Percutaneous coronary intervention of unprotected left main disease: Five-year outcome of a single-center registry

Introduction and AimsPercutaneous coronary intervention (PCI) is increasingly used as a treatment option for unprotected left main coronary artery (ULMCA) lesions. We aimed to evaluate the long-term outcome of patients undergoing ULMCA PCI.Methods and ResultsWe retrospectively analyzed 95 consecutive patients (median EuroSCORE I 2.9 [IQR 1.4;6.1]) who underwent ULMCA PCI between 1999 and 2006, included in a single-center prospective registry. The primary outcome was major adverse cardiovascular events (MACE) defined as all-cause death, myocardial infarction (MI) and target lesion revascularization (TLR) at five years. Forty patients (42.1%) were treated in the setting of acute coronary syndrome and 81 patients (85%) had at least one additional significant lesion (SYNTAX score 24.2±11.8). Single ULMCA PCI was performed in 33% (81.1% with drug-eluting stents) and complete functional revascularization was achieved in 79% of the patients. During the observation period, 20 patients died (21.1%), 6 (6.3%) had MI and 11 (11.6%) had TLR (total combined MACE 28.4%). Independent predictors of MACE were previous MI (HR 2.9 95% CI 1.23–6.92; p=0.015), hypertension (HR 5.7 95% CI 1.86–17.47; p=0.002) and the EuroSCORE I (HR 1.1 95% CI 1.03–1.12; p=0.001). Drug-eluting stent implantation was associated with a significantly lower MACE rate, even after propensity score adjustment (AUC=0.84; HR [corrected] 0.1; 95% CI 0.04–0.26; p<0.001).ConclusionsUnprotected left main percutaneous coronary intervention, particularly using drug-eluting stents, can be considered a valid alternative to coronary artery bypass grafting, especially in high-risk surgical patients and with favorable anatomic features.     

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.

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction

IntroductionPatients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min.ObjectivesTo assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI.MethodsWe performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017.ResultsMedian DIDO time was 82 min (interquartile range, 61–132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062–1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011).ConclusionA DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.     

Coronary artery perforations: Four different cases and a review

Coronary artery perforation (CAP) is a rare but feared complication of percutaneous coronary intervention. With the advent of new devices and technologies, interventionalists attempt more complex lesions, including more calcified or tortuous vessels and chronic total occlusions, which increases the incidence of CAP. A short literature review, in addition to four cases of CAP, is presented in this report.     

Patient-specific 3D printing simulation to guide complex coronary intervention

The field of three-dimensional printing applied to patient-specific simulation is evolving as a tool to enhance intervention results. We report the first case of a fully simulated percutaneous coronary intervention in a three-dimensional patient-specific model to guide treatment.An 85-year-old female presented with symptomatic in-stent restenosis in the ostial circumflex and was scheduled for percutaneous coronary intervention. Considering the complexity of the anatomy, patient setting and intervention technique, we elected to replicate the coronary anatomy using a three-dimensional model. In this way, we simulated the intervention procedure beforehand in the catheterization laboratory using standard materials. The procedure was guided by optical coherence tomography, with pre-dilatation of the lesion, implantation of a single drug-eluting stent in the ostial circumflex and kissing balloon inflation to the left anterior descending artery and circumflex. Procedural steps were replicated in the real patient's treatment, with remarkable parallelism in angiographic outcome and luminal gain at intracoronary imaging.In this proof-of-concept report, we show that patient-specific simulation is feasible to guide the treatment strategy of complex coronary artery disease. It enables the surgical team to plan and practice the procedure beforehand, and possibly predict complications and gain confidence.     

