Increased aortic stiffness in patients with coronary artery ectasia

OBJECTIVE: Alterations in aortic stiffness may reflect the elastic properties of the larger arteries. In many diseases, aortic elastic properties have been investigated to show whether the larger arteries are involved. The elastic properties of aorta in patients with coronary artery ectasia, however, have not been studied yet. We aimed to investigate aortic stiffness parameters in patients with coronary artery ectasia and to compare patients with coronary artery ectasia and coronary artery disease with the control group. METHOD: Thirty-three patients with coronary artery ectasia, 31 patients with coronary artery disease and 30 patients with angiographically normal coronary arteries were included in this study. Aortic diameters were measured on the M-mode tracing obtained at a level 3 cm beyond the aortic valve at parasternal long-axis view. Aortic diameter change, aortic strain, aortic distensibility and stiffness parameters were measured as aortic stiffness parameters. RESULTS: Aortic diameter changes were fewer in the coronary artery ectasia and coronary artery disease group than in the control group (0.4 +/- 0.1 and 0.3 +/- 0.1 vs. 0.8 +/- 0.2; P < 0.001). Aortic distensibility and aortic strain were significantly lower in patients with coronary artery ectasia and coronary artery disease than in the controls (for aortic distensibility P < 0.001 and for aortic strain P < 0.001, < 0.001, respectively). In contrast, a significantly higher aortic stiffness index was observed in patients with coronary artery ectasia and coronary artery disease than in the control group (14.2+/-2.6 and 18.1 +/- 2.9 vs. 5.9 +/- 1.8; P < 0.001, respectively). CONCLUSIONS: The impairment in aortic elastic properties in patients with coronary artery ectasia indicates that this disease is a generalized disease rather than a localized disease of the coronary arteries.     

Surgical implications and results of combined aortic valve replacement and myocardial revascularization.

To better define the indications for and results of simultaneous aortic valve replacement and myocardial revascularization, a cohort of 271 patients with angiographically defined coronary anatomy who underwent xenograft bioprosthetic aortic valve replacement were analyzed. Two hundred and twelve patients had predominant aortic stenosis, and 55 had pure aortic regurgitation. Discordance between the clinical assessment of angina and the angiographic assessment of coronary artery disease was apparent in 39 percent of the patients with aortic stenosis and 45 percent of the patients with aortic regurgitation. Thirty-seven percent of patients in the aortic stenosis subgroup without angina and 41 percent of patients in the aortic regurgitation subgroup without angina had hemodynamically significant coronary artery disease. Concomitant coronary artery bypass grafting and aortic valve replacement were performed in 101 patients. The incidence of perioperative myocardial infarction and operative death was significantly greater (P < 0.05) in the subsets of patients with coronary disease than in those without coronary disease (9.9 percent versus 0.7 percent and 8.3 percent versus 2.2 percent, respectively). Late postoperative angina and myocardial infarction also correlated with the preoperative presence of coronary artery disease. Excluding operative mortality, the late actuarial survival rate (mean follow-up, 1.6 years; maximal follow-up, 4.9 years) was not statistically lower for the patients with coronary disease.It is concluded that angina pectoris in patients with aortic valve disease is not a reliable indicator of coronary artery disease and that patients with coronary disease who undergo aortic valve replacement have an increased risk. It is inferred from this study that preoperative coronary arteriography is advisable in most adults undergoing the evaluation of aortic valve disease and that simultaneous aortic valve replacement and myocardial revascularization may provide some protection against late attrition due to the combined effects of coexistent aortic valve and coronary artery disease.     

