from an initial cohort of 650 consecutive patients, we analyzed 499 patients who met the inclusion criteria after exclusions. Plaque morphology and characteristics were assessed by CCTA, and MACE occurrences were recorded at follow-up. A predictive score for LAD disease progression (CLAP score) was developed and validated. Results: severe proximal LAD stenosis was detected in 32% (160/499) of patients by CCTA. MACE occurred in 12.5% of patients at follow-up. Significant predictors of MACE were LMBA > 80° (HR: 4.47; 95% CI: 3.80–6.70; p < 0.001), diabetes (HR: 2.94; 95% CI: 1.54–4.63; p = 0.031), chronic kidney disease (HR: 1.71; 95% CI: 1.31–6.72; p = 0.041), high-risk plaques (HR: 2.30; 95% CI: 1.45–3.64; p < 0.01), obstructive CAD (HR: 2.50; 95% CI: 1.50 to 4.10, p = 0.01), and calcium score (CAC) (HR: 1.05; 95% CI: 1.02–1.08, p = 0.004). The CLAP score demonstrated good discriminatory power in both the development (AUC 0.91; 95% CI: 0.86–0.96) and validation cohorts (AUC 0.85; 95% CI: 0.79–0.91); Conclusions: LMBA > 80°, diabetes, chronic kidney disease, obstructive CAD, CAC score >180 and high-risk plaques were significant predictors of MACE in CCTA patients. The CLAP score effectively predicted LAD disease progression, aiding in risk stratification and optimization of intervention strategies for suspected coronary artery disease.

The contemporary management and coronary angioplasty outcomes in young patients with ST-Elevation myocardial infarction (STEMI) age < 40 years old: the insight from nationwide Thai PCI registry

BackgroundCardiovascular disease (CVD) remains one of the major causes of death around the world in which ST elevation MI (STEMI) is in the lead. Although the mortality rate from STEMI seems to decline, this result might not be demonstrated in young adults who basically have different baseline characteristics and outcomes compared with older patients.MethodsData of the STEMI patients aged 18 years or older who underwent PCI during May 2018 to August 2019 from Thai PCI Registry, a prospective, multi-center, nationwide study, was included and aimed to investigate the predisposing factors and short-term outcomes of patients aged < 40 years compared with age 41–60, and > 61 years.ResultsData of 5,479 STEMI patients were collected. The patients’ mean age was 62.6 (SD = 12.6) years, and 73.6% were males. There were 204, 2,154, and 3,121 patients in the youngest, middle, and oldest groups. The young patients were mainly male gender (89.2% vs. 82.4% and 66.6%; p < 0.001), were current smokers (70.6%, 57.7%, 34.1%; p < 0.001), had BMI ≥ 25 kg/m2 more frequently (60.8%, 44.1%, 26.1%; p < 0.001), and had greater family history of premature CAD (6.9%, 7.2%, 2.9%; p < 0.001). The diseased vessel in the young STEMI patients was more often single vessel disease with the highest percentage of proximal LAD stenosis involvement. Interestingly, there were trends of higher events of procedural failure (2.9%, 2.1%, 3.3%; p = 0.028) and procedural complications (8.8%, 5.8%, 9.4%; p < 0.001) in both youngest and oldest groups compared to the middle-aged group. In-hospital death was found in 3.4% in the youngest group compared to 3.3% in the middle-aged patients and 9.2% in the older patients (p < 0.001).ConclusionsDespite experiencing higher rates of procedural failure and complications during treatment compared to middle-aged and older patients, young STEMI individuals demonstrate a significantly lower risk of death during hospitalization and within one year of the event. Younger patients might have a more robust physiological reserve or benefit from more aggressive post-procedure management. However, the higher prevalence of modifiable risk factors like smoking and obesity in younger individuals underscores the need for preventative measures. Encouraging smoking cessation and weight control in this demographic is crucial not only to prevent STEMI but also to potentially improve their long-term survival prospects.

