Triple-vessel Coronary Artery Disease Research Articles

In between the cracks.

A 65-year-old man with end-stage renal failure, severe aortic stenosis, and triple vessel coronary artery disease was admitted for percutaneous coronary intervention to the left anterior descending artery prior to transcatheter aortic valve replacement.

To determine the frequency of triple vessel coronary artery disease in patients admitted with acute coronary syndrome.

Objective: To determine the frequency of triple vessel coronary artery disease in patients less than 40 years of age undergone diagnostic coronary angiography and were admitted with acute coronary syndrome Study Design: Cross Sectional study. Setting: Department of Cardiology, Punjab Institute of Cardiology, Lahore. Period: 3rd Sep 2018 to 2nd March 2019. Methods: It was consisted of 90 patients Results: Total 90 cases were enrolled in the study. All presented with central or left sided chest pain clinically diagnosed to be having acute coronary syndrome. All patients undergo diagnostic coronary angiography for the first time. 36.7 % of the presenting cases included in the present study were females while 63.3 % were males who had acute coronary syndrome. Average age of patients included in present study was 30.1±5.9 Data was stratified according to age, gender, type of ACS present. Post stratification chi-square test was applied. It showed that 23.29 % patients had triple vessel coronary artery disease whereas 76.71% did not have triple vessel coronary artery disease. Conclusion: TVCAD was observed in 23.29% of patients presented with acute coronary syndrome in patients less than 40 years of age.

Sex differences in surgical site infections following coronary artery bypass grafting: a retrospective observational study

Surgical site infection (SSI) following cardiac surgery poses a significant challenge for healthcare providers. Despite advances in surgical techniques and infection control measures, SSI remains a leading cause of morbidity and mortality, in addition to being a significant economic burden on healthcare services. Current literature suggests there is a reproducible difference in the incidence of SSI following cardiac surgery between sexes. We aim to assess the sex-specific predictive risk factors for sternal SSI following coronary artery bypass grafting (CABG) in addition to identifying any differences in the causative organisms between groups. Adult patients undergoing isolated CABG between January 2012 and December 2022 in one UK hospital organization were included. In this 10-year, retrospective observational study, a total of 10,208 patients met the inclusion criteria. Pre-operative risk factors were identified using univariate analysis. To assess dependence between sex and organism or Gram stain, a Pearson Chi-squared test with Yates correction for continuity was performed. In total there were 8457 males of which 181 developed a sternal SSI (2.14%) and 1751 females, 128 of whom had a sternal SSI (7.31%). Male patients were found to be significantly more likely to develop an SSI secondary to a Gram-positive organism, whereas female patients were more likely to have a Gram-negative causative organism (P<0.00001). Staphylococcus was statistically more likely to be the causative organism genus in male patients. Pseudomonas aeruginosa was found to be twice as common in the female cohort compared with the male group. In our study, we found a statistically significant difference in the causative organisms and Gram stain for post-CABG sternal SSIs between males and females. Male patients predominately have Gram-positive associated SSIs, whereas female SSI pathogens are more likely to be Gram negative. The preoperative risk profiles of both cohorts are similar, including being an insulin-dependent diabetic and triple vessel coronary artery disease. Given these findings, it prompts the question, should we be tailoring our SSI treatment strategies according to sex and associated risk profiles?

Case Report: Multiple atherosclerotic plaques at its extreme in synchrony

Peripheral artery (PAD) disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral artery disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

Association of lipoprotein(a) with severity of coronary artery atherosclerosis in patients with acute coronary syndromes