Effects of the rise in aortic pressure on coronary flow reserve in dogs. Comparison between constriction of the descending thoracic aorta and injection of methoxamine

In order to investigate the effect of a rise in aortic pressure on coronary flow reserve and also on the difference of its effect according to the methods used to raise aortic pressure, this experiment was performed. Using 7 anesthetized dogs with heart rate held constant by a pacemaker, both the resting and the peak reactive hyperemic left circumflex coronary flow were measured following raising of the aortic pressure by either descending thoracic aorta constriction or methoxamine injection. The resting and peak reactive hyperemic coronary flows both increased linearly following the rise in aortic pressure. The magnitude of the resting flow increment and the resting coronary vascular resistance following raising aortic pressure did not differ significantly between the two different methods. However, the magnitude of the peak hyperemic flow increment and the peak hyperemic coronary vascular resistance following raising aortic pressure were significantly smaller with methoxamine injection than with aortic constriction. These data indicate that coronary flow reserve increases proportionally with a rise in aortic pressure. However, the magnitude of the increment of coronary flow reserve is smaller following an alpha-adrenoceptor-mediated rise in aortic pressure, because the maximal coronary vasodilation was reduced by alpha-stimulated coronary vasoconstriction.     

Left coronary artery anatomy in patients with bicuspid aortic valves

The anatomy of the proximal left coronary artery in 33 adult patients with bicuspid aortic valves was compared with that in 33 adult patients with aortic valve disease of other aetiologies and with that in 50 adult control patients with no valve or congenital heart disease. Patients with bicuspid aortic valves had a higher incidence of immediate bifurcation of the left main coronary artery, of left main coronary length less than 10 mm, and of left coronary artery dominance. The mean length of the left main coronary artery was significantly less in the patients with bicuspid aortic valves. These variations from the usual coronary artery anatomy may be part of the developmental abnormalities responsible for bicuspid aortic valves, and require evaluation and consideration when considering angiography and valve replacement in patients with aortic stenosis.     

Angina pectoris and coronary artery disease in patients with severe aortic valvular disease

We studied the clinical, hemodynamic, and angiographic findings of 90 consecutive patients with significant symptomatic aortic valve disease, 40 years of age or older, to evaluate the prevalence of angina pectoris in relation to coronary artery disease and the effect upon cardiac function.The prevalence of chest pain was 66% (typical angina, 39%; atypical chest pain, 27%), and the prevalence of coronary artery disease was 39%. The prevalence of coronary artery disease in patients with typical angina was 77%, in contrast to 25% in patients with atypical chest pain $\text{(}\text{P}\text{= 0.001)}$. Only two of the 35 patients (6%) with coronary artery disease were free of chest pain. Although the incidence of coronary artery disease in patients with aortic stenosis was slightly higher than in patients with aortic regurgitation or aortic stenosis-aortic regurgitation, it was not statistically significant.Patients with aortic regurgitation and coronary artery disease had significantly lower ejection fraction than patients with aortic stenosis and coronary artery disease. There were no significant differences between ejection fraction in patients without coronary artery disease in the different groups. Patients with aortic stenosis and coronary artery disease tend to have lower mean pressure gradients than those without coronary artery disease. Patients with coronary artery disease in aortic regurgitation and aortic stenosis-aortic regurgitation tend to have higher left ventricular end-diastolic pressure.This study indicates that although patients with aortic valve disease and typical angina are most likely to have associated coronary artery disease, it is not possible to predict this disorder with accuracy by means of clinical or hemodynamic findings.Since the presence or absence of coronary artery disease in patients undergoing aortic valve replacement has prognostic and therapeutic significance, we recommend that coronary arteriography be performed in all patients with significant aortic valve disease undergoing cardiac catheterization when they present with any form of chest pain, or in patients over the age of 40 years even if no chest pain is present. Coronary arteriography would also rule out anomalous aortic origin of the coronary arteries.     

Differences in platelet aggregation in coronary sinus and aortic blood in patients with coronary artery disease: Effect of propranolol

Platelet aggregation was studied in aortic and coronary sinus blood samples obtained from 18 patients with coronary artery disease (CAD). Using epinephrine and ADP as aggregating agents, platelet aggregation was lower in coronary venous blood than in aortic blood. In nine patients on long-term propranolol therapy, platelet aggregation was lower in both aortic and coronary venous blood compared to the nine patients not taking propranolol. Four other subjects without angiographic evidence of coronary disease exhibited no difference in platelet aggregation in aortic and coronary sinus blood. These data suggest that platelet aggregation is lower in the coronary venous blood of certain patients with coronary disease and chronic propranolol treatment may reduce aggregation in both aortic and coronary sinus blood.     