CLINICAL CASE OF A VERY YOUNG PATIENT AFFECTED BY CAD

Abstract Young patient of 24 years old, smoker, dyslipidemic and family history of coronary artery disease (CAD). He was admitted to emergency room for chest pain after moderate effort in December. EKG was normal, troponin was negative and echocardiography showed left ventricle with normal contractility. Blood chemistry test showed LDL 130 mg/dL, Triglycerides 200 mg/dL e Lipoprotein (a) 16 nmol/L. Elective cardiovascular exercise test resulted positive for signs and symptoms of cardiovascular ischemia (Figure 1). Coronary angio–TC showed 60% stenosis of proximal LAD and intramyocardial bridging of mid LAD. Subsequently elective coronary angiography confirmed the description of coronary angio–TC; contextually optical coherence tomography (OCT) was performed and showed fibrous cap rupture of proximal LAD (Figure 2 – 3). The patient was discharged with indication of medical therapy (Cardioaspirina 100 mg, Atorvastatina 40 mg, Bisoprololo 1,25 mg). CAD is a chronic condition usually occurring after the sixth decade of life. However, some populations experience this disease prematurely. In the last few decades, different studies have shown an increased incidence of CAD in very young people. The prevalence of CAD reported in very young people is 1–16%. Clinical and interventional management of CAD in very young people is still subject of discussion today. The literature showed how risk factors such us current smokers, dyslipidemia, and family history of CAD are significantly associated with the existence of severe CAD in patients of ≤40 years. The above risk factors are present in this patient, therefore we opted for correct them by medical therapy and follow–up by OCT at 6 months. The patient was stable and asyntomatic for chest pain at 1 month telephone follow–up.Figure 1.Figure 2.Figure 3.

A COMPLEX POST CARDIAC–ARREST SYNDROME: FROM UNCERTAIN NEUROLOGICAL OUTCOME TO HEMORRHAGIC COMPLICATION

Abstract A 49–years–old woman with type II diabetes mellitus, hypothyroidism and Churg–Strauss syndrome experienced chest pain with loss of consciousness. Emergency service was called and CPR promptly started. Cardiac arrest with shockable rhythm was documented, DC–shock performed with sign of anterior STEMI after ROSC, then refractory cardiac arrest appeared. The patient was centralized in our hospital and VA–ECMO was positioned through a percutaneous femoral access in cath–lab. Coronary angiography showed acute occlusion of the mid–proximal LAD and subocclusive stenosis of the dominant Cx for which PCI with DES was performed, then intra–aortic balloon pump (IABP) was implanted. At ICCU admission the patient was supported by ECMO and IABP with MAP 65 mmHg and lactates 3.5 mmol/L. Echocardiography and chest X–ray showed severe biventricular dysfunction and pulmonary overload (Fig 1). She was ventilated via ECMO circuit and mechanical ventilation setting protective TV values of 6 ml/kg. Diuresis was good with low dose of furosemide, lactates progressively decreased. Temperature control was set within 36°C with the cooling system of the ECMO circuit. Cardioaspirin, ticagrelor and bivalirudin were administered. At early neurological stratification EEG documented absence of epileptiform anomalies, responsiveness to painful stimuli, SSPE showed normal and symmetrical morphology, NSE at 48 h was 59 ng/mL, she opened eyes and performed simple orders. Levosimendan was administered with partial recovery of the right ventricular dysfunction leading to ECMO removal on 5th day. Due to poor consciousness recovery despite sedation reduction, percutaneous tracheostomy was performed on 8th day, IABP removed and the following day all vasopressors suspended. Neurological improvement allowed transition to spontaneous breathing and weaning from mechanical ventilation; on 19th day tracheostomy was removed. Massive enterorrhagia appeared after ECMO removal (figure 2). The colonoscopy showed ischemic pancolitis, therefore ticagrelor was suspended. On 18th day clopidogrel was reintroduced based on hemoglobin stability and endoscopic improvement. She was discharged from the cardiology department after a total length of stay of thirty days, with normal neurological status, no motor deficits, recovery of left and right ventricular function, stable hemoglobin levels.

WHEN AND WHERE DOES A CARRIER OF HEREDITARY TRANSTHYRETIN AMYLOIDOSIS (ILE88LEU) SHOW THE FIRST SIGNS OF THE DISEASE? DIAGNOSTIC CHALLENGES OF A NOT ONLY CARDIOGENIC MUTATION

