Stenotic Lesions Research Articles

262 An attractive endovascular strategy for combined—aneurysmal and stenotic—coronary artery disease

Abstract In patients undergoing coronary angiography the coexistence of aneurysmal and stenotic lesions in adjacent segments of the same epicardial vessel is uncommon. We describe a rare case of single-vessel coronary artery disease (CAD) in a 70-year-old male, presenting with progressive effort-induced angina of 3-months’ evolution. The coronary angiogram revealed a critical calcified stenosis in the context of diffuse ectasia affecting the right coronary artery (RCA). Our report focuses on a complex revascularization procedure using the self-expandable Carotid Wallstent. Highlighting the importance of a multidisciplinary approach, we provide an original and effective endovascular solution for an unusual pathological angiographic finding, which could be of potential interest for interventional cardiologists.

Narrowing the Pipe: Different Etiologies of Tracheal Stenosis

The trachea serves as the conduit for passage of air between the larynx and the lung bronchi. The tracheal luminal caliber may be narrowed in adults by extrinsic mass effect from adjacent structures; intrinsic stenosis secondary to intubation, inflammatory, systemic, or idiopathic disorders; and benign or malignant masses. Contrast-enhanced CT accurately depicts the source of the stenosis and can measure the length and cross-sectional area of the stenosis and evaluate the extent of locoregional spread with malignancies. In addition, the data are capable of being reformatted by several techniques, including virtual endoscopy and surface-rendered reconstruction. Certain imaging characteristics such as the presence of calcifications and involvement or sparing of the posterior membrane can be useful to suggest a particular diagnosis or differential. Imaging, however, is not usually pathognomonic for a specific benign or malignant tracheal stenotic lesion, and ultimately biopsy is needed to establish a definitive histopathologic diagnosis.Learning Objective: To describe the different etiologies of tracheal stenosis

Treatment of patients with occlusive-stenotic diseases of the arteries of the infrarenal aorta by the hybrid method

Annotation. The treatment results of patients with arterial occlusive-stenotic diseases of the lower extremities as a result of obliterating atherosclerosis were analyzed. 79 patients underwent hybrid surgery. Most patients were ranged in age from 46 to 86 years. There were 175 men (72.0%) and 68 women (28.0%). The right lower extremity was affected more often – 148(60.9%) patients than the left ones – 95(39.1%). Of the 20 patients with stenosis of the iliac-femoral segment, 14 hybrid surgeries were completed with stenting. Endarterectomy or profundoplasty with different angioplasty options were mainly performed. Endarterectomy or thrombectomy with various angioplasty options was mainly performed in the occlusion of the femoral-popliteal segment. The main hybrid type of operation in the popliteal segment was thrombectomy of the popliteal segment and balloon angioplasty of the tibial segment. In occlusive stenotic lesions of the arteries of the tibial-foot segment in the vast majority of cases, autovenous plastics of the tibioperoneal trunk with balloon angioplasty of distal arteries were performed. The thrombosis was diagnosed in 8(10,12%) individuals as the most common complication in the early postoperative period. Limb amputation was performed in 3 patients. Mortality rate in the early postoperative period was 4,76%(2 patients died in the comparison group), in the main group there was no mortality. Acute myocardial infarction and stroke are among the most common causes of death.

Palsy of the posterior interosseous nerve treated by targeted ultrasound-guided perineural hydrodissection

Perineural hydrodissection is a minimally invasive technique using an injection of fluid to dissect the perineural plane and tissue space. This report describes a case of palsy of the descending branch of the posterior interosseous nerve (PIN) which was recovered by targeted ultrasound-guided perineural hydrodissection. Ultrasonographic examination was performed, and multiple stenotic lesions interrupted by hyperechoic bands within the fascicles of the PIN were found. Using ultrasonography, perineural hydrodissection was performed four times every other week. Fifteen weeks after the first hydrodissection, there was no restriction in the patient’s thumb and fingers movement, and ultrasonography revealed that multiple stenotic lesions had improved. Today, surgical treatment is recommended for patients with complete nerve constriction. However, there is no standardized approach for patients with incomplete or without nerve constriction. Ultrasound-guided perineural hydrodissection is a noninvasive and easy method. This procedure could be a useful diagnostic and therapeutic modality for the management of the disease.

