LAD Stent Research Articles

Cracking The Case of The Cryptic Coronary: Diagnostic Strategies for Anomalous RCA Originating from LAD

Background: Coronary artery anomalies are typically congenital, though they may remain undetected until routine cardiac catheterization is performed. With a detection rate of only 1.3%, these anomalies often go unnoticed. In rare cases, the right coronary artery may originate from the left coronary system, but this anomaly is generally benign. Case presentation: A 55-year-old male patient was diagnosed with NSTEMI and underwent coronary angiography. However, despite multiple attempts, the medical team could not cannulate into the right coronary ostium. The left coronary ostium was located in the left sinus of Valsalva. Selective left coronary arteriography revealed normal courses of the left main and LAD but identified a critical stenosis in the LCx and a possible CTO at the RCA ostium. The patient received a stent in the LCx and returned the following month for another angiography, during which he received a stent in the proximal LAD. However, during cine angiography, it was found that the patient had an anomalous RCA that originated from the mid-portion of LAD, coursing anteriorly to the pulmonary artery and down to the right atrioventricular groove. Subsequent CCTA confirmed the RCA's origin from the mid-LAD. Conclusion: The report finds a rare RCA origin in the mid-LAD. The heart and its complex arterial network may be examined thoroughly, appreciate to coronary CTA, a non-invasive imaging approach. This allows for effective interventional cardiovascular therapy and is helpful for medical cardiac abnormality detection and assessment. Keyword: Anomalous Right Coronary Artery, CT Coronary Angiography, RCA from LAD, Single Coronary Artery.

Histopathological spectrum of cardiovascular findings in forensic autopsies in Hadoti region: A prospective study of one year

Heart diseases are now the biggest killer in the world. Many cardiovascular pathologies are concealed and found incidentally on post mortem examination. To analyse spectrum of histopathological lesions (related or unrelated to cause of death) in heart autopsies in Hadoti region of Rajasthan. This was a one year prospective hospital-based study. A total of 133 whole heart specimen underwent detailed gross and microscopic examination. Most common histopathological finding was atherosclerosis, seen in 63 cases out of 133 autopsied hearts (47.3%), followed by myocardial hypertrophy in 31 cases and myocardial infarction in 20 cases. Age related changes were seen in 10 cases, severe congestion in 10 cases, myocardial fibrosis in 7 cases. 1 case each of infective endocarditis, myocardial calcification, ventricular rupture, myocarditis, LAD stent, fat embolism was noted. 51 hearts did not reveal any sort of pathology. Correlation of age with atherosclerosis showed a significant p value (0.0009). Males showed a slightly higher prevalence of atherosclerosis but it was not statistically significant. We had 39 (29.3%) cases of sudden cardiac deaths (SCD). SCD cases showed similar histopathological spectrum as all other causes of deaths, but percentage of each heart pathology was much higher in SCD. Most common finding among SCD cases was coronary artery disease (23 cases), followed by myocardial hypertrophy (22 cases) and myocardial infarction (13 cases). Myocardial Fibrosis was seen in 3 cases, age related changes in 2 cases, ventricular rupture in 1 case and severe congestion in 1 case. 61.5% SCD cases showed combination of two or more pathologies. Five SCD cases did not reveal any pathology.In our study heart pathologies make a major contribution towards ill health and death in our society, atherosclerosis being the most common finding.

P305 MULTIVESSEL SUBACUTE STENT THROMBOSIS

Abstract The presence of comorbidities such as psychiatric pathologies negatively influences the prognosis of patients with acute cardiovascular events. A 62–year–old male patient suffering from arterial hypertension, dyslipidemia, ischemic heart disease, treated 3 years earlier with PCI of LAD, Cx e RCA (EF 45%), and schizophrenia, is hospitalized with a diagnosis of NSTEMI. Coronary angiography shows: eccentric stenosis 70% proximal to the pre–existing stent in the middle LAD; Intrastent occlusion of the middle circumflex branch with omocoronary rehabilitation and ulcerated critical plaque in the proximal segment of the right coronary artery with mild intrastent restenosis in the middle. The patient refuses cardiac surgery, so angioplasty with ultra–thin drug–eluting stents is performed. The patient starts DAPT with clopidogrel, choosing a combination formulation to promote compliance, with discharge on the fourth day. Three days after discharge, the patient returns with anterior STEMI, with multivessel intrastent thrombotic closure (LAD, Cx, RCA), so angioplasty with paclitaxel–releasing balloon is performed on LAD and with NC balloons on the right coronary artery; impossibility to obtain total recanalization of the circumflex branch due to the non–transit of guides, even hydrophilic and of different weights. During angioplasty and for the following 12 hours, bolus and infusion of tirofiban is administered due to the high thrombotic burden. The choice of the second antiplatelet agent in this second procedure fell on prasugrel. The patient is discharged on the sixth day and a long conversation is held with his wife regarding the correct management of the home therapy. One year later, the patient a dual–chamber ICD was implanted at another centre, with correct and regular assumption of home therapy. Our case demonstrates an infrequent form of multivessel thrombosis during STEMI. The presence of schizophrenia influences negatively the evolution of the natural history of ischemic cardiopaty. The psychiatric substrate exposes to a greater number of cardiovascular events, given the reduced therapeutic compliance, also as regards the choice of appropriate therapeutic strategies. A joint path between the hospital, local medicine and the family environment would be desirable in order to correctly manage this type of patient.

INTRAVASCULAR ULTRASOUND DERIVED MINIMAL LUMINAL AREA AND PLAQUE BURDEN OF CORONARY VESSELS IN OUR LOCAL POPULATION

Objectives: To report the average IVUS derived MLAs and plaque burden of coronary arteries of our local population.
 Methodology: It was a retrospective observational study. A total of 64 patients having IVUS done from January 2022 to September 2022 was enrolled in this study. IVUS images were acquired using 40 MHz, 3.1 French Opticross IVUS catheter (OptiCross™, Boston Scientific, USA).
 Results: Out of 54 patients, 39 (72%) were males with a mean age of 53.7 ± 14.1 years. The left main (LM) disease was found in n = 43 (79.6%) on coronary angiogram. The LM mean minimal luminal area was 6.68 ± 1.9 mm2 and mean minimal luminal diameter was 3.83 mm ± 1.02. Mean LM plaque burden was 57% (range 0-57). In proximal LAD mean MLA was 5.04 ± 2.7mm2, mean proximal reference diameter was 3.97 ± 0.64 mm and plaque burden was 53.88 ± 16.5%. The pattern of the plaque was diffuse with more calcified in the LAD than in the left main stem. The mean minimal stent area achieved in patients who had received stenting was 13.05 ± 2.88mm2 in LM (n = 15), and 9.71 ± 2.88 mm2 in proximal LAD (n = 30).
 
 Figure 1: (a). IVUS image of left main artery with minimum plaque. (b) well apposed stent in LAD of a patient, (c). heavy plaque burden with calcification causing drop out.
 Conclusion: Our local population has Coronary sizes comparable to those reported in the international literature. The stent size in major vessels like LM and proximal LAD should be guided by the use of IVUS to achieve maximum MSA to reduce adverse outcomes.

WELLENS SYNDROME - REPORT OF TWO CASES IN A PATIENT WITH MULTIVESSEL CORONARY ARTERY DISEASE

Acute coronary syndrome is a leading cause of death and increased morbidity in developed countries.Wellens syndrome as a high-risk of acute coronary syndrome is characterized by changes in the ST-T segment in theprecordial leads, indicating critical stenosis of the left anterior descending artery (LAD). This syndrome belongs tothe subgroup of patients with unstable angina pectoris who have inverted T waves in the anterior precordial leads onthe electrocardiogram (ECG). In our paper, we presented two cases of Wellens syndrome with critical LAD stenosis,performed coronary angiography and LAD stent placement. Wellens' syndrome can be a marker of critical LADstenosis in both its proximal and midsection. Changes can be temporary, last for months or disappear afterrevascularization treatment. Coronary angiography of the patient may also reveal critical stenosis of RCA (80%),LCx (100%), and diagonal-1 (90%). Failure to recognize this syndrome can cause a delay in referring patients forurgent coronary angiography and revascularization therapy that can lead to anterior myocardial infarction,significant left ventricular dysfunction, and even death. About 75% of patients with Wellens syndrome treated withconservative management alone will develop an extensive anterior myocardial infarction within a few days, with anaverage of 8.5 days from the onset of symptoms. This case study concludes that clinicians should be aware of ECGchanges in Wellens syndrome, which may occur during the pain-free period. For the definitive management ofWellens syndrome, the treatment of choice is cardiac catheterization with percutaneous coronary intervention (PCI),to relieve the patient of the symptoms of Wellens syndrome, as well as a number of complications of this acutecondition.

Side Branch Late Thrombosis After Left Main Coronary Artery Crossover Stenting.

BackgroundWith the established use of crossover stenting technique in bifurcation coronary artery lesions, added clinical benefit of final kissing of the side branch remains debatable. We report a case of a stenosis and thrombus formation of an ostial side branch after crossover stenting.Case SummaryA 38-year-old man was admitted with acute coronary syndrome complicated by acute pulmonary oedema. He was treated with stenting of the left descending artery (LAD) into the left main coronary artery (LMCA) 12 months earlier. Coronary angiography showed a filling defect in the ostial left circumflex coronary artery (LCX). Optical coherence tomography revealed neointimal growth of the LAD stent resulting in narrowing the LCX orifice and a large thrombus behind stent struts. After treatment of the lesion and optimised implantations of drug-eluting stents, the patient was transferred to the intensive care unit and monitored closely. Given his advanced ischaemic cardiomyopathy, the patient is being evaluated for heart transplantation eligibility.DiscussionStent struts across a bifurcated major side branch after crossover stenting could risk late stenosis and thrombus formation of the side branch. The clinical usefulness of routine imaging-guided kissing techniques even with good angiographic results in these cases should be evaluated.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40119-022-00270-w.

Stuck OCT Catheter: An Unanticipated Complication.

During an optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) of a calcified left anterior descending artery (LAD), the distal tip of the OCT catheter got stuck, and forceful tugging on the catheter by the operator led to LAD stent deformation proximally across the overlap between the proximal and middle stents. The purpose of these images is to make the readers aware of the very real and serious risk of a stuck OCT catheter, especially while imaging distal coronary arteries and overlapping stents. Increasing the length of the over-the-wire segment and hydrophilic coating of the OCT catheter may also be explored with manufacturers to prevent this complication.

Hybrid revascularization in a patient with Covid-19 and chronic limb ischemia stage IV

The authors report hybrid treatment of a patient with angina pectoris class II, multiple previous reconstructive interventions on the aortofemoral segment and chronic ischemia of the left lower limb stage IV and concomitant COVID-19. Coronary angiography was performed after regression of infectious disease under antiviral therapy. Occlusion of the left anterior descending artery was observed that required LAD stenting. On the next day, hybrid revascularization of the lower extremities was implemented: thrombectomy and endarterectomy from the branch of the aorto-femoral bypass graft and deep femoral artery at the first stage, stenting of the orifice of proximal branch of aorto-femoral bypass graft at the second stage, endarterectomy from superficial femoral artery, recanalization and stenting of superficial femoral artery and popliteal artery at the third stage and prosthetic- femoral bypass with autologous vein at the fourth stage. Postoperative angiography revealed patent stents and no residual stenoses. The choice in favor of these procedures and step-by-step approach has been substantiated. The authors emphasized effectiveness and safety of this treatment strategy.

C30. Clinical Decision Making in Intermediate Coronary Stenosis: Role of Fractional Flow Reserve

Abstract Background Coronary stenosis can be managed by percutaneous coronary intervention (PCI). However, it has limitation by producing only 2D images of the actual 3D vascular lumen. It is necessary to assess the functional significance of stenosis with fractional flow reserve (FFR). Case Summary There are two patients in this case. The first patient was a 52-year-old man with typical chest pain, with a history of PCI in LAD 2 years earlier. Echocardiography revealed regional wall motion abnormality (RWMA) with reduced left ventricular ejection fraction (LVEF) of 30-40%. PCI with FFR guidance was performed. Previous stent in osteal-distal LAD was patent. In the distal LAD, a stenosis of 60-70% was obtained with FFR of 0.81. In distal LCX, 50-60% stenosis was also obtained with FFR of 0.91. No stent was implanted then. The second patient was a 59-year-old man with typical chest pain. The patient had been stented in proximal-mid LAD and LCX-OM a year earlier. Echocardiography showed RWMA with LVEF of 51-54%. LAD and LCX stents were patent. A 70-80% stenosis was found in both mid and distal RCA. FFR was done in the mid-RCA with result of 0.57, so stent was placed in the mid RCA. FFR at distal RCA was 0.31 so that the stent was also placed in the distal RCA. Both showed good results. Discussion Physiologic assessment is important before deciding to revascularize. FFR-guided PCI is expected to better guide us in managing intermediate coronary stenosis.

C30. Clinical Decision Making in Intermediate Coronary Stenosis: Role of Fractional Flow Reserve

Abstract Background Coronary stenosis can be managed by percutaneous coronary intervention (PCI). However, it has limitation by producing only 2D images of the actual 3D vascular lumen. It is necessary to assess the functional significance of stenosis with fractional flow reserve (FFR). Case Summary There are two patients in this case. The first patient was a 52-year-old man with typical chest pain, with a history of PCI in LAD 2 years earlier. Echocardiography revealed regional wall motion abnormality (RWMA) with reduced left ventricular ejection fraction (LVEF) of 30-40%. PCI with FFR guidance was performed. Previous stent in osteal-distal LAD was patent. In the distal LAD, a stenosis of 60-70% was obtained with FFR of 0.81. In distal LCX, 50-60% stenosis was also obtained with FFR of 0.91. No stent was implanted then. The second patient was a 59-year-old man with typical chest pain. The patient had been stented in proximal-mid LAD and LCX-OM a year earlier. Echocardiography showed RWMA with LVEF of 51-54%. LAD and LCX stents were patent. A 70-80% stenosis was found in both mid and distal RCA. FFR was done in the mid-RCA with result of 0.57, so stent was placed in the mid RCA. FFR at distal RCA was 0.31 so that the stent was also placed in the distal RCA. Both showed good results. Discussion Physiologic assessment is important before deciding to revascularize. FFR-guided PCI is expected to better guide us in managing intermediate coronary stenosis.

Abstract 16758: Unexplained Recurrent St-elevation Myocardial Infarction Complicated By Diffuse Alveolar Hemorrhage In Undiagnosed Granulomatosis With Polyangiitis

Case Presentation: A 53-year-old man with a history of well-controlled hypertension and dyslipidemia presented with chest pain due to anterior STEMI for which a proximal LAD stent was placed. A week later, he presented with recurrent chest pain and ST elevation in the anterior chest leads. Coronary angiography showed in-stent thrombosis with heavy thrombus burden extending through the LAD. Manual thrombectomy with a second stent placement was done. He was discharged on triple therapy (aspirin, clopidogrel, and rivaroxaban), later, he presented to our medical facility with a 1-week history of hemoptysis. His clinical condition deteriorated requiring intubation. Laboratory work-up revealed elevated renal functions, proteinuria, and significant hematuria. CXR showed diffuse patchy opacities while CT chest was consistent with diffuse alveolar hemorrhage (Figure 1). Further work-up revealed elevated anti-proteinase 3 (c-ANCA) and low C4. Based on microscopic hematuria, renal impairment, and a positive c-ANCA, a diagnosis of granulomatosis with polyangiitis (GPA) was made. Induction with methylprednisolone, cyclophosphamide, and rituximab was initiated. His condition gradually improved, he was extubated successfully with marked improvement of renal functions. He was discharged on clopidogrel and scheduled for follow-up. Discussion: Few case reports have described STEMI as the initial presentation of GPA, likely attributed to vasculitis and accelerated atherosclerosis from systemic inflammation. Our patient had well-controlled cardiovascular risk factors and renal involvement with hematuria and elevated creatinine at the time of STEMI diagnosis, together with intermittent joint pains, suggesting ongoing systemic vasculitis. Clinicians should have a high index of suspicion for the possibility of non-atherosclerotic coronary stenosis as in cases of coronary vasculitis for early detection and management of a potentially reversible condition.

VASOPRESSIN-INDUCED ST-ELEVATION MYOCARDIAL INFARCTION

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Vasopressin is commonly used to restore blood pressure in hyperdynamic hemodynamic states, thereby reducing catecholamine requirements. The effects of vasopressin are primarily caused by the rise in the mean arterial pressure (MAP) due to systemic vasoconstriction, which, depending on the infusion rate, can also produce notable vasoconstrictive effects on the coronary microvasculature thereby reducing coronary blood flow despite an increase in coronary perfusion pressure. Here we present an interesting case of vasopressin-induced ST-elevation myocardial infarction (STEMI) on postoperative day two of cardiac catheterization for initial STEMI. CASE PRESENTATION: A 67-year-old male with a past medical history of hypertension, hypothyroidism presented to the emergency department (ED) with the complaint of left shoulder pain. In the ED waiting room, the patient suddenly collapsed losing consciousness, and was found to be in cardiac arrest. ACLS protocol was immediately started and ROSC was achieved. An electrocardiogram (EKG) was performed which showed STEMI in the anterolateral leads. Code STEMI was activated, and the patient was taken for the cardiac catheterization where LAD stenosis was observed and stented. Post-procedure, the patient was transferred to Cardiac ICU, where an amiodarone drip was initiated for recurrent episodes of non-sustained ventricular tachycardia. The hospital course was further complicated with pneumonia leading to acute hypoxemic respiratory failure and septic shock. The patient was placed on norepinephrine and appropriate antibiotics. Vasopressin was added to reduce catecholamine requirements and to achieve a target MAP. On postoperative day two, the patient was noted to have ST elevation on the tele monitor, a twelve lead EKG confirmed anteroseptal STEMI. A left heart catheterization revealed a patent LAD stent with no new findings and recommendations were made to stop vasopressin infusion and to continue the rest of the treatment. The patient was successfully extubated to BiPAP, eventually made a slow and steady recovery, and was discharged home with follow-up appointments. DISCUSSION: It has been shown that the levels of vasopressin increase as part of the stress response, which has been shown to exert vasoconstrictive effects on the coronary arteries mainly in the non-epicardial vessels of the microcirculation. These high levels in states like myocardial infarction can lead to coronary slow phenomenon mediating ischemia-perfusion injury. CONCLUSIONS: In advanced distributive shock with accompanied cardiogenic shock state, utmost caution should be taken as the vasoconstrictor properties of vasopressin are not accompanied by positive inotropic qualities, which may depress cardiac function even further as a result of impaired coronary blood flow despite increased coronary artery perfusion pressure and in severe cases can lead to myocardial ischemia. REFERENCE #1: Nobian A, Mohamed A, Spyridopoulos I. The role of arginine vasopressin in myocardial infarction and reperfusion. Kardiol Pol. 2019 Oct 25;77(10):908–17. REFERENCE #2: Hauser B, Asfar P, Calzia E, Laporte R, Georgieff M, Radermacher P. Vasopressin in vasodilatory shock: is the heart in danger? Crit Care. 2008;12(2):132. REFERENCE #3: Asfar P, Radermacher P. Vasopressin and ischaemic heart disease: more than coronary vasoconstriction? Crit Care. 2009;13(4):169. DISCLOSURES: No relevant relationships by Mohammed Ali, source=Web Response No relevant relationships by Humayun Anjum, source=Web Response No relevant relationships by Rahul Dadhwal, source=Web Response No relevant relationships by Salim Surani, source=Web Response

Incidence of Restenosis Following Rapamycin or Paclitaxeleluting Stent in Coronary Stent Implantation.

Coronary artery disease (CAD) is chiefly characterized by atherosclerosis and plaque formation in coronary arteries. The aim of this study was to evaluate the correlation of coronary anatomy as a predictor of restenosis and stent thrombosis in coronary artery disease (CAD) patients 5 years after percutaneous coronary intervention (PCI). In this prospective study, 1070 patients with stent restenosis or stent thrombosis over past 5 years were enrolled. Coronary angiography was performed to evaluate coronary restenosis and stent thrombosis 5 years after PCI. Stent restenosis was defined as >50% angiographic in-stent lumen reduction. Stent thrombosis was defined as sudden complete occlusion of stent presenting with acute myocardial infarction in that territory. Demographic data, clinical features and anatomic factors were prospectively reviewed. Baseline, procedural, and post-procedural characteristics of patients were recorded for analysis. Among demographic characteristics, cardiovascular risk factors (hypertension and diabetes mellitus) and anatomic factors were predictive risk factors for restenosis/thrombosis, p=0.001. The most common site for stent restenosis was proximal to the mid part of the LAD artery, followed by RCA and LCX. A greater diameter of LCX, a greater angle of LM-LAD than LM-LCX and left dominancy increase the incidence of LAD stent restenosis/thrombosis. In this study, the least common restenosis/thrombosis rate in relation to the total number of PCI was in the Ramus intermedius artery. The outcomes of the study indicated that anatomic factors can predict increased risk of restenosis among CAD patients who underwent PCI.

OCT Guidance for Detection and Treatment of Free-Floating Struts Following Ostial LAD Stenting.

OCT Guidance for Detection and Treatment of Free-Floating Struts Following Ostial LAD Stenting.

Dose Load during Angiographic Procedures LAD Stenting

Based on published dosimetric measurements, the dose load received by the interventional cardiologist from scattered X-ray radiation was assessed for an angiographic LAD stenting procedure under X-ray guidance. An angiographic X-ray system “Philips Allura Xper FD10” was used for the study. The dose assessment calculations were made for three positions of the patient table—basic, lowest and highest—and for three measurement points—“head”, “gonads” and “feet”, in which the received dose was measured. Due to the fact that three different projections are used during the procedure (RAO-cranial, LAO-cranial and pure Cranial), and each of them can be basic, calculations are made for each of them as a basic procedure. The obtained results show that the dose load obtained from this procedure is mainly due to the work performed in the radiographic mode of operation. In order to reduce the received dose load, it is necessary to take into account the position of the patient table during work and the use of appropriate individual radiation protection devices.

Review on Acute Cardio-Cerebral Infarction: a Case Report

Objective: To describe a case of a Cardio-Cerebral Infarction (CCI) male patient presented with a history of chest pain recognized using electrocardiography, brain computed tomography, and Percutaneous Coronary Intervention (PCI). Methods: A 69 years old man came with history of chest pain since 13 hours before to the emergency room. Electrocardiography, brain computed tomography, and PCI were performed, leading to the diagnosis of CCI. Results: The electrocardiography showed ST Elevation in Antero-lateral, atrial fibrillation and left-sided hemipharesis, which occurred on the second day. Brain computed tomography demonstrated acute infarct stroke, while the Percutaneous Coronary Intervention (PCI) showed one vessel disease with severe stenosis in LAD and implanted stent in proximal-mid LAD. Therapy prescribed was providing antiplatelet and anticoagulation. Discussion: Acute Myocardial Infarction (AMI) and Acute Infarct Stroke (AIS) have a narrow therapeutic time-window and a delayed intervention may results in morbidity and death. Antiplatelet and anticoagulant used in PCI for AMI increase the risk for hemorrhagic, and AIS with thrombolytic increase the risk of cardiac wall rupture in AMI. Direct Oral Anticoagulant (DOAC) treatment should reduce ischaemia and lower bleeding. The optimal time point to start anticoagulant treatment might be between 4-14 days after the onset of stroke. Duration of post-PCI triple therapy should be minimized depending on bleeding and risks of ischemia.

Efficacy and safety of one-month DAPT followed by 23-month ticagrelor monotherapy in patients undergoing proximal LAD stenting: Insights from the GLOBAL LEADERS trial

BackgroundsData on optimal antiplatelet therapy in patients undergoing stenting of the proximal left anterior descending artery (LAD) are limited. MethodsThis is a post-hoc analysis of the GLOBAL LEADERS trial, a prospective, multi-center, randomized controlled trial, comparing the experimental strategy (1-month dual anti-platelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) with the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in relation to stenting of the proximal LAD. The primary endpoint was the composite of all-cause death or new Q-wave myocardial infarction (MI) and key secondary safety endpoint was Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding at two years. ResultsAmong 15,845 patients included in the analysis, 3823 (23.9%) patients underwent stenting of the proximal LAD, while 12,022 (75.2%) did not. In the proximal LAD stenting group, there was no significant difference in the risk of the primary endpoint between the two antiplatelet strategies (3.38% vs. 3.93%; hazard ratio [HR]:0.86; 95% CI:0.62–1.20; Pinteraction = 0.951). However, the risk of any MI (2.63% vs. 3.88%; HR:0.68; 95% CI:0.47–0.97; Pinteraction = 0.015) and any revascularization (7.84% vs. 9.94%; HR:0.78; 95% CI:0.63–0.97; Pinteraction = 0.058) was significantly lower in the experimental strategy group, while demonstrating a similar risk of BARC type 3 or 5 bleeding between the two antiplatelet strategies (1.93% vs. 1.99%; HR:0.98; 95% CI:0.62–1.54; Pinteraction = 0.981). ConclusionsThe present study showed patients having stenting to the proximal LAD could potentially benefit from the experimental strategy with lower ischaemic events without a trade-off in major bleeding at two years.

In-stent restenosis and longitudinal stent deformation: a case report

BackgroundLongitudinal stent deformation (LSD) is an infrequent complication of percutaneous coronary intervention (PCI), and it may lead to catastrophic clinical outcomes. However, reports of cardiac adverse events associated with LSD are rare.Case presentationA 55-year-old man with chest pain was treated for a severe left anterior descending branch (LAD)-diagonal 1 (D1) bifurcation lesion by PCI with two stents in the proximal LAD. LSD occurred during the withdrawal of the trapped D1 wire. High-pressure balloon dilatation was performed in the deformed stent, and the end-angiographic appearance was acceptable, but no additional corrective measures were implemented. Ten months later, the patient represented with acute coronary syndrome. Severe in-stent restenosis (ISR) had suboccluded the proximal LAD, and optical coherence tomography (OCT) visualized multilayered stent struts protruding into the lumen at the compressed segment of the stent. Following complete apposition with balloon dilation, a drug-coated balloon (DCB) was used to avoid an additional permanent metallic layer. He remained angina free, and the angiographic result demonstrated no residual stenosis at the six-month follow-up. To our knowledge, this case demonstrates the first report of ISR triggered by LSD in patients treated with DCBs under the guidance of OCT.ConclusionsThe current report underscores the importance of awareness of LSD, and OCT seems to be the preferred modality to confirm complete apposition. If left without performing additional corrective measures, LSD may be associated with a risk of ISR. Complete apposition with balloon dilation followed by a DCB is a feasible treatment option.

P1329 An unexpected finding in a patient wth previous coronary artery bypass grafts and atypical chest pain

Abstract A 79-year-old male with a previous history of ischaemic heart disease and previous coronary artery bypass grafting (CABG) in 2005 presented with atypical chest pain. He also had past medical history of hypertension, hyperlipidaemia and bladder diverticulum which has been previously investigated by an abdominal CT. The latter had showed an incidental finding of what was reported to be a large pericardial cyst. Despite poor acoustic window, transthoracic echocardiography revealed a spherical echo–free structure in the area of the right atrioventricular groove (Figure 1, panel A white arrow). As the patient was too claustrophobic to undergo cardiac MRI, he was subsequently referred for a cardiac CT in order to further investigate the cystic mass and assess graft patency. The CT revealed an occluded left internal mammary artery (LIMA) to the LAD, severe left main (LM) and proximal LAD disease, a patent vein graft to an obtuse marginal (OM) branch and identified a largely thrombosed giant aneurysm (62x65x89 mm) of an otherwise patent vein graft to the RCA (Figure 1, panels B–E, white arrows point to the thrombosed and yellow arrows point to the non-thrombosed segments of the vein graft aneurysm). Coronary angiography confirmed occlusion of the LIMA, patency of the OM vein graft and identified only the non-thrombosed segment of the RCA vein graft aneurysm (Figure 1, panel F). The case was discussed at an MDT meeting and it was decided to proceed with LM and LAD stenting, and initially conservative management and close surveillance of the RCA vein graft aneurysm as the patient was high–risk for repeat CABG due to age, frailty and other comorbidities. Abstract P1329 Figure 1

P1481 Embolic infarct in a known coronary artery disease patient

Abstract A 60 y/o diabetic and hypertensive lady with previous anterior infarction treated by primary PCI with stenting of the proximal LAD (2011) and CABG for stent thrombosis, presented for chest pain. Admission ECG showed ST segment elevation in II, III aVF, ST segment depression in V1-V2 (A). Urgent coronary angiography was performed. It showed non-significant lesions on RCA and LCX, occlusion of the proximal LAD stent, patent LIMA to LAD and first diagonal with non-significant stenosis of the distal anastomosis (B). Transthoracic echocardiography (C) showed calcific mass involving the mitral annulus and posterior mitral leaflet, moderate mitral regurgitation, hipokinesia of the basal segment of the inferior wall with preserved LV ejection fraction. Transesophageal echocardiography (D) confirmed the calcified mass involving the mitral annulus and the posterior mitral leaflet. There was no significant mitral stenosis, and mitral regurgitation was moderate. Thoracic CT showed massive mitral calcification and a possible thrombus attached to it. (E) Myocardial infarction was confirmed by troponin rise and fall. The patient was discharged on dual antiplatelet therapy, ACE-I, betablocker and statin. At one month follow-up transthoracic echocardiography the central area of the mitral mass became hypoechogenic, and a bilobated hypermobile structure was seen attached to the ventricular side of the mass (F). Blood cultures were negative and there was no inflammatory syndrome. Cardiac magnetic resonance (H) confirmed myocardial infarction and showed massive calcification of the posterior mitral annulus. TEE performed after another month showed a very long hypermobile structure attached to the mitral annulus calcification, which was entering the left ventricular outflow tract reaching the plane of the aortic valve (G). The patient underwent surgical mitral valve replacement and redo CABG and the mass was excised. The pathologic aspect of the excised material was cazeous and friable (I). The initial presentation was presumably an embolic infarct with cazeous material. Abstract P1481 Figure.