Abstract We present the case of a 58–year–old man with a familiar history (mother affected) positive for ATTR–v (Ile88Leu) amyloidosis. The mother initially had a pure cardiac phenotype and was firstly treated with tafamidis, but progression of the disease to the nervous system warranted a switch to patisiran. Our patient carried the Ile88Leu mutation and had a medical history notable for surgically treated left carpal tunnel syndrome (CTS) and untreated right CTS. Furthermore, he was affected by systemic arterial hypertension and was a habitual smoker. He has been followed at our Institution since 2018. His first echocardiogram showed normal left ventricular ejection fraction (LVEF 65%), mild hypertrophy (anterior septum: 12 mm), and borderline values of GLS (– 16%) without any specific pattern. Further exams were executed: Bone scintigraphy (BS): negative (Perugini score 0); Coronary artery ct scan: moderate stenosis of proximal LAD; Neurologic evaluation: no signs of peripheral neuropathy. The clinical picture remained unaltered in 2020 and 2021. However, during November 2022 the patient developed atrial fibrillation (AF) and presented to the ED for dyspnea and palpitations. Electrical cardioversion was performed with success but subsequent recurrences warranted AF ablation in April 2023. At that moment, the patient was re–evaluated. Basal ECG did not show any significant alteration (FIg.1)This time, echocardiogram showed mild worsening of hypertrophy (13 mm septum), GLS – 16% with apical sparing pattern, no other major variations (Fig.2). BS was repeated and revealed grade 1 Perugini score (Fig.3). Hence, a series of clinical question arose: Should we begin a specific treatment or is the disease in an excessively early stage that does not warrant treatment? Is AF linked to concomitant arterial hypertension or might it be an early marker of disease? We questioned the usefulness of endomyocardial biopsy in this specific setting. In this case, we repeated electromyography that showed mild axonal sensitive–motor polyneuropathy. Finally, we concluded for initial signs of systemic amyloidosis ATTR–v (Ile88Leu) type with mixed phenotype (neurological+cardiac). The neurological involvement allowed us to start a gene–silencer (Patisiran). In conclusion, a periodic neurological evaluation is necessary and has crucial therapeutic implications in all genotypes. Indeed, there is increasing evidence that Ile88Leu is a not only cardiogenic mutation.

Stent retrieval from renal artery by wire twist technique

ABSTRACT Wire twist technique is an important technique for retrieval of dislodged stent or broken coronary wire in areas where snare cannot be negotiated because of its bulky profile. In our patient dislodged coronary stent had been successfully retrieved from renal artery using twist wire technique. A 59 years gentleman, diabetic, hypertensive and smoker admitted with recent anterior wall myocardial infarction and ongoing chest pain. On coronary angiogram patient had approx. 80% stenosis in proximal LAD and approx. 80% stenosis in large OM1. PCI to LAD done with a 3X24 DES placed from ostium of LAD. But balloon dilation of OM lesion was difficult because of its tortuosity and also a 3X33 stent couldn’t be negotiated . During removal of stent balloon came out and the stent was struck and hanging in the LCX to LM to Aorta. It spontaneously dislodged from coronary artery and entered right renal artery. However PCI to OM done with a smaller stent of 3X28 DES. A snare had been tried but couldn’t be negotiated through the renal artery using right femoral route and JR(5F) guide cath. As an alternative approach three coronary wires had been passed through the side of the dislodged stent and multiple twisting done through a torquer. Thus the stent was entangled with the wires and the whole system was pulled and removed.

Discordance between Invasive and Non-Invasive Coronary Angiography: An In-Depth Functional and Anatomical Analysis

A 79-year-old male with chronic coronary syndrome with complex coronary artery disease was included in the first-in-man trial of surgical revascularization guided solely by coronary computed tomography angiography (CCTA) and fractional flow reserve derived from CCTA (FFRCT). In CCTA analysis, the patient had calcified three-vessel disease, with a global anatomical SYNTAX score of 27. In contrast, in the initial FFRCT, only the ramus intermediate stenosis was physiologically significant, with no other vessels having an FFRCT ≤ 0.80 (functional SYNTAX score of 2). Discordance between the results of the CCTA and FFRCT necessitated an in-depth analysis by using both invasive and non-invasive coronary angiography. Angiography-derived fractional flow reserve (FFR) confirmed that the stenosis in the proximal left anterior descending artery (LAD) was physiologically significant, while it remained functionally negative in the second assessment of FFRCT. Extensive calcification is the most plausible explanation for the underestimation of the stenosis of proximal LAD in CCTA-derived FFR technology.

222 INFARCT-LIKE MYOCARDITIS IN A PATIENT WITH CORONARY ARTERY DISEASE PRESENTING WITH CHEST PAIN: LOOKING BEYOND THE SIMPLEST DIAGNOSIS

Abstract Background A significant proportion of patients with acute myocarditis (AM) presents with chest pain as their first symptom, with ST-segment elevation, regional myocardial dysfunction and cardiac enzyme release (“infarct-like” pattern). Case description A 68-year-old patient, already known for coronary artery disease (CAD) who underwent a percutaneous coronary intervention (PCI) with drug eluting stent (DES) implantation of distal left anterior descending artery (LAD) six months before, presented with chest pain at rest. An ECG showed ST elevation in the infero-postero-lateral leads with specular ST-depression in aVL; hsTnI was 5900 ng/L (UNL &amp;lt; 51 ng/L). A coronary angiography excluded acute thrombosis, and showed a normal right coronary artery (RCA), significant (70%) stenosis of proximal LAD and left circumflex artery, both treated with PCI + DES. A transthoracic echocardiogram (TTE) showed hypokinesia of the middle portions of the inferior, posterolateral and inferior interventricular septum (SIV) walls. According to a research protocol ongoing in our hospital in post-myocardial infarction patients, a cardiac magnetic resonance (CMR) was performed 48 hours later, showing signs of acute non-ischemic myocardial damage (myocardial edema involving the whole infero-septal wall, late gadolinium enhancement with subepicardial – non-coronary - distribution at apical and antero-apical septum). A final diagnosis of infarct-like AM was established. No complications occurred during the hospital stay and hsTnI progressively decreased (at discharge 37 ng/L). A 6-month follow-up CMR showed normal biventricular function and kinesis, and absence of alterations in tissue characterization sequences. Conclusion This case highlights how even patients with a known CAD can present with AM mimicking myocardial infarction. Multimodality evaluation, including CMR, can help make the right diagnosis to avoid unnecessary therapies or procedures (i.e. PCI), especially in case of discrepancy between different clinical findings, (i.e. ST-elevation in the inferior leads with a dominant unscathed RCA, non-occlusive stenosis at angiography, echocardiography wall motion abnormalities in RCA territory).

Abstract 428: A Localized Giant Coronary Artery Aneurysm

Background: Coronary artery aneurysm (CAA) incidence is thought to be as common as 0.3 to 5 % of the angiographically examined patients. Regardless of underlying pathogenic mechanism, it results in adverse long-term outcomes. The management of the CAA can be challenging because of lack of clearly defined guidelines. Case Presentation: A 75-year-old male without known history of tobacco abuse, DM, hypertension, OSA, CAD, PCI or connective tissue disorder presented with a chief complaint of 2 months of intermittent angina. He had an unremarkable serum troponin level and an EKG. Echocardiogram revealed moderate mitral regurgitation without any regional wall motion abnormality [1]. Because of equivocal exercise stress EKG test, he underwent a coronary angiogram which showed a proximal LAD stenosis followed by a localized fusiform aneurysm [2]. Given his significant symptoms, large size of the aneurysm, ostial LAD stenosis and proximity of diagonal arterial branch the patient underwent CABG surgery involving LIMA to LAD. Discussion: CAA patients may present with stable angina, ACS or it may just be an incidental finding on a coronary angiogram. The pathogenesis of CAA is not well known. However, some of the risk factors can be genetic predisposition, underlying atherosclerotic coronary artery disease, autoimmune and connective tissue disorders, trauma such as following PCI, and infections. Coronary CT can be of great utility in evaluating giant CAA as it can help to delineate mechanical complications of these aneurysms. In our patient it was unusual to see localized CAD and an aneurysm limited to one coronary artery territory when atherosclerotic CAAs usually affect more than one artery. Conclusion: Since pathophysiology of CAA is not well understood and there are no obvious society guidelines regarding their management, therefore, it becomes important to tailor treatment based on the location and size of the CAA, underlying risk factors and the clinical presentation.

Identification of Specific Coronary Artery Disease Phenotypes Implicating Differential Pathophysiologies.

Background and AimsThe roles of multiple risk factors of coronary artery disease (CAD) are well established. Commonly, CAD is considered as a single disease entity. We wish to examine whether coronary angiography allows to identify distinct CAD phenotypes associated with major risk factors and differences in prognosis.MethodsIn a cohort of 4,344 patients undergoing coronary angiography at Heidelberg University Hospital between 2014 and 2016, cluster analysis of angiographic reports identified subgroups with similar patterns of spatial distribution of high-grade stenoses. Clusters were independently confirmed in 3,129 patients from the LURIC study.ResultsFour clusters were identified: cluster one lacking critical stenoses comprised the highest percentage of women with the lowest cardiovascular risk. Patients in cluster two exhibiting high-grade stenosis of the proximal RCA had a high prevalence of the metabolic syndrome, and showed the highest levels of inflammatory biomarkers. Cluster three with predominant proximal LAD stenosis frequently presented with acute coronary syndrome and elevated troponin levels. Cluster four with high-grade stenoses throughout had the oldest patients with the highest overall cardiovascular risk. All-cause and cardiovascular mortality differed significantly between the clusters.ConclusionsWe identified four phenotypic subgroups of CAD bearing distinct demographic and biochemical characteristics with differences in prognosis, which may indicate multiple disease entities currently summarized as CAD.

Robotically assisted coronary artery bypass graft surgery versus drug-eluting stents for patients with stable isolated proximal left anterior descending disease.