Cutting Balloon Combined with Drug-Coated Balloon Angioplasty for the Treatment of In-Stent Restenosis.

Drug-coated balloon (DCB) has emerged as an alternative therapeutic choice for in-stent restenosis (ISR) lesions. Cutting balloon angioplasty (CBA) is also a strategy utilized to treat tight stenotic lesions or ISR lesions. Few studies have focused on whether CBA plus DCB could achieve a better result in lowering the incidence of recurrent ISR. This study aimed to evaluate the efficacy of CBA plus DCB for ISR lesions.Between August 2011 and December 2017, 681 patients (937 lesions) were diagnosed with ISR and treated with DCBs in our hospital. The CBA plus DCB group comprised 90 patients who underwent PCI with further CBA plus DCB, and the DCB alone group comprised 591 patients who underwent percutaneous coronary intervention (PCI) with DCB alone.Baseline characteristics, the types of previous stents, lesion type, prevalence of ostial lesion and left main lesion, and pre-PCI and post-PCI stenotic percentage showed no significant difference between the two groups. Only post-PCI reference luminal diameter and size of DCB were larger in the CBA plus DCB group. During the one-year follow-up period, late loss and clinical outcomes did not differ between the two groups before and after propensity score matching. The incidence of subtotal/total occlusion with delay flow was lower in the CBA plus DCB group after propensity score matching (4.1% versus 10.9%; P = 0.030).In these patients with ISR lesions, the clinical outcomes and the incidence of repeat target lesion revascularization were similar after treatment with CBA plus DCB versus DCB alone. Further study is warranted, including prospective, randomized comparisons.

Pulmonary artery stenosis versus supravalvular pulmonic stenosis: Correctly describing a congenital stenosis of the pulmonic outflow tract in a domestic cat

AbstractPulmonary artery stenosis and pulmonic stenosis are rare congenital heart diseases in domestic cats. This case describes the incidental finding of pulmonary artery stenosis in an asymptomatic cat that was originally described as pulmonic stenosis; it highlights the criteria for differentiation of the two conditions. This cat was initially diagnosed at 1.5 years with pulmonic stenosis. During a recheck at 13 years of age, the stenotic lesion was determined to be anatomically supravalvular rather than at the level of the valve. There was debate as to whether the lesion should be classified as supravalvular pulmonic stenosis, but ultimately, pulmonary artery stenosis was considered more appropriate. There are discrepancies in the literature regarding what the qualifications for these conditions are, and if supravalvular pulmonic stenosis is the appropriate terminology. The purpose of this case report is to further explore these qualifications to justify the diagnosis of pulmonary artery stenosis in this patient.

Abstract 12852: Acute Stenting Of Persistently Stenotic Cervical Lesions In Atherosclerotic Tandem Occlusions Does Not Improve Neurologic Outcomes

Introduction: There is a lack of consensus regarding the endovascular management of atherosclerotic tandem occlusions with persistent cervical stenosis during acute ischemic stroke. The aim of this study was to determine if patients who did not undergo stent placement during thrombectomy had better neurological outcomes. Methods: A retrospective analysis of consecutive mechanical thrombectomies for large vessel occlusions at our institution was conducted from 2011 to 2019. Atherosclerotic tandem occlusions with persistently severe cervical stenosis (&ge 70%) before and after thrombectomy were identified and evaluated for clinical baseline data, perioperative data, and post-thrombectomy outcomes such as re-occlusion rates and modified Rankin score at 90 days. Results: A total of 69 patients with atherosclerotic tandem occlusions were identified. Thirty-five patients underwent acute carotid stent placement. Thirty-four patients did not receive a stent and had persistently severe cervical stenosis after thrombectomy. Demographics, NIHSS, reperfusion rates, and length of stay were similar between groups. Post-thrombectomy carotid re-occlusion (p = 0.434) and neurological outcomes (p = 0.82) were similar between stented and non-stented groups at 90 days after discharge. Conclusions: The acute stenting of persistently severe cervical stenosis in atherosclerotic tandem lesions does not reduce the rate of re-occlusion and is not associated with better neurologic outcomes at 90 days after discharge. Randomized clinical trials are warranted to determine a standardized means of endovascular management of atherosclerotic carotid lesions in tandem occlusions during acute ischemic stroke.