Left coronary artery anatomy in patients with bicuspid aortic valves.

The anatomy of the proximal left coronary artery in 33 adult patients with bicuspid aortic valves was compared with that in 33 adult patients with aortic valve disease of other aetiologies and with that in 50 adult control patients with no valve or congenital heart disease. Patients with bicuspid aortic valves had a higher incidence of immediate bifurcation of the left main coronary artery, of left main coronary length less than 10 mm, and of left coronary artery dominance. The mean length of the left main coronary artery was significantly less in the patients with bicuspid aortic valves. These variations from the usual coronary artery anatomy may be part of the developmental abnormalities responsible for bicuspid aortic valves, and require evaluation and consideration when considering angiography and valve replacement in patients with aortic stenosis.     

中-重度主动脉瓣反流患者的主动脉根部形态与冠状动脉血流速度的关系

目的:探讨中-重度主动脉瓣反流患者的冠状动脉血流速度变化,同时了解主动脉根部形态对冠状动脉血流速度的影响.方法:收集我院2018年8月至2019年5月期间中-重度主动脉瓣反流患者41例(反流组),术前行经食道三维超声心动图检查,通过半自动方法获得主动脉根部形态参数.同时选取20例主动脉瓣功能正常的院内就诊者作为对照组,...     

合并主动脉夹层的冠心病患者联合冠状动脉介入治疗的临床分析

目的评价合并主动脉夹层的冠心病患者联合进行覆膜支架及冠状动脉介入治疗的安全性和有效性。方法选择合并主动脉夹层的冠心病患者共12例,已行外科治疗Ⅰ型主动脉夹层1例,大血管CT血管成像明确诊断Ⅲ型主动脉夹层和壁间血肿11例,冠状动脉造影并置入支架,住院观察,并行院外随访。结果 1例Ⅰ型主动脉夹层患者大血管CT血管成像可见覆膜支架、人工血管形态正常,冠状动脉造影显示,3支血管病变,共置入支架3枚;另11例Ⅲ型主动脉夹层和壁间血肿患者行大动脉覆膜支架治疗,大动脉造影显示,破口封闭,冠状动脉造影显示,16支血管病变,共置入支架18枚。其中1例术后仍有胸背部疼痛,大血管CT血管成像显示,主动脉弓降部可见残存破口,真腔明显受压,再次置入微创覆膜支架后症状缓解出院,住院及随访期间无胸痛再发、死亡、肾功能恶化、偏瘫等。结论对同时合并主动脉夹层的冠心病患者进行联合介入治疗安全性好,术后恢复快。     

Aortic valve replacement in patients with mild or moderate aortic stenosis and coronary bypass surgery

PURPOSE: To assess whether there is survival benefit for patients with mild or moderate aortic stenosis if they undergo aortic valve replacement at the time of coronary artery bypass surgery. METHODS: From 1985 to 1995 we evaluated all patients at our institution who underwent coronary artery bypass surgery and who had the echocardiographic diagnosis of mild (mean gradient <0 mm Hg and/or valve area >1.5 cm(2)) or moderate (mean gradient > or =30 and < or =40 mm Hg and/or valve area >1.0 < or =1.5 cm(2)) aortic stenosis. Using propensity analysis, survival was compared between 129 patients who underwent coronary artery bypass surgery alone and 78 patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. RESULTS: Perioperative mortality was similar among patients who underwent coronary artery bypass surgery alone compared with patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. By Kaplan-Meier analysis, 1-year and 8-year survival were better at 90% and 55% for patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement compared with 85% and 39% for patients who underwent coronary artery bypass surgery alone (P <0.001). This benefit was limited to patients with moderate aortic stenosis (propensity-adjusted relative risk = 0.43; 95% confidence interval: 0.20 to 0.96; P = 0.04). CONCLUSION: Concomitant aortic valve replacement at the time of coronary artery bypass surgery for mild or moderate aortic stenosis appears to convey a survival advantage for patients with moderate aortic stenosis but not for those with mild aortic stenosis.     