To compare the midterm outcomes of patients with isolated left anterior descending disease (iLAD) who underwent robotically assisted coronary artery bypass graft (R-CABG) and percutaneous coronary intervention (PCI) with drug eluting stents (DES). Clinic data was collected in 223 patients who underwent R-CABG in our hospital between July, 2007 to November, 2014. Cardiology Database System of our hospital was used to identify 4047 patients who underwent PCI with DES for LAD lesion between April, 2011 to November, 2014. Total 496 patients received DES and 108 patients underwent R-CABG after screening. Patients were propensity matched into 108 R-CABG and DES pairs according to vital statistic. Mortality, myocardial infarction (MI), stroke, repeat target lesion revascularization (r-TLR), main adverse cardiac and cerebral events (MACCE), and angina relief were compared across pairs. Kaplan-Meier estimates for R-CABG and DES had no significant difference in mortality (p = 1.00), MI (p = .32), Stroke (p = .80), and MACCE (p = .47), but the rate of r-TLR (p = .03) were lower in R-CABG group. Patients who underwent R-CABG had better angina relief (p = .02), lower rate of arrhythmia (p < .001), and recurrent angina (p = .02) after operation compared patients received DES. R-CABG offers lower r-TLR rate and better angina relief compared with DES for revascularization in patients with isolated proximal LAD stenosis and there was no difference in mortality, MI, stroke, and MACCE between them.

AN ACUTE MYOCARDIAL INFARCTION CAUSING A MOTOR VEHICLE ACCIDENT OR THE MOTOR VEHICLE ACCIDENT CAUSING AN ACUTE MYOCARDIAL INFARCTION: A CLINICAL DILEMMA

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute myocardial infarction is seen in very few patients (0.5%) who are admitted post-motor vehicle accidents (MVAs) (1). It is, however, one of the common natural causes of incapacitation leading to MVA (2). We present a case of a male, who suffered a V-fib cardiac arrest post-MVA and was subsequently diagnosed with a 99 percent occlusion of the proximal left main coronary artery. CASE PRESENTATION: A 68-year old male known to have hypertension was brought to the ED after a head-on motor vehicle collision. EMS reported that the patient self-extricated from the vehicle, walked on the sidewalk, and fell unconscious afterward with V-fib arrest. The patient achieved ROSC after one round of CPR with cardioversion, and 1mg epinephrine. Due to low GCS, he was intubated and transferred to ICU. His labs were significant for elevated white blood cells and troponin of 0.14 (normal<0.03). EKG showed sinus rhythm with non-specific ST-T wave changes in Leads I, aVL, V5, and V6. CT chest showed non-displaced multiple ribs and sternal fractures with small retrosternal hematoma. TTE demonstrated a 25-30% ejection fraction and multiple wall motion abnormalities with apical ballooning. The patient was extubated after his respiratory status showed signs of improvement. Meanwhile, since the troponin levels continued to rise (0.14 < 1.93 < 3.62 < 6.89 < 7.02), heparin drip was started. Although the patient was finally alert and oriented, he had amnesia of the event. However, he denied having any chest pain, or anginal symptoms before the accident. Our differential diagnoses were cardiac injury from either accident or CPR, Takostubo cardiomyopathy, or myocardial infarction. His repeat EKG was different from the one on arrival and showed biphasic T-wave in V2 -V3 and symmetric T-wave inversion in V4-V6. On the second day of his hospital stay, cardiac catheterization was performed that showed 99% proximal LAD stenosis, leading to percutaneous coronary intervention. His status slowly improved and was discharged on a life vest with a follow up with a cardiologist. DISCUSSION: While myocardial injury post blunt trauma, associated with MVAs, are common, thrombotic occlusions are rare. Unlike our case, in a few of the reported cases of thrombotic occlusion, (3) (4) the patients were fairly young. The presentations of the case poised a clinical dilemma because we could not establish if MI caused the MVA or vice-versa. Also, coronary thrombosis was not the top differential diagnosis in this case given the trauma, CPR, rib fractures, and TTE findings. Regardless, a timely cardiac catheterization with revascularization was performed, and the patient recovered. CONCLUSIONS: Acute myocardial infarction should always be one of the differential diagnoses after cardiac injury associated with trauma as timely cardiac catheterization and revascularization can be life-saving. Reference #1: 1.Alkhouli M, Alqahtani F. Incidence and outcomes of acute myocardial infarction during motor vehicle accident related hospitalizations. The American journal of cardiology. 2019 Mar 1;123(5):725-8. Reference #2: 2. Antecol DH, Roberts WC. Sudden death behind the wheel from natural disease in drivers of four-wheeled motorized vehicles. The American journal of cardiology. 1990 Dec 1;66(19):1329-35. Reference #3: 3.Watt AH, Stephens MR. Myocardial infarction after blunt chest trauma incurred during rugby football that later required cardiac transplantation. Heart. 1986 Apr 1;55(4):408-10. 4.Calvo Orbe L, Garcia Gallego F, Sobrino N, Sotillo J, Lopez-Sendon JL, Oliver J, Coma I, Frutos A, Sobrino JA, Navarro JM. Acute myocardial infarction after blunt chest trauma in young people: need for prompt intervention. Catheterization and cardiovascular diagnosis. 1991 Nov;24(3):182-5. DISCLOSURES: No relevant relationships by Abhishek Kalidas Kulkarni, source=Web Response No relevant relationships by Odalys Lara-Garcia, source=Web Response No relevant relationships by Ruby Maini, source=Web Response No relevant relationships by Priyanka Parajuli, source=Web Response No relevant relationships by Manjari Regmi, source=Web Response No relevant relationships by Mohsin Salih, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response