Revascularization Strategies for Multivessel Coronary Artery Disease in the Elderly Population

Prospective trials comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of multivessel coronary disease (MVCAD) have included mostly younger patients. We compared treatment strategies in the elderly population. We performed a propensity-score-matched comparison of patients ≥75 y who underwent isolated CABG or PCI for MVCAD between 2011 and 2018, excluding those with prior cardiac surgery and/or significant left main disease. The primary outcome was 5-year Kaplan Meier survival, and secondary outcomes included readmissions and major adverse cardiovascular and cerebrovascular events (MACCE). Propensity-matching yielded 536 patients (266 PCI and 266 CABG). Rates of complete revascularization of all stenotic lesions were higher in the CABG arm (86.8% versus 21.8%; P < 0.001). Thirty-d mortality was similar between cohorts, though PCI recipients had shorter hospital stay and greater likelihood of discharge to home. Unadjusted one- (89.1% versus 88.4%) and 5-year (73.8% versus 60.1%) survival were both higher in patients who underwent CABG (P=0.0332). Patients undergoing CABG had reduced, but nonsignificant cumulative incidence of all-cause hospital readmission and MACCE at 5 y. Subgroup analysis of patients 80 y or older revealed similar late survival benefit with CABG when compared to PCI. Among patients undergoing CABG, there did not appear to be any 5-year benefits from multi-arterial grafting. Despite longer hospitalization and higher rate of nonhome discharge, CABG was associated with improved late survival over PCI in the elderly population. Cardiac surgeons should be included in the multidisciplinary evaluation of older patients with MVCAD.

Abstract 9941: Coronary Artery Calcification Score is Associated with Left Ventricular Diastolic Function in Patients Without Coronary Artery Disease

Introduction: Left ventricular (LV) diastolic dysfunction is a strong predictor of cardiovascular events, and it shares several risk factors with coronary artery disease (CAD). It is not well elucidated whether coronary atherosclerosis could affect LV diastolic function even in patients without CAD. Hypothesis: Coronary artery calcification (CAC) score by computer tomography (CT) might be associated with LV diastolic function even in non-ischemic patients. Methods: We enrolled non-ischemic patients who underwent CT coronary angiography (CTA) and echocardiography, using the following inclusion criteria; (1) age ≥65 years (2) no history of ischemic events, coronary revascularization or mitral valve operation, (3) no significant stenotic lesion on CTA, and (4) regular sinus rhythm at echocardiography study. We measured CAC score on CT and diastolic parameters including median E/e’ ratio on echocardiogram. Continuous variables were expressed as median [interquartile range] and were compared using Kruskal-Wallis rank sum test. Results: We enrolled consecutive 242 patients for the present study (72 [68, 77] years, male; 56.2%). We divided them based on CAC score, as no (N: score 0, n=61), low- (L: 1-99, n=86), and high (H: ≥100, n=95) CAC group. There was difference in gender and history of diabetes among the groups, but not in age, BMI, hypertension and dyslipidemia. Significant difference was observed in E/e’ ratio among 3 groups (N: 8.1[6.9,9.9], L:8.7 [7.3,10.8], H: 9.1 [7.5,11.0], p=0.035), and the H-group had higher E/e’ than the N-group (p=0.036). There were also difference in left atrial volume (N: 35.2ml [26.8, 44.0], L:41.6 ml [30.5, 55.5], H: 42.5 [34.5 ,58.3], p=0.002) and in LV mass index (N: 82.7 g/m 2 [71.2, 93.3], L:84.1 g/m 2 [75.4, 97.7], H: 95.2 g/m 2 [80.8, 109.9], p=0.0004), and those in the H-groups were higher than those in the N-group. No difference was observed in LV ejection fraction or in E/A ratio. CAC score could detect E/e’ ratio ≥14 with 57% sensitivity and 63% specificity, using 71.0 as the cutoff value (AUC 0.64). Conclusions: High CAC score was associated with impaired LV diastolic function, implying the relationship between coronary artery atherosclerosis and LV diastolic dysfunction in patients without CAD.

Arterial Preparation by Longitudinal Micro-Incisions Before Balloon Angioplasty of the Superficial Femoral and Popliteal Artery: Acute and 12-Month Results

Purpose: Percutaneous transluminal angioplasty (PTA) with conventional plain old balloon (POBA) and/or drug-coated balloon (DCB) is the primary intervention to treat peripheral artery stenoses. However, acute dissections during the procedure and potential for future target lesion revascularization remain procedural complications. The purpose of this study was to assess the acute and 12-month outcomes in patients who underwent novel vessel preparation with longitudinal, controlled-depth micro-incisions prior to PTA. Materials and Methods: Patients with symptomatic lower extremity peripheral arterial disease with a Rutherford class of 2 to 6 and >70% de novo stenosis of the superficial femoral or popliteal arteries were included in this retrospective study. Patients with thrombotic or embolic lesions, restenosis, or in-stent restenosis were excluded. The FLEX Vessel Prep System (FLEX VP) was used to prepare the vessel prior to PTA by creating micro-incisions at the target lesion. The FLEX VP was followed by POBA or paclitaxel DCB. Results: The study included 65 patients. Lesion characteristics were 90% median stenosis (range = 70%–100%), 75.4% mild-to-severe calcifications, and 33.8% occlusion rate, and median lesion length was 196 (range = 10–480) mm. Following vessel preparation, 82.1% of the patients had low severity dissection or no flow-limiting dissection. The provisional stent rate postprocedure was 16.9%, with a median stent length of 60 mm. The freedom from target lesion revascularization (FFTLR) in 63 evaluable patients at 6 and 12 months was 98.4% and 93.7%, respectively. Freedom from amputation was 100%. Conclusion: In this real-world/all-comers patient population with long, stenotic lesions across the calcification spectrum, vessel preparation with longitudinal micro-incisions prior to PTA was associated with low dissection rate, low dissection severity, low stent implantation, and high FFTLR with the absence of amputation at 12 months relative to published reports in long-lesion cohorts. These results support vessel preparation via micro-incisions.

Conservative Management of Rectovaginal Deep Endometriosis: Shaving Should Be Considered as the Primary Surgical Approach in a High Majority of Cases.

Deep endometriosis infiltrating the rectum remains a challenging situation to manage, and it is even more important when ureters and pelvic nerves are also infiltrated. Removal of deep rectovaginal endometriosis is mandatory in case of symptoms strongly impairing quality of life, alteration of digestive, urinary, sexual and reproductive functions, or in case of growing. Extensive preoperative imaging is required to choose the right technique between laparoscopic shaving, disc excision, or rectal resection. When performed by skilled surgeons and well-trained teams, a very high majority of cases of deep endometriosis nodule (>95%) is feasible by the shaving technique, and this is associated with lower complication rates regarding rectal resection. In most cases, removing a part of the rectum is questionable according to the risk of complications, and the rectum should be preserved as far as possible. Shaving and rectal resection are comparable in terms of recurrence rates. As shaving is manageable whatever the size of the lesions, surgeons should consider rectal shaving as first-line surgery to remove rectal deep endometriosis. Rectal stenosis of more than 80% of the lumen, multiple bowel deep endometriosis nodules, and stenotic sigmoid colon lesions should be considered as indication for rectal resection, but this represents a minority of cases.

The Correlation between the Right Ventricular Strain and the Severity of Right Coronary Artery Lesions in Patients with Stable Coronary Artery Disease

Background A recent study demonstrated that in patients with stable coronary artery disease who were indicated for coronary angiography and it resulted in single proximal RCA significant lesion and 2D echocardiography was normal, speckle tracking on RV free wall detected significant impact on its segments and its global strain. Aim of the Work: To correlate between the RV strain and the degree of RCA stenosis in patients with stable Angina. Methods: a prospective observational study done included large number of persons complaining of typical anginal pain indicated for coronary angiography. Conventional 2D TTE was done and we excluded patients with RV dysfunction or RV dilatation. Speckle tracking on RV was done before doing coronary angiography. Patients with single ostial, para ostial or proximal dominant RCA lesions were chose to correlate their degree of stenosis with right ventricular free wall and RV global strain speckle tracking. Also, control group with normal speckle tracking and normal coronary angiography was taken in the study. Data was collected &amp; coded using Microsoft Office Excel Worksheet while statistical analysis was performed using statistical package for social sciences (SPSS) version Results: The study showed that regarding the Echocardiography parameters, there were statistically significant difference between the 2 groups regarding the B RVFW, MRVFW, APRVFW and GLsRV. Significant relation was detected between degree of the proximal RCA stenotic lesion and speckle tracking parameters of RVFW and GLsRV. Conclusion: RVFWLS and GLsRV has highly significant correlation with the degree of the proximal stenotic lesion.

Angiographic characteristics of ruptured versus unruptured vertebral artery dissecting aneurysm.

ObjectiveVertebral artery dissecting aneurysm (VADA) is a rare and critical disease. VADA rupture can cause subarachnoid hemorrhage which is a major complication of VADA due to their high rebleeding rate and poor outcome. In the present study, ruptured and unruptured VADAs were compared by analyzing angiographic findings to determine useful predisposing factors for VADA rupture for appropriate treatment selection.MethodsSubjects with VADA treated during a 10-year period were retrospectively identified. The 57 cases diagnosed with VADA were divided into ruptured (n=15) and unruptured (n=42) groups. In addition, each case was analyzed using angiographic 3-dimensional (3-D) reconstructed images. Factors such as length, dilated and stenotic diameter, shape, and vessel around the vertebral artery (VA) were measured and statistically compared.ResultsIn the ruptured group, stenotic findings of the affected lesion were more common and severe than in the unruptured group. The average stenotic diameter was 2.27 mm (vs. 2.84 mm). And stenotic degree was 62% and 53% in the ruptured and unruptured groups, respectively. Posterior communicating artery (PcomA) flow was more common in the ruptured group (87% vs. 55%, p=0.028).ConclusionsBased on angiographic findings, stenotic lesions, which may be influenced by PcomA flow, are more common in ruptured VADAs.

The diagnostic role of IVUS in pelvic venous disease

The two main mechanisms for pelvic venous disease (PeVD) are reflux of ovarian vein and obstruction of left common iliac or left renal vein. Some patients have a combination of the two. Adequate assessment of the location and degree of stenosis and delineation of venous anatomy are the key elements in the success of interventions to treat chronic obstructions causing PeVD. While venography is more accessible and less expensive to perform than intravascular ultrasound (IVUS), an increasing number of studies have demonstrated that IVUS is significantly more sensitive than venography in identifying stenotic lesions and real-time anatomical alterations of the affected venous segments. In this paper, we discuss the derived information and the clinical applications of IVUS during such interventions. The definitive diagnosis of PeVD can be achieved with venography combined with IVUS to evaluate for obstructive lesions in the iliac veins and compression of the left renal vein. Venography has poor sensitivity and specificity in the detection of venous stenosis. However, IVUS can detect fine intraluminal trabeculae and outside compression that can be missed with standard multiplanar venography. The IVUS can confidently confirm the persistent venous stenosis regardless of the hemodynamical alterations of venous pressure, as well. Moreover, it is possible to precisely measure the diameter of ovarian vein with IVUS. This may be helpful to decide about the diameter of the coils or the plugs needed to avoid migration. In conclusion, IVUS enables us to accurately evaluate the underlying cause of PeVD and apply a patient"s tailored treatment on table.

Comparison of Clinical Outcomes in Patients Undergoing a Salvage Procedure for Thrombosed Hemodialysis Arteriovenous Grafts.

BackgroundThe major limitation of arteriovenous graft access is the high incidence of thrombotic occlusion. This study investigated the outcomes of our salvage strategy for thrombosed hemodialysis arteriovenous grafts (including surgical thrombectomy with balloon angioplasty) and evaluated the efficacy of intragraft curettage.MethodsSalvage operations were performed for 290 thrombotic occluded arteriovenous grafts with clinical stenotic lesions from 2010 to 2018. Of these, 117 grafts received surgical thrombectomy and balloon angioplasty from 2010 to 2012 (group A), and 173 grafts received surgical thrombectomy and balloon angioplasty, with an additional salvage procedure using a curette and a graft thrombectomy catheter, from 2013 to 2018 (group B). Outcomes were described in terms of post-intervention primary patency and secondary patency rates.ResultsThe post-intervention primary patency rates in groups A and B were 44.2% and 66.1% at 6 months and 23.0% and 38.3% at 12 months, respectively (p=0.003). The post-intervention secondary patency rates were 87.6% and 92.6% at 6 months and 79.7% and 85.0% at 12 months, respectively (p=0.623). Multivariate Cox regression analysis demonstrated that intragraft curettage was a positive predictor of post-intervention primary patency (hazard ratio, 0.700; 95% confidence interval, 0.519–0.943; p=0.019).ConclusionSurgical thrombectomy and balloon angioplasty showed acceptable outcomes concerning post-intervention primary and secondary patency rates. Additionally, intragraft curettage may offer better patency to salvage thrombotic occluded arteriovenous grafts with intragraft stenosis.

Stents in the Management of Stenotic and Occlusive Lesions in the Venous System.

Occlusive disease of the iliac veins or major intrathoracic veins have traditionally been managed by conservative management or by major vascular reconstructive procedures. Over the past 15-20 years, these lesions have become amenable to management with venous stents. Lesions in the iliac venous system are typically due to thrombus secondary to deep vein thrombosis, and lesions in the superior vena cava are due to either malignant intrathoracic lesions, indwelling central venous catheters, pacemaker leads, or enlarged nodes due to granulomatous disease. The success rate for implantation is between 92% and 95% and associated implantation complications vary between 2% and 5%. Primary patency of iliac stents is 70-90% at three years. Venous stents have higher patency in the treatment of stenotic lesions compared to totally occlusive lesions. Primary patency of stents placed in the superior vena cava is also about 70-90% and generally lower in lesions due to malignancy likely related to life expectancy. Stents in the venous system are associated with few complications at the time of insertion and have excellent long-term patency.

A Comparison Between Pressure Wire and Microcatheter Measurements for Evaluating the Cerebral Venous Pressure Gradient.

Introduction: A pressure gradient of over 8 mm Hg across the stenosis (usually located in the transverse-sigmoid junction) is one of the criteria for cerebral venous stenting in idiopathic intracranial hypertension (IIH) patients. The possible inaccuracy of the traditional microcatheter-based pressure measurements has been discussed in previous studies. In the cardiology field, a dual-sensor pressure wire is routinely used for the evaluation of stenotic lesions. Using a pressure wire for cerebral vasculature was previously discussed in a small case series and case reports. In this study, we compared venous pressure measurements obtained using both a microcatheter and a pressure wire in patients who were candidates for stenting.Methods: A retrospective study was conducted, comparing the two methods of pressure measurements in 26 patients with venous stenosis. Altogether, 120 measurements were performed using both methods. Demographic characteristics, medical history, procedural details, medications, indications for the procedure, and complications were collected from the patient charts.Results: Based on an 8-mm Hg pressure gradient cutoff indication, 19 patients were found eligible to go through unilateral venous stenting based on catheter measurements alone. The wire results corroborated the catheter results in detecting all cases indicated for a stent. This finding implies a sensitivity equal to 100% for the wire measurements. There were no wire-related complications, demonstrating its safety.Conclusions: We conclude that the pressure wire is as safe as the microcatheter and can identify cases requiring intervention. A larger-scale study is needed to assess the measurement accuracy of the pressure wire in brain vasculature.