The relation between homocysteine and calcific aortic valve stenosis

BACKGROUND: In patients diagnosed with calcific aortic valve stenosis, cardiac risk factors are similar to those of coronary artery disease; homocysteine concentration is an independent risk factor for coronary artery disease. The aim of this study was to investigate the correlation between plasma homocysteine levels and aortic valve stenosis and the influence of homocysteine levels on the coexistence of coronary artery disease in patients with moderate to severe aortic valve stenosis. METHODS: Fifty-eight patients who had been diagnosed with moderate to severe aortic stenosis formed the test group of this study, and 47 healthy subjects without coronary artery disease or aortic valve stenosis formed the control group. The patients with aortic stenosis were divided into two groups according to the presence or absence of coronary artery disease in their coronary angiograms. After 12 h fasting venous blood samples were collected and total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides and homocysteine levels were measured and compared between the two groups. MEASUREMENTS AND RESULTS: The mean blood homocysteine level was 10.8 +/- 3.3 micromol/l in patients with aortic valve stenosis and 8.1 +/- 4.7 micromol/l in the control group; the difference between these levels was statistically insignificant. The patients with aortic valve stenosis had significantly higher levels of total cholesterol and hypertension and were more likely to have a positive family history for coronary artery disease. When the two subgroups of patients with aortic valve stenosis were compared, mean blood homocysteine levels were 13.2 +/- 3.1 and 8.3 +/- 2.2 micromol/l, respectively, showing significantly higher levels in the group with coronary artery disease. In this comparison patients with coronary artery disease were also found to have significantly higher levels of total cholesterol and LDL and they were more likely to be smokers. CONCLUSIONS: Although there was no relation between blood homocysteine levels and the existence of aortic valve stenosis, in cases with both coronary heart disease and aortic stenosis homocysteine levels were significantly higher than in the patients with pure aortic valve stenosis.     

Influence of changes in heart rate, aortic pressure and flow rate upon experimental coronary insufficiency

This study was designed to evaluate the role of heart rate, aortic pressure, and aortic flow in the development of coronary insufficiency following acute coronary stenosis. In dogs, each of these parameters was controlled at a predetermined level while the left anterior descending coronary artery was constricted with a small screw clamp. The critical coronary pressure (CCP), i.e. the pressure below which a rise of left atrial pressure could be detected, was determined at various levels of hemodynamic load. Increases in aortic pressure, elevation of the heart rate and an increase in aortic flow rate were all associated with an elevation of the CCP and an increase in tension-time index (TTI). The changes in CCP were most striking when TTI was increased by aortic flow rate change. These findings suggest that with high aortic pressure, further constriction of coronary artery is required to precipitate coronary insufficiency, that the level of pacing required to induce coronary insufficiency is a useful index in assessing the degree of coronary stenosis, and that an augmentation of aortic flow rate is an important factor in the initiation of coronary insufficiency.     

Coronary artery anomalies and bicuspid aortic valves in the Syrian hamster

Summary: The condition of coronary arteries and aortic valves was studied in 552 Syrian hamsters belonging to a single family subjected to high endogamous pressure. The study was carried out using a corrosion-cast technique. In 178 hamsters the aortic valve was bicuspid. In 138 specimens, 54 of them with normal aortic valves and 84 with bicuspid aortic valves, anomalies in the origin of the coronary arteries could be classified in three morphologic types: left coronary artery from the pulmonary trunk (36 cases); single right coronary artery (84 cases); left coronary artery from the dorsal aortic sinus (18 cases). Results of a ² contingency test show that the frequency of left coronary artery from the pulmonary trunk and single right coronary artery significantly increases when the aortic valve is bicuspid. The present findings suggest that there is a developmental complex consisting of bicuspid aortic valve and anomalous origin of the coronary arteries.     

Coronary arterial anatomy in bicuspid aortic valve. Necropsy study of 100 hearts.

In a necropsy study, the conjoined cusps of 50 congenitally and 50 acquired bicuspid aortic valves most commonly involved the right and left aortic cusps. In hearts with congenitally bicuspid aortic valves, the left coronary ostium arose at or above the aortic sinotubular junction in 44 per cent, whereas the incidence for the left coronary ostium in the acquired group was 20 per cent and that for the right coronary ostium in both groups was less than 20 per cent. In hearts with congenitally bicuspid aortic valves, the incidence of left coronary dominance (26%) was higher than in normal hearts. In hearts with apparently acquired bicuspid aortic valves, this incidence was also higher than normal, possibly because of acquired fusion of atypical congenitally bicuspid valves in some cases. In both types of aortic valve disease, the length of the left main coronary artery was similar; this length, however, was significantly shorter in hearts with left coronary dominance than in those with right or shared dominance.     

Significance of angina pectoris in aortic valve stenosis.

Of 60 patients aged 45 to 66 years with aortic valve stenosis, 28 (47 per cent) had angina pectoris. Significant coronary arterial obstruction was shown by selective coronary cineangiography in 14 of them. Systolic pressure gradients across the aortic valve were lower in patients with angina than in those without. In those with angina, systolic gradients were higher in those with normal coronary arteriograms than in those with demonstrable coronary arterial disease. Aortic valve replacement relieved the angina in all patients who had normal coronary arteriograms. When valve replacement was combined with coronary bypass grafting in those with coronary arterial disease, surgical mortality was higher and symptomatic relief less predictable. Incapacitating angina in patients with aortic stenosis was nearly always associated with significant coronary disease. In those with less severe angina it was impossible to predict the state of the coronary arteries. Two patients, who did not have angina and who did not undergo coronary arteriography, died after aortic valve replacement and were found at necropsy to have unsuspected severe coronary disease. We, therefore, suggest that coronary arteriography should be carried out in all patients over the age of 40 years in whom surgery is being considered for aortic stenosis.     

Left predominant coronary circulation in patients with valvular aortic stenoses

This study was conducted to examine whether a correlation exists between the incidence of aortic stenosis and predominant left coronary perfusion. Therefore, coronary angiograms of 77 patients with mitral stenosis (Group 1), 50 patients with combined mitral valve disease and pure mitral insufficiency (Group 2), 61 patients with aortic insufficiency with or without mitral valve disease (Group 3), 49 patients with pure aortic stenosis (Group 4), and 69 patients with combined aortic valve disease and aortic stenosis with concomitant mitral valve disease (Group 5) were reviewed. Group 6 consisted of 20 patients with coronary heart disease. A statistically significant accumulation of left coronary circulation was found in patients with pure aortic stenosis (Group 4) (33%) as well as in patients with combined aortic valve disease (19%). The frequency of predominant left coronary circulation was comparable in all other patients (Group 1: 8%; Group 2: 10%; Group 3: 8%; Group 6: 7.5%). Thus, the presence of left predominance in a diagnostic coronary arteriogram performed in a patient with aortic stenosis could be a clue that the aortic stenosis is congenital.     

Aortic stiffness as a risk factor for recurrent acute coronary events in patients with ischaemic heart disease.

AIMS: Aortic elasticity is an important determinant of left ventricular performance and coronary blood flow. Moreover, it has been shown that aortic elastic properties deteriorate in patients with coronary artery disease. However, the predictive role of aortic elasticity in the occurrence of coronary events, has not been addressed so far. Therefore, we set out to test prospectively the hypothesis that invasive as well as non-invasive measures of aortic elastic properties, assessed at rest from pressure-diameter relationships, could predict the development of recurrent coronary events. METHODS AND RESULTS: Clinical variables and measures of aortic function were assessed in 54 normotensive patients with coronary artery disease. The aortic pressure-diameter relationship was derived invasively with a high-fidelity Y shaped catheter (developed in our Institution) for aortic diameter measurements, simultaneously with a Millar catheter for aortic pressure measurements. Aortic root distensibility was assessed by non-invasive techniques. During an average of 3 years follow-up, 12 of 54 patients either developed unstable angina (n=8) or acute myocardial infarction (n=4). By multivariate Cox model analysis, aortic stiffness was the strongest predictor of progression to any end-point (relative risk: 3.24, CI: 1.79 to 5.83;P=0.000). When aortic stiffness was not considered, aortic distensibility was the only independent predictor for acute coronary syndromes (relative risk: 0.37 CI: 0.21 to 0.65;P=0.000). CONCLUSION: In patients with coronary artery disease, aortic elastic properties are powerful and independent risk factors for recurrent acute coronary events.     

Intraortic pulse pressure is correlated with coronary artery stenosis

There is increasing evidence that peripheral pulse pressure measured at the brachial artery is a good predictor of coronary heart disease. However, the relation between pulse pressure and angiographically demonstrated coronary artery stenosis has not been fully elucidated. We designed the present study to investigate the association of the various components of blood pressure, such as systolic pressure, diastolic pressure, and pulse pressure of both peripheral and central arteries with angiographically determined coronary artery stenosis. Levels of aortic systolic pressure, aortic diastolic pressure, aortic pulse pressure, peripheral systolic pressure, peripheral diastolic pressure, and peripheral pulse pressure were determined in 323 patients who underwent diagnostic coronary angiography. Of these 323 patients, 215 patients had significant organic coronary artery stenosis. Aortic pulse pressure was significantly higher in patients with coronary artery stenosis (P = 0.0050). Aortic diastolic pressure was lower in patients with coronary artery stenosis (marginally significant, P = 0.0462). However, no statistically significant difference was observed between other blood pressure components and coronary artery stenosis. Multivariate analyses showed that aortic pulse pressure was associated with coronary artery stenosis independently of aortic diastolic pressure. Moreover, aortic pulse pressure was positively correlated with the number of vessels involved (P = 0.0024). The results of the present study indicate that aortic pulse pressure is significantly and independently correlated with angiographically determined coronary artery stenosis.     

Feasibility of complex coronary intervention in combination with percutaneous aortic valve implantation in patients with aortic stenosis using percutaneous left ventricular assist device (TandemHeart®)

Coronary atherosclerosis is a common finding in patients with severe aortic stenosis. Indeed, aortic stenosis is associated with risk factors similar those of coronary atherosclerosis such as older age, hypertension, diabetes, hypercholesterolemia and smoking. In light of the evolution of percutaneous aortic valve implantation (PAVI) and ongoing improvements in techniques of PCI, a combined approach using PCI and PAVI can be proposed for patients with complex coronary artery and aortic valve disease. This report describes the feasibility of the combination of percutaneous coronary intervention and percutaneous aortic valve implantation with peripheral left ventricular assist device (TandemHeart) support in 3 elderly patients with complex coronary altery disease and aortic stenosis considered too high risk for conventional surgical therapy. © 2009 Wiley‐Liss, Inc.     

Coronary Angiography and Percutaneous Coronary Intervention After Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has revolutionized the management of patients with symptomatic severe aortic stenosis, and indications are expanding towards treating younger patients with lower-risk profiles. Given the progressive nature of coronary artery disease and its high prevalence in those with severe aortic stenosis, coronary angiography and percutaneous coronary intervention will become increasingly necessary in patients after TAVR. There are some data suggesting that there are technical difficulties with coronary re-engagement, particularly in patients with self-expanding valves that, by design, extend above the coronary ostia. The authors review the challenges of coronary angiography and percutaneous coronary intervention post-TAVR and examine the geometric interactions between currently approved transcatheter aortic valves and coronary ostia, while providing a practical guide on how to manage these potentially complex situations.