P715 When "wait and see" is the best option: a case report of a spontaneous coronary artery dissection

Abstract Introduction Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and is now being identified more frequently, in part because of increased awareness. Case report We present the case of a 63-year-old female, without cardiovascular risk factors or relevant past medical history. She complained of atypical chest pain in the last year. The patient was admitted due to acute chest pain at rest, hemodynamically stable, with unremarkable physical examination, including absence of heart failure signs. The EKG revealed a dynamic ST depression in leads V4-V6. The peak of high sensitivity troponin I was 13744pg/mL (ULN&amp;lt; 15.6) and CK 874U/l (ULN &amp;lt;168). The echocardiogram showed preserved left ventricular ejection fraction and hypokinesia of mid-apical segments of anterior wall. Considering the diagnosis of NSTEMI the patient underwent coronary angiography that revealed luminal narrowing of 70% in left main artery, 70% in proximal anterior descending artery (LAD) and 99% in first obtuse marginal. Given the absence of cardiovascular risk factors, the smooth angiographic appearance of coronary lesions and absence of calcium, we suspected of spontaneous dissection or vasculitis. Considering the absence of angina revascularization was delayed. A first coronary angio-CT confirmed the luminal narrowing and suggested a spontaneous dissection. Two weeks later the coronariography and the angio-CT were repeated with a significant improvement, showing only intermediate stenosis of proximal LAD. The additional imaging study revealed a 45mm ascending aortic dilation and a left primitive carotid stenosis without other vascular territory alterations, excluding fibromuscular dysplasia. The auto-immune study was unremarkable. With all these results it was assumed the diagnosis of a spontaneous coronary artery dissection and the patient was discharged asymptomatic under single antiplatelet therapy and Rivaroxaban. Three months later a new coronary angio-CT showed no significant coronary artery stenosis and the patient was asymptomatic. Discussion and conclusion The recognition of spontaneous coronary artery dissection is essential to the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in these patients are suboptimal and conservative management is probably the best option. Abstract P715 Figure. angio-CT

Hybrid coronary revascularization versus off-pump coronary artery bypass grafting and percutaneous coronary intervention for the treatment of two-vessel coronary artery disease with proximal left anterior descending artery stenosis.

This study sought to compare clinical outcomes of hybrid coronary revascularization (HCR) with off-pump coronary artery bypass grafting (OPCAB) and percutaneous coronary intervention (PCI) for the treatment of two-vessel coronary artery disease (CAD) including proximal LAD stenosis. From January 2009 to December 2016, 52 patients of two-vessel CAD including proximal LAD stenosis underwent HCR at Rui Jin Hospital. Using propensity score methodology, these patients were matched with those in the OPCAB and PCI cohorts. The primary endpoint during follow-up was main adverse cardiovascular and cerebrovascular events (MACCE). The intensive care unit (ICU) length of stay (LOS) and the hospital LOS were shorter in the HCR group than in the OPCAB group (ICU LOS: P<0.001; hospital LOS: P=0.027). The mean follow-up time was 59 months (interquartile range, 42 to 79 months). The 8-year freedom from MACCE of the HCR group was higher than that of the PCI group (P=0.008), but similar to that of the OPCAB group (P=0.893). HCR provides favorable outcomes for selected patients with two-vessel CAD including proximal LAD stenosis.

TCTAP C-099 Bifurcation PCI in a Chronic Spontaneous Long Coronary Dissection

### Patient Initials or Identifier Number LY ### Relevant Clinical History and Physical Exam 63 yrs old male Hypertension, Ex-smoker. Admitted in another hospital for anterolateral STEMI. On diagnostic angiography: severe 99% stenosis of proximal LAD and long spontaneous spiral dissection of

Abstract 422: Recognition of Pharyngeal Pain as an Angina Equivalent

A 64-year-old man presented to his physician with a 5-day history of throat pain and hoarseness. An initial diagnosis of pharyngitis was made, and the patient was sent home with a 7-day course of antibiotic therapy. He returned 6 days after his initial visit with persistent symptoms, which he now described as worsening on exertion such as when lifting weights. He was sent for a neck computed tomography to evaluate cervical soft tissues: No masses, enhancing lesions, lymphadenopathies, or imaging findings suggesting vocal cord paresis were noted. An ECG was ordered by the patient’s primary care physician and demonstrated new lateral T-wave inversions. The patient was also referred to ENT, and via direct laryngoscopy normal true vocal cords and questionable evidence of laryngopharyngeal reflux were visualized. He was then recommended to begin lifestyle modifications and start empiric treatment with omeprazole twice daily. Due to the ECG findings, an exercise stress test was ordered. During the exercise stress test, He developed throat tightness and the study was converted to a Lexiscan nuclear stress test. The stress test revealed inferior wall ischemia of moderate severity. Consequently, a coronary cath demonstrated quadruple vessel disease with 75% occlusion of left main, 70% stenosis of proximal LAD, 60% stenosis of the first diagonal, and total occlusion of the mid RCA. After undergoing quadruple coronary bypass surgery, the patient experienced a total resolution of his throat pain. Discussion: When approaching craniofacial pain elicited with exertion, it is essential for the clinician to consider ischemic heart disease as an etiology. Furthermore, the link of pain with physical activity and, additionally, pain relief with rest should drive the physician to consider cardiac ischemia. Isolated craniofacial pain or sole pharyngeal pain of cardiac origin are infrequent indicators of significant coronary artery disease. In a prospective multicenter study, only 6% of patients with confirmed ischemic cardiomyopathy presented with craniofacial pain as the only complaint. This case illustrates the importance of a thorough history and physical examination as well as a broad differential diagnosis when evaluating patients with throat pain and hoarseness.

INDICATIONS FOR MYOCARDIAL REVASCULARIZATION – ARE THEY USING EQUALLY FOR CHOOSING OF INVASIVE STRATEGY IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE?

The purpose was to reveal the value of separate indications for myocardial revascularization as well as their combinations for choosing invasive or conservative strategy of treatment in patients with stable coronary artery disease (CAD) during 2012–2015 years. Materials and methods . The retrospective data of 1196 patients (mean age: 52.5 ± 8.4 years; 77,0 % men) were analyzed, from the register of patients with stable CAD (2012–2015 years), who had separate indications for myocardial revascularization and their combination. Patients were divided into 2 groups: with an invasive (n = 481 patients without considering the revascularization method) and conservative (n = 715 patients) treatment strategy. Indications for revascularization are taken from the recommendations of the European Society of Cardiology 2014. Results. The most common indication for myocardial revascularization was the presence of any coronary stenosis in combination with the limiting angina in the context of optimal medication (88.1 % in the invasive treatment group, 94.3 % in the conservative therapy group, p 50 % + proximal stenosis LAD >50 %+ limiting angina pectoris occurred in 1.5 % of the patients in the invasive treatment group versus 3.8 % with the conservative strategy (p = 0.020). Proximal stenosis LAD >50 % was more common among operated patients (10.6 % vs 4.6 % in the conservative treatment group, p <0.001). Two- and three-vessel lesions + ejection fraction LV <40 % + limiting angina pectoris also occurred more frequently in the invasive treatment group (2.5 % vs 0.6 % in the conservative strategy group, p = 0.006).The remaining indications for myocardial revascularization and their combination were equally common in both groups. Conclusion. The presence of isolated proximal LAD stenosis or multivessel lesion with reduced left ventricular function accompanied with limiting angina was associated with the choice of invasive strategy in patients with stable CAD (data for 2012–2015 years). The lesion LM combined with proximal stenosis LAD and limiting angina pectoris and requiring coronary artery bypass grafting was associated with the choice of a conservative strategy. Almost half of the patients (48.6 %) had revascularization to improve the quality of life.

Assessment of left anterior descending artery stenosis of intermediate severity by fractional flow reserve, instantaneous wave-free ratio and non-invasive coronary flow reserve

Ninety-four stable consecutive patients (mean age, 68±10years; 19 women) with angiographic proximal or mid LAD stenosis of intermediate severity (40-70% diameter stenosis on quantitative coronary angiography), were prospectively studied. They underwent IFR that was calculated as a trans-lesion pressure ratio during a specific period of baseline diastole, FFR with intracoronary bolus adenosine (180μg), and CFR using intravenous adenosine (140μg/kg/min over 2min) in the distal part of the LAD, the same day. CFR was defined as hyperemic peak diastolic LAD flow velocity divided by baseline flow velocity and FFR as distal pressure divided by mean aortic pressure during maximal hyperemia. The mean values of IFR, FFR, and CFR were 0.88±0.07, 0.81±0.09, and 2.4±0.6 respectively. A significant correlation was found between CFR and FFR (R=0.63, curvilinear relationship), FFR and IFR (R=0.6, linear relationship), and between CFR and IFR (R=0.5) (all, P<0.01). Using a ROC curve analysis, the best cut-off to detect a significant lesion based on FFR assessment (FFR≤0.8, N=31) was IFR≤0.88 with a sensitivity (Se) of 74%, specificity (Sp) of 73%, AUC 0.81±0.04; and CFR≤2 with a Se=77%, Sp=89%, AUC 0.88±0.04, (all, P<0.001). Based on these cut-offs, discordant results between CFR and FFR were observed in 14 cases (agreement 85%), between CFR and IFR in 26 cases (agreement 72%), and between IFR and FFR in 26 cases (agreement 72%). In stable patients with LAD stenosis of intermediate severity, non-invasive CFR is a useful tool to detect a significant lesion based on FFR. Furthermore, there was a better correlation and agreement between CFR and FFR than with IFR.

Pain and the Quality of Life Following Robotic Assisted Minimally Invasive Surgery.

Minimally invasive bypass grafting is a promising surgical treatment in proximal LAD stenosis procedures. The main goal of this study was to make comparisons between robotically assisted minimally invasive coronary bypass surgery and conventional surgery in isolated proximal LAD lesions in terms of pain and quality of life improvement. The study contains patients with proximal LAD lesions who were treated with robotically assisted minimally invasive coronary artery bypass surgery and conventional bypass surgery between June 2005 and November 2012. Fifty patients treated with coronary bypass with cardiopulmonary bypass and complete sternotomy were categorized as Group 1. Fifty patients who applied for robotically assisted minimally invasive bypass surgery were categorized as Group 2. The evaluations of pain and quality of life were done according to the Verbal Rating Scale (VRS) and SF-36 health survey questionnaire, respectively. The conventional bypass group and robotic group had 4.8 ± 1.9 years and 4.3 ± 1.6 years mean follow-up time, respectively. The robotic bypass group had a significantly shorter ICU stay and hospital stay than the conventional bypass group (P &lt; .05). The pain score was higher in the robotic bypass group on the 1st postoperative day (P &lt; .05), but the score on the 4th postoperative day was higher in the conventional bypass group (P &lt; .05). In terms of domains of the SF-36 questionnaire, patient scores were significantly higher in patients who were operated with robotically assisted minimally invasive direct coronary artery bypass (MIDCAB) procedure than in patients who were operated with conventional bypass technique. Patients operated with robotically assisted MIDCAB procedure had results with lesser pain, shorter ICU stay, and shorter hospital stay than the other group in isolated proximal LAD stenosis. The same group also had better quality of life results according to the SF-36 questionnaire results.

A novel method for left anterior coronary artery flow velocity assessment by transthoracic echocardiography at the peak of a supine bicycle test.

Assessment of coronary flow is only performed during pharmacological tests. Supine bicycle tests permit the visualization of coronary flow assessments during exercise. To assess the parameters of coronary flow in the left anterior descending artery (LAD) during exercise, which could be a sign of significant LAD narrowing. A total of 253 patients were enrolled: Group 1, 186 non-selective participants before undergoing a coronary angiography; and Group 2, 67 controls without coronary artery disease (CAD). All the patients performed a supine bicycle echocardiography test. Coronary flow velocities and coronary flow velocity reserve (CFVR) were measured at the mid-segment of the LAD during exercise. Patients in Group 1 underwent a coronary angiography. In comparison with participants without significant LAD stenosis, patients with LAD lesions had a lower ΔV (16 ± 21 vs. 27 ± 20 cm/s, P < 0.04) and a lower CFVR (1.5 ± 0.8 vs. 2.0 ± 0.6, P < 0.004). In comparison with patients without significant proximal LAD stenosis, the patients with proximal LAD lesions had a lower flow velocity at the peak of exercise (49 ± 32 vs. 61 ± 19 cm/s, P < 0.02), a lower ΔV (13 ± 19 vs. 26 ± 22 cm/s, P < 0.004), and a lower CFVR (1.4 ± 0.6 vs. 1.9 ± 0.7, P < 0.0001). In comparison with the control group, the patients with LAD stenosis had a lower flow velocity at the peak of exercise, a lower ΔV, and a lower CFVR. Non-invasive CFVR measurement in the LAD could provide valuable additional information to a conventional echocardiography exercise test. In routine clinical practice, CFVR is sufficient for a diagnosis of severe stenosis.