Prognostic role of right ventricular geometry and function in patients undergoing double valve surgery

Abstract Introduction Multiple valvular heart disease, a combination of stenotic and regurgitant lesions occurring on two or more valves, is a highly prevalent condition. For these patients, surgical correction is the only definitive treatment to improve prognosis, yet concomitant aortic and mitral (double) valve surgery is associated with poor post-operative outcomes. While current guidelines outline left ventricular dimensions and function as surgical triggers, little is known regarding the importance of right ventricular (RV) remodelling in these patients. Purpose We sought to evaluate the prognostic value of RV remodelling in patients undergoing double valve surgery. Methods RV remodelling was characterised by transthoracic echocardiography in 152 patients undergoing concomitant aortic and mitral valve replacement (n=118) or aortic valve replacement and mitral valve repair (n=34). Four patterns of RV remodelling were defined according to the presence of RV dilation (tricuspid annulus diameter&amp;gt;35mm) and RV systolic dysfunction (percentage RV fractional area change &amp;lt;35%): normal RV size and systolic function (pattern 1); dilated RV with normal systolic function (pattern 2); RV systolic dysfunction with normal RV size (pattern 3); and dilated RV with systolic dysfunction (pattern 4). Adverse events were defined as the composite of all-cause mortality and hospitalisation for heart failure. Results Overall, 62 (41%), 31 (20%), 35 (23%), and 24 (16%) patients were classified as RV remodelling patterns 1, 2, 3, and 4, respectively. Patients with advanced RV remodelling patterns were more frequently male, had worse renal function, and a higher EuroSCORE II. During a median follow-up of 43 months, 41 adverse events (22 heart failure hospitalisation and 19 deaths) occurred. Patients with patterns 3 and 4 RV remodelling had an increased risk of adverse events compared to pattern 1 (log-rank χ2 27.42; p&amp;lt;0.001; Figure 1). After adjustments for EuroSCORE II and significant tricuspid regurgitation, RV remodelling patterns 3 (Hazard Ratio [HR] 3.24, 95% Confidence Interval [CI] 1.27–8.24, p=0.014) and 4 (HR 6.18, 95% CI 2.49–15.32, p&amp;lt;0.001) were independently associated with poor post-operative outcomes. Importantly, RV remodelling patterns provided incremental prognostic value to EuroSCORE II (χ2 increased from 18 to 38, p&amp;lt;0.001). Conclusion In patients with concomitant aortic and mitral valve disease, RV remodelling is frequent and associated with poorer outcomes. Our study highlights the involvement of the RV in left-sided valvular heart disease and underlines the importance of preoperative assessment of RV geometry and function in patients undergoing double valve surgery. Funding Acknowledgement Type of funding sources: None. Figure 1

Determinants of high-risk coronary artery disease in ostensibly healthy male master endurance athletes