Impella support for cardiogenic shock and high-risk percutaneous coronary intervention: A single-center experience

Introduction and ObjectivesThe use of mechanical circulatory support is increasing in cases of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). The Impella® is a percutaneous ventricular assist device that unloads the left ventricle by ejecting blood to the ascending aorta. We report our center's experience with the use of the Impella® device in these two clinical settings.MethodsWe performed a single-center retrospective study including all consecutive patients implanted with the Impella® between 2007 and 2019 for CS treatment or prophylactic support of HR-PCI. Data on clinical and safety endpoints were collected and analyzed.ResultsTwenty-two patients were included: 12 were treated for CS and 10 underwent an HR-PCI procedure. In the CS-treated population, the main cause of CS was acute myocardial infarction (five patients); hemolysis was the most frequent device-related complication (63.7%). In-hospital, cumulative 30-day and one-year mortality were 58.3%, 66.6% and 83.3%, respectively. In the HR-PCI group, all patients had multivessel disease (mean baseline SYNTAX I score: 44.1±13.7). In-hospital, 30-day and one-year mortality were 10.0%, 10.0% and 20.0%, respectively. There were no device- or procedure-related deaths in either group.ConclusionThe short- and long-term results of Impella®-supported HR-PCI were comparable to those in the literature. In the CS group, in-hospital and short-term outcomes were poor, with high mortality and non-negligible complication rates.     

The use of reperfusion and revascularization procedures in acute coronary syndrome in Portugal: A systematic review

Introduction and ObjectivesReperfusion and revascularization therapies play an important role in the management of coronary heart disease and have contributed to decreases in case fatality rates. We aimed to describe the use of these therapies for the treatment of acute coronary syndrome (ACS) patients over time in Portugal.MethodsPubMed was searched in July 2012. The proportion of patients treated with fibrinolysis, primary percutaneous coronary intervention (PCI), any PCI and coronary artery bypass grafting (CABG) was described according to type of ACS: STEMI (≥90% patients with ST-segment elevation or Q-wave myocardial infarction), NSTE-ACS (≥90% patients with non-ST-segment elevation ACS) and mixed ACS (all others).ResultsWe identified 41 eligible studies, published between 1989 and 2011. Twenty-eight reported on samples considered representative of ACS patients treated in Portugal. The small number of estimates of the use of each treatment in STEMI and NSTE-ACS patients precluded identification of any time trend. In the last 20 years, the proportion of mixed ACS patients treated with fibrinolysis decreased and the use of PCI increased, while the use of CABG did not change.ConclusionsThe general pattern of the use of reperfusion and revascularization is in accordance with that reported in other developed countries, reflecting a favorable trend in the quality of care of ACS patients. The relatively small number of estimates on the same procedure in comparable patients limits the generalizability of the conclusions, and highlights the need for systematic approaches to monitor the use of treatments over time.     

Left main and/or three-vessel disease in patients with non-ST-segment elevation myocardial infarction and low-risk GRACE score: Prevalence,clinical outcomes and predictors

Introduction

A low-risk GRACE score identifies patients with a lower incidence of major cardiac events, however it can erroneously classify patients with severe coronary artery disease as low-risk. We assessed the prevalence, clinical outcomes and predictors of left main and/or three-vessel disease (LM/3VD) in non-ST-elevation acute myocardial infarction (NSTEMI) patients with a GRACE score of ≤108 at admission.

The role of Impella in high-risk percutaneous coronary intervention

Percutaneous coronary intervention (PCI) has been increasingly performed in patients with severely depressed left ventricular function and complex coronary lesions, including multivessel disease.Mechanical ventricular assist devices play an increasingly important role in high-risk PCI. Impella CP^® (Abiomed, Inc.) is a new percutaneous left ventricular assist device, designed for short-term circulatory support. It is a promising option for hemodynamic support in high-risk procedures and can potentially reduce PCI-related complications.The authors present two case reports of high-risk PCI using the Impella CP^® device.In the setting of low coronary flow reserve, severely depressed left ventricular function and potential hemodynamic instability, the Impella CP^® device has made it possible to maintain hemodynamic stability during procedures, without being associated with vascular complications.     

Fórmula de CKD‐EPI versus Cockcroft‐Gault na predição de nefropatia induzida por contraste após intervenção coronária percutânea,em pacientes sem disfunção renal significativa

Introduction

Individuals with glomerular filtration rate (GFR) ≥ 60 ml/min/1.73 m² estimated by the Cockcroft‐Gault formula (CG) who undergo percutaneous coronary intervention (PCI) frequently develop contrast‐induced nephropathy (CIN). This study aimed to assess whether individuals with significant renal impairment assessed by the Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) formula, but not by CG, more often develop CIN following PCI than those without renal impairment by either formula.

Spontaneous coronary artery dissection: A single-center case series and literature review

Background

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome (ACS). Better recognition and diagnosis has raised awareness of this condition. However, the pathophysiology of SCAD and its prognosis are still little understood. We aimed to investigate the characteristics and prognosis of patients with SCAD, and subsequently performed a review of literature.

Coronary artery bypass grafting in a child with Kawasaki disease

Kawasaki disease (KD) with cardiac involvement can result in the development of coronary aneurysm, stenosis or thrombosis with significant cardiovascular implications. We report the case of a 23-month-old male with a late diagnosis of KD, in whom intravenous immunoglobulin treatment was not feasible. The patient's course was assessed by routine echocardiography. At the age of five years, angiographic assessment revealed an aneurysm of the anterior descending coronary artery measuring 17 mm×7 mm involving the first diagonal branch, 90% post-aneurysmal stenosis, and an aneurysm of the right coronary artery measuring 32 mm×6 mm. Due to the critical anatomy of the anterior descending artery the revascularization method of choice was coronary artery bypass surgery with an internal mammary artery graft, under cardiopulmonary bypass. There were no significant intraoperative or postoperative complications. This confirms coronary artery bypass grafting as a reliable treatment option for patients who present with coronary sequelae from KD, even at a very young age.     

Double coronary thrombosis in a patient with Behçet's disease

Behçet's disease is a chronic relapsing multisystem autoinflammatory condition, in which cardiac involvement is rare, but among the most life-threatening complications. Treatment is largely empirical, and is aimed at suppressing vasculitis. In this role glucocorticoids and colchicine are frequently used.We present the case of a 42-year-old male with previously diagnosed Behçet's disease presenting to our emergency department with an anterior-inferior STEMI. He presented combined thrombosis of the distal anterior descending coronary artery and proximal right coronary artery, and was treated with sequential primary percutaneous coronary interventions and implantation of drug-eluting stents, but required two interventions due to high thrombotic load.His clinical course during hospitalization was good, with no systolic dysfunction at discharge. During follow-up, he has so far had no new cardiovascular events.     

Development of deep learning segmentation models for coronary X-ray angiography: Quality assessment by a new global segmentation score and comparison with human performance

Introduction and objectivesAlthough automatic artificial intelligence (AI) coronary angiography (CAG) segmentation is arguably the first step toward future clinical application, it is underexplored. We aimed to (1) develop AI models for CAG segmentation and (2) assess the results using similarity scores and a set of criteria defined by expert physicians.MethodsPatients undergoing CAG were randomly selected in a retrospective study at a single center. Per incidence, an ideal frame was segmented, forming a baseline human dataset (BH), used for training a baseline AI model (BAI). Enhanced human segmentation (EH) was created by combining the best of both. An enhanced AI model (EAI) was trained using the EH. Results were assessed by experts using 11 weighted criteria, combined into a Global Segmentation Score (GSS: 0–100 points). Generalized Dice Score (GDS) and Dice Similarity Coefficient (DSC) were also used for AI models assessment.Results1664 processed images were generated. GSS for BH, EH, BAI and EAI were 96.9+/-5.7; 98.9+/-3.1; 86.1+/-10.1 and 90+/-7.6, respectively (95% confidence interval, p<0.001 for both paired and global differences). The GDS for the BAI and EAI was 0.9234±0.0361 and 0.9348±0.0284, respectively. The DSC for the coronary tree was 0.8904±0.0464 and 0.9134±0.0410 for the BAI and EAI, respectively. The EAI outperformed the BAI in all coronary segmentation tasks, but performed less well in some catheter segmentation tasks.ConclusionsWe successfully developed AI models capable of CAG segmentation, with good performance as assessed by all scores.     

Congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery: An interesting case report

Intercoronary communication is a very rare coronary artery anomaly. It is defined as an open-ended circulation with bidirectional blood flow between two coronary arteries. