Decreased plasma concentrations of adiponectin in patients with slow coronary flow

Adiponectin has multiple protective effects on vascular endothelium through anti-inflammatory and anti-atherogenic properties. Recent data suggested that endothelial activation and inflammation may contribute to the pathogenesis of slow coronary flow (SCF). Therefore, we investigated whether adiponectin plasma concentrations were decreased in patients with SCF compared to subjects with normal coronary flow. The study population consisted of 35 patients with angiographically documented SCF in all three coronary arteries and 35 sex- and age-matched cases with normal coronary flow. Coronary flow rates of all participants were determined by Thrombolysis in Myocardial Infarction (TIMI) frame count. Plasma adiponectin concentrations were measured by an enzyme-linked immunosorbent assay method using commercially available adiponectin kits. There were no statistically significant differences between the patients with SCF and the subjects with normal coronary flow in terms of demographic characteristics and cardiovascular risk factors (P > 0.05). Plasma adiponectin concentrations of patients with SCF were found to be significantly lower than those with normal coronary flow (4.77 ± 3.86 mg/ml vs 10.8 ± 6.60 mg/ml, P = 0.001, respectively). Plasma adiponectin levels were correlated significantly and inversely with mean TIMI frame count in patients with SCF (r = −0.441, P = 0.008). Furthermore, the Receiver Operator Characteristics curve of adiponectin concentrations showed that an adiponectin <4.6 mg/ml is associated with SCF with a sensitivity of 68.6%, specificity of 82.9%, positive predictive value of 80.0%, and negative predictive value of 72.5%. Our findings suggest that endothelial inflammation may play a role in the pathogenesis of SCF phenomenon.     

冠状动脉慢血流与心肌缺血的关系

目的:通过腺苷负荷心肌灌注显像(SPECT),评价冠状动脉慢血流现象(CSF)与心肌缺血的关系。方法:选择经冠状动脉造影(CAG)诊断为CSF者20例,CAG显示无管腔狭窄及无慢血流者20例为对照组。使用校正的TIMI血流分级(CTFC)方法评价冠状动脉血流速度,2组均行心电图及腺苷负荷SPECT检查。结果:CSF者发生心电图及腺苷负荷SPECT异常的例数比对照组明显增多,同时心肌缺血的范围与缺血程度也均大于血流正常者(P<0.01)。结论:腺苷负荷SPECT发现CSF存在可逆性心肌缺血,可能CSF与心肌缺血关系密切。     

Inverse correlation between coronary and retinal blood flows in patients with normal coronary arteries and slow coronary blood flow

Background

The “Slow Coronary Flow” (SCF) phenomenon in the presence of angiographically normal coronaries is attributed to microvascular and endothelial dysfunction. The microcirculation can be non-invasively assessed by measuring retinal blood flow velocity.The aim of the present study was to evaluate the efficacy of the “Retinal Functional Imager” (RFI) device as a noninvasive method of diagnosing patients with slow coronary flow.

Methods

Coronary blood flow velocity assessed by corrected TIMI Frame Count and retinal arterioles blood flow assessed by RFI were measured in 28 consecutive patients with normal coronary arteries. The patients were divided into 2 groups: a slow coronary flow (SCF) and a normal coronary flow (NCF) groups.

Results

Inverse correlation was found between retinal and coronary blood flows so that higher retinal arterial flow velocity was observed in the SCF group (3.8 ± 1.1 mm/s vs. 2.9 ± 0.61 mm/s, respectively, p = 0.022). RFI provided 73% sensitivity and 77% specificity for diagnosing SCF using ROC analysis. Additionally, patients with SCF had higher values of serum LDL cholesterol (104.7 ± 18.93 mg/dl vs. 81.55 ± 14.62 mg/dl in NCF, p = 0.005), Glucose (96.9 ± 23.0 mg/dl vs. 83.55 ± 9.7 mg/dl in NCF, p = 0.024), and lower percentage of statin consumption (40.0% vs. 76.9% in NCF, p = 0.049).

Conclusions

Slow coronary blood flow can be non-invasively diagnosed with Retinal Functional Imager. Patients with normal coronary arteries and slow coronary blood flow have high retinal arteriolar blood flow. Early non-invasive diagnosis of SCF might help detect individuals who are at higher risk to develop coronary atherosclerosis, and to provide them with early preventive measures.     

冠脉慢血流患者脑循环的探讨

目的 探讨冠状动脉慢血流患者脑循环是否受到损害.方法 选取60例因胸痛症状住院并行冠脉造影检查结果示冠状动脉血流缓慢,但管腔无明显狭窄的患者为研究组;同期因胸痛症状入院并行冠脉造影检查为正常冠脉的55例患者为对照组,两组患者冠脉造影术后24小时通过经颅多普勒彩超测量大脑中动脉、基底动脉血流速度,比较两组病例大脑中动脉、基底动脉血流是否存在差异.结果 冠脉慢血流患者两侧大脑中动脉、基底动脉收缩期、舒张末期及平均血流速度明显慢于对照组.结论 冠脉慢血流患者脑循环也受到损害,慢血流现象可能是体循环系统受损的局部表现.     

炎症与冠状动脉慢血流现象

目的探讨炎症在冠状动脉慢血流（CSF）现象形成中的病理生理作用。方法经冠状动脉造影（CAG）诊断为CSF患者38例,CAG显示无管腔狭窄且无慢血流者25例为对照组,使用校正的TIMI血流分级（CTFC）方法评价冠状动脉血流速度。两组均采用ELIA法测定高敏C反应蛋白（hs—CRP）及白细胞介素6（IL-6）浓度,比较两组间hs—CRP及IL-6的差异,分析冠状动脉血流速度与hs—CRP及IL-6的相关性。Logistic多因素分析评价CSF发生的影响因素。结果CSF组hs—CRP和IL-6浓度明显高于对照组。冠状动脉平均血流速度与hs—CRP及IL-6浓度呈正相关。Logistic多因素分析显示hs—CRP和IL-6与CSF的发生相关（P=0．004,0．001）。结论炎症参与CSF的形成。     

Plateletcrit and red cell distribution width are independent predictors of the slow coronary flow phenomenon

Background and purposeEndothelial dysfunction may play a role in the pathogenesis of the slow coronary flow (SCF) phenomenon. A detailed examination of blood cellular components has not been performed for this condition. We investigated the relationship between SCF and whole blood cell counts.MethodRecords of 17,315 patients who underwent coronary angiography between January 2006 and December 2012 were evaluated retrospectively. A total of 146 patients with SCF were compared with 148 patients with normal coronary arteries according to demographic data, complete blood count, and biochemical parameters.ResultsThe following parameters were significantly higher in SCF patients than in patients with normal coronary arteries: percentage of smokers (36.3% vs. 25%, p = 0.036), body mass index (26.69 ± 2.84 vs. 26.07 ± 3.15, p = 0.049), white blood cells (WBCs) (7.52 ± 1.43 × 10³ mm^–3 vs. 7.01 ± 1.42 × 10³ mm^–3, p = 0.002), red cell distribution width (RDW) (13.68 ± 1.42% vs. 13.15 ± 1.13%, p < 0.001), platelets (250.29 ± 50.96 × 10³ mm^–3 vs. 226.10 ± 38.02 × 10³ mm^–3, p < 0.001), plateletcrit (PCT) (0.214 ± 0.40% vs. 0.184 ± 0.29%, p < 0.001), mean platelet volume (8.63 ± 1.10 fL vs. 8.22 ± 0.83 fL, p < 0.001), platelet distribution width (PDW) (16.58 ± 0.76% vs. 16.45 ± 0.57%, p = 0.028), and neutrophils (4.44 ± 1.25 × 10³ mm^–3 vs. 4.12 ± 1.24 × 10³ mm^–3, p = 0.029). Positive PCT values [odds ratio (OR), 4.165; 95% confidence interval (CI), 2.493–6.959; p < 0.001) and RDW (OR, 1.304; 95% CI, 1.034–1.645; p = 0.025) were independent predictors of SCF.ConclusionAlthough within the normal range, the increased numbers of WBCs and neutrophils in patients with SCF suggest that SCF may be a subclinical inflammatory condition. Furthermore, increased RDW and PDW in SCF patients may cause microvascular blood flow resistance due to impaired cell deformability. The PCT provides reliable data regarding total platelet mass and may be a useful predictor of SCF.     

Effects of slow coronary artery flow on P-wave dispersion and atrial electromechanical coupling

Aim

Slow coronary flow (SCF) is characterized by angiographically normal coronary arteries with delayed opacification of the distal vasculature. The purpose of this study was to evaluate atrial electromechanical couplings and P-wave dispersion (Pd) reflecting intraatrial and interatrial conduction delays in SCF patients and the relationship between these parameters and Thrombolysis in Myocardial Infarction (TIMI) frame count.

Methods

Thirty-four patients with SCF and 40 controls were enrolled. From 12-lead surface electrocardiograms, Pd was calculated. Atrial electromechanical coupling (PA), intraatrial, and interatrial electromechanical delay were measured with tissue Doppler imaging.

Results

Maximum P-wave duration (Pmax) and Pd were higher in SCF patients than those of controls (109.2 ± 9.3 vs 92.3 ± 13.5 milliseconds; P < .0001 and 50.4 ± 9.4 vs 34.4 ± 8.9 milliseconds; P < .0001). Atrial electromechanical coupling at the left lateral mitral annulus (lateral PA), septal mitral annulus (septal PA), and right ventricular tricuspid annulus (RV PA) were significantly higher in SCF patients than controls (68.1 ± 8.1 vs 52.6 ± 7.3 milliseconds; P < .0001; 49.3 ± 9.8 vs 38.2 ± 5.3 milliseconds; P < .0001; 47.5 ± 9.0 vs 37.6 ± 4.6 milliseconds, P < .0001, respectively). Interatrial electromechanical delay (lateral PA − RV PA) was significantly longer in SCF patients (20.6 ± 9.1 vs 15.0 ± 6.0 milliseconds; P = .0002). A positive correlation was detected between circumflex coronary artery TIMI frame count and interatrial electromechanical delay (r = 0.45; P < .01).

Conclusions

Prolongation of interatrial electromechanical delay, Pmax, and Pd suggest that SCF might contribute to development of adverse functional and electrophysiologic atrial characteristics in these patients.     

Carotid artery intima-media thickness correlates with intravascular ultrasound parameters in patients with slow coronary flow

Background

Coronary slow flow (CSF) phenomenon is characterized by delayed opacification of coronary vessels in a normal coronary angiogram. Although clinical and pathological features have been previously described, the underlying pathophysiology has not been fully elucidated. We aimed to determine and compare the carotid intima-media thickness (CIMT) values of SCF patients and healthy subjects, and to correlate patients’ values with intimal thickness and TIMI frame counts of their coronary arteries (assessed by intravascular ultrasound).

Methods

The study population consisted of 50 patients with SCF [38(76%) male, aged 53 ± 7 years] and 40 normal subjects [22(55%) male, aged 51 ± 8 years]. CIMT values, intravascular ultrasonographies and TIMI frame counts of the patients, and CIMT of the controls were investigated.

Results

Upon intravascular ultrasonography investigation, the common finding was longitudinally extended massive calcification throughout the epicardial coronary arteries in 44 (88%) of patients. Mean coronary intimal thickness was 0.52 ± 0.1 mm. CIMT was significantly increased in SCF patients than controls (0.84 ± 0.14 vs. 0.66 ± 0.13, p < 0.0001). Besides, CIMT was significantly correlated with coronary intima-media thickness. TIMI frame counts were positively correlated with CIMT and coronary intimal thickness (p < 0.05 and p < 0.05 respectively).

Conclusion

These results support the theory that SCF is the result of coronary atherosclerosis which is the part of systemic involvement.     

Steroid-induced recurrent myocardial ischemia

We report the case of a female patient under oral prednisolone therapy due to a diagnosis of idiopathic intracranial hypertension with papilledema. Unfortunately, short-term treatment with prednisolone caused an unusual complication in the patient, i.e., recurrent myocardial ischemia. Possible mechanisms leading to this complication were evaluated in the light of current knowledge.     

Effects of atorvastatin on coronary flow reserve in patients with slow coronary flow

BACKGROUND: Statins improve endothelial functioning in patients with coronary artery disease and hypercholesterolemia, while substantially little is known about induced changes in myocardial microcirculation. However, although previous studies have suggested that microvascular abnormalities and endothelial dysfunction is responsible for slow coronary flow (SCF), there is no study investigating possible effects of statins on coronary microvascular function in patients with SCF. HYPOTHESIS: We prospectively investigated the effects of short-term lipid-lowering therapy with atorvastatin on coronary flow reserve (CFR) reflecting coronary microvascular function in patients with SCF assessed by transthoracic Doppler echocardiography (TTDE). METHODS: In an open clinical trial, CFR was studied in 20 subjects with SCF. TTDE was used to assess CFR at baseline as well as after 8 weeks of atorvastatin therapy. Coronary flow was quantified according to TIMI frame count (TFC). Coronary diastolic peak flow velocities were measured at baseline and after dipyridamole infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocities. RESULTS: CFR was independently correlated with TFC. After 8 weeks of atorvastatin therapy, CFR values increased significantly (1.95 +/- 0.38 vs. 2.54 +/- 0.56, (p < 0.001). No change in hemodynamic parameters was noted during the entire study. The improvement in CFR was not correlated to the amount of lipid-lowering effect of atorvastatin. CONCLUSIONS: These findings suggest that short-term lipid-lowering therapy with atorvastatin improved CFR, which reflects coronary microvascular functioning in patients with SCF.     

内脏脂肪素与冠心病的相关性及PCI术后变化

目的探讨内脏脂肪素与冠心病的相关性及 PCI 术后变化的意义。方法:90 例冠心病患者分为急性心肌梗死组 30 例、不稳定心绞痛组 30 例、稳定心绞痛组 30 例,均行冠脉造影确诊,其中 52 例患者行 PCI术。另选正常对照组 30 例 . 用酶联免疫法检测各组及PCI 术后血浆内脏脂肪素(visfatin)水平,于生化室检测肝功、肾功、血糖、血脂、高敏 C 反应蛋白(hs-CRP), 对行 PCI 术患者记录病变支数,植入支架个数及长度,最大球囊扩张压力,术后 TIMI 血流分级。结果:冠心病组 visfatin 和 hs-CRP 高于对照组,且 AMI 组和UAP 组较 SAP 组升高更明显,各组间有显著性差异(p<0.05), 冠心病组 visfatin 与 hs-CRP 水平的独立相关 (p<0.001), PCI 术后 visfatin 水平高于术前(p<0.01),且与最长支架长度和植入支架个数相关(p<0.05)。结论:血浆 visfatin 的水平反应斑块的不稳定程度,其参与冠脉硬化发生发展的过程,另外 PCI 术后 visfatin 较术前升高,可能参与术后再狭窄。     

The effects of trimetazidine on heart rate variability in patients with slow coronary artery flow

OBJECTIVE: We sought to examine the effect of trimetazidine (TMZ) on heart rate variability (HRV), endothelin-1 (ET-1), NO, and anginal symptoms in patients with slow coronary artery flow (SCAF). METHODS: The 48 patients with SCAF (29 women and 19 men; mean age, 52 +/- 9 years) were included in the study. Twenty milligrams TMZ 3 times a day or matched placebo were given randomly in a double-blinded fashion for 4 weeks. Patients were divided into 4 groups as follows: exercise-positive, TMZ-given group (group A, n = 12); exercise-positive, placebo-given group (group B, n = 12); exercise-negative, TMZ-given group (group C, n = 12); and exercise-negative, placebo-given group (group D, n = 12). RESULTS: After TMZ treatment, HRV parameters, including SD of the all R-R intervals, SD of the averages of R-R intervals in all 5-minute segments of the entire recording, percentage of R-R intervals with more than 50-millisecond variation, and the square root of the mean of the sum of the squares of differences between adjacent R-R intervals, significantly improved both in exercise-positive and exercise-negative groups when compared with baseline. After TMZ treatment, ET-1 and NO levels significantly altered both in exercise-positive and exercise-negative groups when compared with baseline (17.7 +/- 2.7 vs 13.9 +/- 2.8 pg/mL [P = .01] and 18.1 +/- 3.8 vs 14.2 +/- 2.6 pg/mL [P = .01], respectively). After TMZ treatment, NO levels significantly increased in both exercise-positive and exercise-negative groups when compared with baseline (36.4 +/- 5.4 vs 43.3 +/- 6.8 micromol/L [P = .01] and 36.8 +/- 7.8 vs 43.3 +/- 4.8 micromol/L [P = .01], respectively). However, in placebo group, neither HRV parameters nor ET-1 and NO levels altered when compared with baseline. Also, after treatment, a significant correlation was detected between HRV parameters, including SD of the averages of R-R intervals in all 5-minute segments of the entire recording, SD of the all R-R intervals, percentage of R-R intervals with more than 50-millisecond variation, and the square root of the mean of the sum of the squares of differences between adjacent R-R intervals, and NO and ET-1 levels in TMZ group but not placebo. CONCLUSION: Short-term TMZ therapy improved HRV parameters and endothelial products such as ET-1 and NO as well as anginal symptom in patients with SCAF. Improvement in HRV parameters was correlated with ET-1 and NO levels.     

经微导管注射药物治疗冠脉支架置入后慢血流和无复流的疗效观察

目的观察经微导管内注射药物对冠脉支架置入后出现慢血流和无复流的临床疗效。方法入选72例冠脉内支架置人后出现慢血流和无复流现象的急性冠脉综合征（ACS）患者,其中33例为试验组,经微导管向靶血管内依次注射硝酸甘油、替罗非班、维拉帕米等药物;回顾39例为对照组,经指引导管向靶血管内依次注射上述同样的药物,观察两组靶血管前向血流的心肌梗死溶栓试验血流分级（thrombolysisjnmyocardialinfarction,TIMI）。结果试验组治疗慢血流和无复流现象达到TIMI3级血流的有效率明显优于对照组。结论经微导管内注射药物对急性冠脉综合征患者冠脉支架置入后出现慢血流和无复流现象是一种更有效、安全的治疗途径。     

Lack of association between the Glu298Asp polymorphism of endothelial nitric oxide synthase and slow coronary flow in the Turkish population

BACKGROUND:

Coronary endothelial dysfunction plays an important pathogenetic role in patients with slow coronary flow (SCF). No data exist regarding the possible contribution of the Glu298Asp polymorphism genotype of the endothelial nitric oxide synthase (eNOS) gene to human SCF in the literature.

OBJECTIVE:

To investigate the association between SCF and the Glu298Asp polymorphism of the eNOS gene.

METHODS:

The study population consisted of 85 consecutive patients. The patient group included 66 patients with angiographically proven normal coronary arteries with SCF, and 19 subjects with normal coronary arteries with no SCF. The thrombolysis in myocardial infarction frame count was used for the diagnosis of SCF. The Glu298Asp polymorphism was determined by polymerase chain reaction and restriction fragment length polymorphism.

RESULTS:

The baseline characteristics were similar between the two groups, except for high-density lipoprotein cholesterol, which was higher in the SCF group than in the controls. The genotype distribution of Glu298Asp was as follows: GG 26%, GT 56% and TT 12%, where G is guanine and T is thymine. There was no difference in the frequency of the various genotypes or the alleles in patients with SCF versus normal controls.

CONCLUSIONS:

The Glu298Asp polymorphism genotype of the eNOS gene is not a risk factor for SCF in the present study population.     

Serum visfatin levels, adiposity and glucose metabolism in obese adolescents

Objective: Visfatin, an adipokine, has insulin-mimetic effects. The main determinants of both the production and the physiologic role of visfatin are still unclear. The aim of this study is to determine the relation of serum visfatin to adiposity and glucose metabolism.Methods: 40 pubertal adolescents (20 females, 20 males; age range: 9-17 years) with exogenous obesity and 20 age- and sex-matched healthy adolescents (10 females, 10 males) were enrolled in the study. Oral glucose tolerance test (OGTT) was performed in the obese group. Serum glucose, insulin and visfatin levels were analyzed in the fasting state in the controls and at 0, 60 and 120 minutes during the OGTT in the obese group.Results: The obese group had higher serum visfatin levels than the control group [11.6 (3.3-26) ng/mL vs. 7.5 (3.3-10.5) ng/mL, p<0.001]. Visfatin levels were correlated positively with body mass index, waist/hip ratio, insulin, and homeostasis model assessment for insulin resistance and negatively with glucose/insulin ratio in the combined group (obese subjects plus controls). Visfatin levels were essentially similar in obese subjects with and without insulin resistance (p>0.05). Serum visfatin levels did not change at 60 and 120 minutes of the OGTT compared to the baseline levels (p>0.05).Conclusions: Serum visfatin levels are elevated in obese adolescents and do not change with acute changes in glucose metabolism. Visfatin levels are related with adiposity and glucose metabolism parameters. However, the role and contribution of adiposity and glucose metabolism to the circulating visfatin levels in obese patients remain to be explored. Conflict of interest:None declared.     

瑞舒伐他汀对冠状动脉慢血流患者冠状动脉贮备功能和超敏C反应蛋白的影响

目的:探讨长期瑞舒伐他汀治疗对冠状动脉慢血流患者冠脉贮备功能(CFR)和超敏C反应蛋白(hsCRP)的影响。方法:选择冠状动脉造影正常但存在冠脉慢血流的患者48例,所有患者随机分为试药组和对照组,对照组(22例)予常规治疗,试药组(26例)在常规治疗基础上加用瑞舒伐他汀20 mg/d,治疗期为6个月。治疗前后测定两组患者的血脂,hsCRP,利用腺苷负荷超声记录左前降支远端血流频谱评评价CFR。结果:经过6个月瑞舒伐他汀的治疗后,试药组总胆固醇(TC)和低密度脂蛋白胆固醇(LDL-C)较对照组明显下降,[TC:(3.2±0.9)mmol/Lvs.(5.4±1.2)mmol/L,P<0.05;LDL-C:(2.1±0.7)mmol/L vs.(3.4±0.8)mmol/L,P<0.05]。hsCRP较对照组明显下降[(2.1±1.4)mg/L vs.(3.7±2.1)mg/L,P<0.05]。试药组静息冠脉血流速度(bCFV)较对照组和治疗前显著下降[(21±6)cm/s vs.(26±5)cm/s和(21±6)cm/s vs.(25±7)cm/s,P<0.05],而最大冠状动脉扩张状态hCFV较对照组和治疗前增加[(71±9)cm/s vs.(56±8)cm/s和(71±9)cm/s vs.(56±10)cm/s,P<0.05],冠状动脉血流储备CFR较对照组和治疗前明显增加[(3.2±0.6)cm/s vs.(2.1±0.5)cm/s和(3.2±0.6)cm/s vs.(2.2±0.4)cm/s,P<0.05)]。结论:冠状动脉慢血流患者经过瑞舒伐他汀治疗可以有效改善冠脉贮备功能。     

Giant coronary aneurysm culprit of an acute coronary syndrome

A 66-year-old male ex-smoker with hypertension, type 2 diabetes mellitus and dyslipidaemia was admitted due to a non-ST segment elevation myocardial infarction. The catheterisation depicted an extensive and calcified disease: chronic total obstruction of the right coronary and severe disease with a giant aneurysm at the first marginal branch as the culprit vessel. After discussion, the right coronary was treated before the circumflex-giant aneurysm was closed with a stent graft and its multiple severe stenosis solved with two drug-eluting stents. We provide a multimodality approach for a complex case and briefly discuss the available options.     

Platelet function disorder in patients with coronary slow flow

BACKGROUND: Some patients evaluated for chest pain with angiographically normal coronary arteries show coronary slow flow phenomenon (CSFP) on angiography. Slow flow of dye in epicardial coronary arteries is also not an infrequent finding in patients during routine coronary angiography. The precise pathophysiology of CSFP is not known yet. HYPOTHESIS: This study investigates the presence of platelet function disorders in patients with CSFP. METHODS: The patient group included 24 patients with CSFP detected by coronary angiography via the TIMI "frame count" method, and a control group included 23 patients with normal coronary flow. Platelet aggregability induced by use of ristocetin, collagen, and adenosine diphosphate (ADP), was measured from all blood samples in both control and patient groups. RESULTS: The ratio of platelet aggregability increased significantly in patients with CSFP compared with patients with normal coronary flow (ristocetin 57.6 +/- 15 vs. 45.4 +/- 17.1, collagen 62.9 +/- 16.4 vs. 48.9 +/- 25.3, ADP 59.4 +/- 18 vs. 42.4 +/- 15.2, p < 0.05). CONCLUSION: Platelet aggregability is increased in patients with CSFP.     

Percutaneous coronary intervention due to chronic total occlusion in the left main coronary artery after bypass grafting: A feasible option in selected cases

Introduction

Chronic total occlusion (CTO) of the left main coronary artery (LMCA) is an infrequent finding. Revascularization is recommended in the presence of demonstrated viability or ischemia. Coronary artery bypass grafting (CABG) has long been considered the preferred option. Patients with previous CABG due to LMCA disease with occlusion of one graft and progression of the LMCA to CTO constitute a special population, as just one ischemic artery remains. For these patients, there is no other option for revascularization other than cardiac surgery (requiring resternotomy) or percutaneous coronary intervention (PCI) of the LMCA.

Acquired anomalies of the coronary arteries after arterial switch operation. Usefulness of coronary computed tomography angiography and impact on follow-up

IntroductionMortality and morbidity in patients with transposition of the great arteries after an arterial switch operation depends mainly on the status of coronary perfusion. Coronary computed tomography angiography (CCTA) provides accurate information on coronary morphology, however its use in these patients is not yet routine procedure.ObjectiveWe sought to assess its accuracy to identify acquired coronary anomalies in this population, compared to conventional angiography in a subset of patients, and assess its impact on postoperative management.MethodsRetrospective analysis of clinical data on transposition of the great arteries in patients who underwent CCTA between January 2013 and September 2017.ResultsBetween January 2013 and September 2017, 18 patients underwent CCTA. Seven patients (39%) disclosed iatrogenic coronary lesions (stenosis 1; kinking 2, occlusion 1; filiform coronary 3). The exam was performed in 78% of patients due to suggestion of myocardial ischemia (symptoms or altered exams). Only 16% needed to undergo additional exams, and in four patients the CCTA result modified therapeutic management.Conventional coronary angiography was also performed in 10 patients (55%), and in three cases, the results were discordant with underestimation or non-identification of coronary lesions on conventional angiography.The medium radiation dose used was 2.4 mSv and no complications after CT were reported.ConclusionCCTA accurately identified iatrogenic postoperative coronary lesions and it has proven to be superior to conventional angiography in this population. It should be performed routinely in this group of patients, even in the absence of symptoms.