Abstract Background Healthy male master endurance athletes have a greater prevalence of high coronary calcium (CAC) scores compared to healthy sedentary counterparts, and some demonstrate high-risk plaque features. A number of theories have been postulated but reasons remain unclear. Concurrently atherosclerotic coronary artery disease (CAD) is the most common cause of sudden cardiac death in male master athletes drawing much public and scientific interest and making this an important public health issue. Purpose To examine the relationship of age, resting systolic blood pressure (SBP), exercise dose and sporting discipline with high-risk CAD markers in male master endurance athletes. Methods A prospective study undertaken over 19 months evaluated 214 male master (40–65 years) endurance athletes, free from known cardiovascular risk factors, symptoms or relevant health conditions. Clinical evaluation included cardiopulmonary exercise test, resting blood pressure (BP) and coronary computed tomogram angiography (CCTA). CCTA assessed CAC score, significant stenosis, (&amp;gt;50%) and plaque vulnerability markers. Exercise dose was defined by years of endurance exercise and average MET-hours/week (lifetime exercise volume multiplied by the metabolic equivalent scores). Resting BP was the average of 3 consecutive supine measures after at least 5 minutes rest. Results Athletes (mean age 51, SD 70.1) exercised for minimum 6 hours/week (median 8.5) for a median of 15 years (2–26). Almost half (60.2%) were multi-endurance athletes i.e. any combination swimming, cycling and running. The remainder were runners (22.4%) and cyclists (15.4%). Median Framingham risk score 3.2% (1.8–5.8). The mean resting BP was 129/80 mmHg and a quarter (26%) of athletes were hypertensive (≥140/90 mmHg) at rest. A CAC score &amp;gt;100 Agatston units (AU) was present in 16% of athletes. There was a total of 15 stenotic lesions in 11 (5%) athletes. 13% had plaque vulnerability markers. Logistic regression evaluated whether age, resting SBP, exercise dose measures and sporting discipline were predictive for a CAC score &amp;gt;100 AU, significant stenosis and plaque vulnerability markers (table 1). CAC score was associated with age, years of endurance exercise and resting SBP. A Stenosis &amp;gt;50% and plaque vulnerability markers were associated with resting SBP and cycling compared with all other sporting disciplines. Conclusion Despite correcting for age, higher exercise dose (years endurance exercise) is associated with CAC score &amp;gt;100 AU but does not predict significant stenosis or plaque vulnerability markers. Resting SBP and cycling strongly predict high-risk disease. Cycling enables a greater intensity of exercise compared with other endurance sports, which may be associated with prolonged rises in SBP. Resting SBP and cycling are important determinants for high-risk CAD in middle-aged male endurance athletes and should be considered when risk stratifying in pre-participation evaluation. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Relationship of diabetes to atherosclerotic plaque characteristics of coronary artery lesions by differing angiographic stenosis severity

Abstract Background There is a strong relationship between atherosclerotic plaque characteristics (APCs) and major adverse cardiovascular events. However, whether APCs are different in obstructive vs. non-obstructive lesions, and whether diabetic status modifies this relationship is unknown. Purpose This study examines the relationship between APCs and angiographic stenosis severity in diabetic vs. non-diabetic patients. Methods We evaluated 303 subjects referred for invasive coronary angiography with coronary computed tomographic angiography and classified lesions as obstructive (&amp;gt;50%) or non-obstructive using blinded quantitative coronary angiography. APCs, including plaque volume (PV), low density non-calcified plaque (LD-NCP), non-calcified plaque (NCP), calcified plaque (CP), lesion length, positive remodeling (PR), and high-risk plaque (HRP) were quantified and normalized for vessel volume. The relationship between APCs and angiographic stenosis severity was compared in diabetics vs. non-diabetics. Results Among 362 coronary lesions observed, 48.3% were obstructive, 51.7% were non-obstructive. In diabetics, NCP was significantly higher in obstructive vs. non-obstructive lesions (p=0.0033); however, in non-diabetics, no difference was observed (p=0.0525). In non-diabetics, PR was significantly higher in non-obstructive vs. obstructive lesions (p=0.0424); however, among diabetics, no difference was observed (p=0.7509). Comparing ACPs in obstructive lesions between diabetics and non-diabetics, diabetics had less NCP and HRP, more CP, PR and LD-NCP with comparable PV and lesion lengths. Comparing APCs in non-obstructive lesions, diabetics had greater PV, CP and PR with less LD-NCP, NCP, HRP, and shorter lesion lengths. Conclusion In diabetics, NCP is significantly higher in obstructive vs. non-obstructive lesions. Thus, measuring NCP may help identify high-grade stenotic lesions in this population. Funding Acknowledgement Type of funding sources: None.