Abstract Background Elevated level of lipoprotein (a) [Lp(a)] is an independent risk factor for atherosclerotic cardiovascular disease. However, the association of Lp(a) with acute coronary syndromes (ACS) has not been sufficiently studied. Purpose To evaluate the relationship between high serum levels of Lp(a) and (i) factors that play a role in the long-term development of the severity of coronary artery disease (CAD), (ii) extent of CAD amongst patients with ACS. Methods In this study we enrolled 74 consecutive patients hospitalized for ACS in tertiary cardiology center form December 2022 to January 2023. Patients characteristics were compared for patients with Lp(a) &amp;lt;75 nmol/L (53 patients) and ≥75 nmol/L (21 patients). Logistic regression analyses were performed to evaluate the relationship of Lp(a) with severity of CAD. Results In the studied population, the mean age of patients with high Lp(a) levels was 65 years. They were more likely to have arterial hypertension and hypercholesterolemia than those with normal Lp(a) levels (p &amp;lt;0.05). There were no significant differences in distribution of ACS subtype between groups. On univariate analysis, triple vessel CAD [odds ratio (OR) 4.22, 95% confidence interval (CI) 1.34-13.27, p = 0.014), and multivessel CAD (OR 3.05, 95% CI 1.06-8.81, p = 0.040) were significantly associated with abnormal Lp(a) levels. Multivariable determinants of of high Lp(a) levels were also triple vessel CAD (OR 4.19, 95% CI 1.33-13.26, p = 0.013), and multivessel CAD (OR 3.04, 95% CI 1.05-8.80, p = 0.042). Conclusions Lp(a) ≥75 nmol/L was closely associated with the extent and severity of CAD in patients with ACS.

436 Total Arterial Revascularisation Complicated by Unexpected Vasoconstrictor Requirements

Abstract Introduction The debate surrounding conduit selection in multi-vessel coronary artery bypass grafting (CABG) persists. Whilst combined arterial and venous conduits remains the gold standard approach, some studies report superior long-term outcomes with total arterial revascularisation (TAR). Case Description A 48-year-old male was admitted with acute coronary syndrome. Investigations demonstrated significant triple vessel coronary artery disease with preserved biventricular systolic function. He had no major comorbidities. He underwent uneventful urgent off-pump CABG x 3 with TAR. Conduits used were a skeletonised left internal mammary artery (LIMA) and a radial artery. They were anastomosed to make a Y configuration. The LIMA was anastomosed end-to-side to the mid-LAD and the radial artery was anastomosed side-to-side to the first obtuse marginal and end-to-side to the posterior descending artery. Post-operatively the patient had significant drain output, resulting in haemodynamic instability and a significant increase in vasoconstrictor requirements. This led to vasoconstrictive spasm of the arterial grafts and cardiac arrest ensued. The patient underwent emergency re-sternotomy and institution of cardiopulmonary bypass. The arterial grafts were removed, and the patient was re-grafted with three saphenous vein grafts. The patient was successfully discharged home in a stable condition on the tenth post-operative day. Discussion Careful management of post-operative complications in patients who underwent TAR is required in order to reduce the risk of arterial graft spasm. Pre-operative planning should include the consideration of alternative conduit strategies in patients where higher post-operative vasoconstrictor requirements are anticipated.

The Fatal Interplay between Stress Induced Cardiomyopathy, Arrhythmia and Cardiogenic Shock

A 59-year-old man presents to the hospital following a syncopal episode after a low-speed car accident without visible injuries. He was diagnosed with stress cardiomyopathy and severe triple-vessel coronary artery disease. The case was complicated by complete heart block that culminated in refractory cardiogenic shock. Literature and current approach are reviewed.

Case Report: Multiple atherosclerotic plaques at its extreme in synchrony

Peripheral vascular disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral vascular disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

Serum Malondialdehyde-Oxidized Low-Density Lipoprotein Level Is Associated with Arterial Stiffness by Cardio-Ankle Vascular Index in Coronary Artery Bypass Graft Patients.

A high malondialdehyde-oxidized low-density lipoprotein (MDA-oxLDL) level is associated with atherosclerotic cardiovascular diseases and major adverse cardiovascular events. A higher cardio-ankle vascular index (CAVI) is independently associated with an increased risk of cardiovascular events, cardiovascular mortality, myocardial infarction, and stroke in patients with cardiovascular risk. Thus, this study aimed to evaluate the relationship between serum MDA-oxLDL levels and CAVI in patients with triple-vessel coronary artery disease who underwent coronary artery bypass graft (CABG) surgery. Fasting blood samples and baseline characteristics were obtained from 88 patients who had undergone CABG. A commercialized enzyme-linked immunosorbent assay was used to measure MDA-oxLDL levels. An automatic pulse wave analyzer was used to measure CAVI values, and each side of CAVI values of ≥9 was designated as arterial stiffness. In total, 47 participants were assigned to the arterial stiffness group. More patients had diabetes mellitus, were older, and had higher serum MDA-oxLDL levels in the arterial stiffness group than in the control group. A multivariate logistic regression analysis disclosed that MDA-oxLDL and diabetes mellitus were independent predictors of arterial stiffness. Moreover, according to the Spearman's correlation analysis, the serum MDA-oxLDL level was positively associated with both left and right CAVI. Serum MDA-oxLDL levels were positively associated with arterial stiffness in patients who had undergone CABG.

Off-pump CABG surgery in left main coronary artery disease: a single-center prospective registry.

The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Patients with left main multi-vessel coronary artery disease (LM CAD) have concerns regarding incomplete revascularization and reduced survival with off-pump (OPCAB) when compared with on-pump (ONCAB) coronary bypass surgery. To evaluate outcomes among high-risk LM CAD patients undergoing OPCAB, we performed a registry-based prospective study. We performed 4868 coronary artery bypass graft (CABG) surgeries from Jan 2013 to Jun 2019 with 4662 (95.8%) OPCAB. In OPCAB cohort, we had 1323 patients (28.4%) with significant LM (> 50%) triple vessel CAD. Data regarding clinical features, extent of CAD, operative details, in-hospital outcomes, and 3-year follow-up were obtained. Descriptive statistics are reported. The study cohort (n = 1323) was aged 63 ± 9years with men 88.4%. Tobacco use was in 328 (24.8%), diabetes 598 (45.2%), previous myocardial infarction 463 (35.0%), previous coronary intervention 40 (3.0%), and congestive heart failure in 54 (4.1%). All patients had LM (100.0%) with triple vessel disease in 99.4% (LAD, left anterior descending 100.0%; LCX, left circumflex 99.4%; RCA, right coronary artery 78.7%). Vessels bypassed/patient were 2.7 ± 0.4 with 3.2 ± 0.7 total grafts and 2.1 ± 0.8 venous grafts. In total, 1278 (96.5%) patients received left internal mammary artery (LIMA), 63(4.7%) bilateral internal mammary artery (BIMA), and 74 (5.6%) radial artery grafts. There was no patient with conversion from OPCAB to ONCAB. In-hospital major adverse cardiovascular events (MACE: all-cause deaths, myocardial infarction, and stroke) were in 21 (1.6%). At 3-year follow-up (n = 1041), MACE rates were in 84 (8.1%) and cardiovascular deaths in 28 (2.7%). This study shows that off-pump CABG surgery is safe in patients with LM CAD. There is low in-hospital mortality and MACE and 3-year outcomes are similar to the published data of LM CAD patients who undergo on-pump CABG. The online version contains supplementary material available at 10.1007/s12055-023-01526-3.

Rita-Rae (Right Internal Thoracic Artery to Radial Artery Extension): Experience With Total Arterial Revascularisation Without Aortic Anastomoses

Total arterial revascularisation using internal thoracic and radial arteries are emerging as desirable long-term solutions for triple vessel coronary artery disease (CAD). Achieving this goal can sometimes be challenging due to a shortage of available arterial conduit, need for aortic anastomoses, limited length of conduits, and optimal use. This study explored a novel configuration of connecting the radial artery graft to the distal end of the right internal thoracic artery (RITA) as an adjunct to the conventional left internal thoracic artery (LITA) to left anterior descending (LAD) graft.

Assessment of Platelet Mitochondrial Respiration in the Setting of Cardiopulmonary Bypass: A Case Report

Aortic stenosis is the most common valvular disease worldwide. Coronary artery disease (CAD) is often associated with degenerative aortic stenosis, particularly among older patients. Surgical treatment of the combined pathologies is highly recommended because the results are durable. Assessment of mitochondrial respiration in blood cells has recently emerged as a potential biomarker of the bioenergetic health but data regarding the changes in the setting of cardiopulmonary bypass (CPB) are scarce. A 67-year-old man was referred to the clinic for progressive breathlessness, constrictive thoracic pain and fatigue. Investigations revealed severe aortic stenosis and triple-vessel CAD. The aortic valve was replaced with a mechanical aortic prosthesis and coronary artery bypass graft was performed under mild hypothermia. We assessed platelet complex I (CI)- and complex II (CII)-dependent mitochondrial respiration and found a significant increase in the net active respiration supported by CI and the maximal uncoupled respiration in platelets harvested after CPB compared to those isolated pre-CPB. At variance, the active coupled respiration and electron transfer capacity for CII were decreased. The relative contribution of the complex cardiac pathology and CPB to the impairment of CII-dependent respiration and/or a possible relation with patients’ outcome are worth further investigation in a pilot study.

P155 CT EVIDENCE OF PARTIAL ISCHEMIC PAPILLARY MUSCLE RUPTURE

Abstract A 77–year–old man was referred for coronary CT following an episode of prolonged chest pain that occurred about 30 days earlier, with subsequent onset of dyspnea on moderate exertion. Coronary CT demonstrated right dominance, occlusion of the right coronary artery, as well as severe stenosis of the distal segment of the left anterior descending artery and of the first obtuse marginal branch. CT scan also showed an intraventricular image consistent with partial rupture of the posteromedial papillary muscle (Figure 1). The patient was transferred to the emergency department. An ECG showed signs of inferolateral necrosis. Transthoracic echocardiography confirmed akinesia of the inferior and inferolateral walls and of the basal segment of the inferior septum, with severe mitral valve insufficiency from anterior leaflet prolapse (A3 scallop) from partial rupture of the posteromedial papillary muscle (Figure 2). Transesophageal echocardiography confirmed the diagnosis (Figure 3). The patient was admitted to the CCU and underwent coronarography, which confirmed the severe triple vessel coronary artery disease with occlusion of the right coronary artery, and then urgent mitral valve replacement with bioprosthesis and aortocoronary bypass with saphenous vein grafting to the posterior descending artery. The postoperative course was uneventful. Ischemic papillary muscle rupture is a rare cause of mitral insufficiency. Papillary rupture typically occurs within 5 days of an acute myocardial infarction, and causes mitral insufficiency by prolapse and flail of one or, more rarely, both mitral valve leaflets. The posteromedial papillary muscle is most commonly affected, since the anterolateral papillary muscle has dual supply from the anterior interventricular artery and the circumflex artery. Papillary muscle rupture can be total or partial; however, most cases of partial rupture progress to complete rupture and therefore require urgent surgical treatment. The peculiarity of this case lies in the fact that it is the first case described in the literature of a papillary muscle rupture documented on CT.

Five-year follow-up on two revascularization methods used on patients with left main artery disease and/or multivessel coronary artery disease.

Coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) are the main treatment methods for left main artery disease (LMAD) and triple-vessel coronary artery disease (TVCAD). This study aimed to evaluate the five-year post-treatment effects of CABG and PCI in patients with severe coronary vasculopathy. A total of 430 patients with LMAD and/or triple-vessel coronary artery disease from November 2014 to July 2015 were enrolled retrospectively in the affiliated cardiovascular hospital of Shanxi Medical University and divided into the CABG group and PCI group. The living conditions of the patients were obtained through medical records and telephonic follow-ups five years after the surgery date. The independent risk factors for major adverse cardiovascular and cerebrovascular events (MACCE) were analyzed using logistic regression analysis. The effects of the two treatment methods were followed up and evaluated to measure the predictive ability of the Global Risk Classification (GRC) scoring system for MACCE after five years. There were 212 cases in the CABG group and 218 cases in the PCI group. Smoking (P= 0.047), diabetes (P= 0.031), LVEF (P= 0.020), LMAD (P= 0.008), and anterior descending branch lesions (P= 0.038) were significantly correlated with MACCE. The prevalence of MACCE in the CABG group and PCI group had no significant difference (P= 0.549). The GRC scoring system received an AUC of 0.701 for predicting MACCE. For patients with severe coronary artery disease, there was no significant difference in the prevalence of MACCE between the CABG and the PCI groups. Several independent risk factors for MACCE were found. The GRC scoring system showed a strong predictive ability for MACCE after five years of revascularization.

Early and mid-term outcomes of off-pump versus on-pump coronary artery bypass surgery in patients with triple-vessel coronary artery disease: a randomized controlled trial

Background and aim of the studySeveral studies have compared early and late outcomes of on-pump coronary artery bypass grafting (CABG) and off-pump CABG. However, there is still an ongoing debate on this matter, especially in patients with triple-vessel coronary artery disease (3VD).MethodsWe randomly assigned 274 consecutive patients with 3VD to two equal groups to undergo on-pump CABG or off-pump CABG. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), including all-cause mortality, acute coronary syndrome, stroke or transient ischemic attack, and the need for repeat revascularization. The secondary outcomes were postoperative infection, ventilation time, ICU admission duration, hospital stay length, and renal failure after surgery.ResultsThe median follow-up duration was 31.2 months (range 24.6–35.2 months). The mean age of patients was 61.4 ± 9.3 years (range: 38–86), and 207 (78.7%) were men. There were 15 (11.2%) and 9 (7.0%) MACCE occurrences in on-pump and off-pump groups, respectively (P value = 0.23). MACCE components including all-cause death, non-fatal MI, CVA, and revascularization did not significantly differ between on-pump and off-pump groups. We observed no difference in the occurrence of MACCE between off-pump and on-pump groups in multivariable regression analysis (HR = 0.57; 95% CI 0.24–1.32; P value = 0.192). There were no statistical differences in postoperative outcomes between the off-pump and on-pump CABG groups.ConclusionsOff-pump CABG is an equal option to on-pump CABG for 3VD patients with similar rates of MACCE and postoperative complications incidence when surgery is performed in the same setting by an expert surgeon in both methods. (IRCT20190120042428N1).

Wellens’ syndrome following severe COVID-19 infection, an innocent coincidence or a deadly association: two case reports

BackgroundCoronavirus disease 2019 (COVID-19) has been associated with late-onset cardiovascular complications primarily due to a hypercoagulable state. Its association with Wellens’ syndrome, which reflects a stenosis in the proximal left anterior descending coronary artery, is not well established. We present two cases diagnosed with this syndrome following their COVID-19 acute phase despite taking adequate anticoagulation.Case presentationWe present two patients with incidental electrocardiography (ECG) showing the typical Wellens’-related changes, with an underlying severe triple-vessel coronary artery disease a few weeks following a severe COVID-19 infection associated with high inflammatory markers. The stenotic lesions were diagnosed by cardiac catheterization, and both patients underwent Coronary Artery Bypass Grafting successfully. Notably, patients’ baseline ECGs were normal, and they were maintained on Rivaroxaban 10 mg following their viral illness.ConclusionDespite advances in the preventive measures for COVID-19 complications, its pathophysiologic impact on vasculature and atherosclerosis is still incompletely understood. Further clinical trials must be conducted to study this association between Wellens’ syndrome and this virus to prevent life-threatening complications.

Monitoring of regional cerebral oximetry by near-infrared spectroscopy during off-pump coronary artery bypass grafting to evaluate the impact on postoperative neurocognitive dysfunction – A prospective study

Abstract Background and Aims: Postoperative neurological dysfunction is a common noncardiac complication following cardiac surgery. Primary objective of our study was to evaluate the effects of cerebral oxygen desaturation on the neurological outcome in the postoperative period by monitoring regional cerebral oxygen saturation in off-pump coronary artery bypass grafting (OPCABG). Secondary objective was to study the correlation between regional cerebral oxygen saturation and mean arterial pressure (MAP) during grafting. Setting and Design: It was a prospective observational study in 100 patients of the American Society of Anesthesiologists physical status grading II-III of either sex, having triple vessel coronary artery disease undergoing OPCABG. Patient, having left ventricular ejection fraction (LVEF) &lt;35%, carotid artery disease, on extracorporeal membrane oxygenator or intra-aortic balloon pump, preexisting neurological disorder with standardized mini-mental state examination (SMMSE) score &lt;23, undergoing emergency surgery, re-do surgery, and co-existing valvular diseases were excluded from the study. Surgeries were conducted under general anesthesia with midazolam 0.1 mg/kg, fentanyl 5 μg/kg, and vecuronium 0.1 mg/kg. Anesthesia was maintained with intermittent boluses of fentanyl, vecuronium, and isoflurane. Materials and Methods: The SMMSE was performed preoperatively, 8 and 12 h after extubation. Patients with postoperative SMMSE score of 24–30 were allocated to Group A and patients with SMMSE score ≤ 23, were allocated to Group B. The cerebral oxygen saturation (rSO2), heart rate, MAP, and arterial blood gas were monitored perioperatively. Statistical Analysis: The Chi-square test was used to compare categorical variables and independent Samples t-test was used to compare continuous variables. Pearson bivariate correlation test was used to correlate between the continuous variables. Results: The mean difference of right and left rSo2, between baseline value, and during saphenous vein graft (SVG) to obtuse marginal grafting were 8.70 ± 3.38, 8.78 ± 3.19 in group A and 18.8 ± 2.40, 18.91 ± 1.88, respectively, in group B and were found to be statistically significant. The mean difference of right and left rSO2, between baseline value and during SVG to posterior descending artery grafting were 6.48 ± 3.91, 7.10 ± 3.67 in group A and 18.1 ± 3.57, 17.9 ± 3.60 in group B and were found to be statistically significant. Mean difference and percentage variation from baseline of right and left rSo2 and MAP from preinduction to grafting from left internal mammary artery to left anterior descending artery were found to be statistically insignificant. Conclusion: A decrease of regional cerebral saturation value by 25% from baseline or an absolute reduction of rSO2 value by 50% and reduction in MAP from baseline, during the period of grafting was associated with postoperative neurocognitive dysfunction.

Improved detection of coronary artery disease by CZT regional coronary blood flow evaluation

IntroductionCZT cameras have enabled the noninvasive quantification of myocardial flow reserve (MFR), an important physiologic measure. This study aimed to compare myocardial perfusion SPECT (MPS) with or without MFR evaluation for the detection of obstructive coronary artery disease (CAD).Methods48 patients with CAD (&amp;gt;50% obstruction) detected at invasive coronary angiography or CT angiography underwent dipyridamole MPS and MFR evaluation within 30 days. A 1-day protocol (rest-stress) was used to quantify MFR. The acquisition of dynamic rest and stress images was initiated simultaneously to 99mTc sestamibi injection (370 and 1,110 MBq, respectively), both lasting for 11 min, followed by 5-min imaging. Pharmacologic stress with dipyridamole (0.56 mg/kg for 4 min) was performed with the patient positioned in the CZT camera. The images were processed and time-activity curves were generated, calculating global and regional MFR in a semiautomatic software. A global or regional MFR &amp;lt;2 was considered abnormal. MPS perfusion images were classified as normal or abnormal. The images were interpreted by experienced physicians blinded to the results of MFR and coronary angiography/CT.ResultsMean age of the population was 61 ± 9 years, 54.2% female. Twenty patients (41.7%) had single-vessel CAD, 22 (45.8%) 2-vessel CAD and 6 (12.5%), triple-vessel CAD. Among the 82 vessels with obstruction, 48 had perfusion abnormalities in MPS and 60 had reduced MFR, while among the normal vessels, had 54 normal MPS and 52 had preserved MFR. The sensitivity of MFR (69%) was higher than that of MPS (55.2%), without significant changes in specificity (86 vs. 83.7%).ConclusionsMFR in the CZT camera is more sensitive for the detection of CAD than perfusion abnormalities in MPS, especially in patients with multivessel CAD.

Frequency of Triple Vessel Coronary Artery Disease in Diabetic and Non Diabetic Patients Presenting with NSTEMI

Multi-vessel coronary artery disease (MVD) has profound challenges to the revascularization system. Several investigations showed diverse forms of CAD associated with complete or incomplete revascularization in MVD in PCI. Diabetic patient had more multi-vessel CAD as compared to non-diabetics. Objectives: To determine the frequency of triple vessel coronary artery disease and afterwards compare the triple vessel coronary artery disease in diabetic v/s non-diabetics in patients presenting with NSTEMI. Methods: This Descriptive Cross-Sectional Study was conducted at Emergency Department of the National Institute of Cardiovascular Diseases (NICVD), Karachi for Six months from March 4, 2019, to September 3, 2019. Samples size n=250 was calculated through non-probability consecutive sampling technique. All the patients of either gender presenting NSTEMI and undergone coronary angiography, aged &gt;40 and &lt; 75 years and agreed to participate after their volunteer affirmation were included in this study. Results: Out of 250 patients, 75.6% were male while 24.4% were female with a mean age of 56.60. Triple Vessel Disease was documented in 107(42.8%) patients. As for the study main objective variable diabetes, the comparative analysis of triple vessel disease between diabetic versus non-diabetic resulted in significant difference was noted i.e., p-value =0.030. Conclusions: Diabetic Mellitus has a significant factor for 3VD among the patients of NSTEMI patients. As a risk factor and comorbid, DM screening is a necessary factor in all NSTEMI patients who diagnosed with 3VD.

Management of an Elderly Patient Via Trans-Catheter Approach for a Post-Cardiac Surgery Aortic Pseudoaneurysm: A Case Report

Pseudoaneurysm of the ascending aorta is a rare but dreadful complication following cardiac surgery and it has more chances of rupturing in elderly females. It occurs as a result of lengthy cardiopulmonary bypass time and associated degenerative changes in old patients. Due to the poor prognosis, early diagnosis and management of this complication is essential. Our case is of a 68-year old female who developed a 44 mm large ascending aortic pseudoaneurysm 7 days after undergoing (coronary artery bypass grafting) CABG for long-standing. (Triple vessel coronary artery disease) TVCAD. The location of the pseudoaneurysm was found to be just above the vein graft to the RCA on (computerized tomography) CT-Aortogram. 2D-Echocardiography showed an Ejection Fraction of 45% and a 22 mm neck of the aneurysmal sac. Trans-catheter device closure was planned and the neck was successfully closed with no residual leak seen on (computerized tomography) CT-Aortogram performed after 3 days. However, she developed cardiac arrest during the device closure and even after successful resuscitation she went into a state of septic shock in the following weeks that did not respond to maximum medical treatment which unfortunately led to her death. A review of 3 similar cases of post-cardiac surgery aortic pseudoaneurysms which were successfully managed via trans-catheter device closure is also discussed. Early diagnosis and interventional treatment of post-cardiac surgery aortic pseudoaneurysms in elderly patients is necessary alongside very careful surgical technique while performing cardiac surgery to minimize the risk of aneurysm formation.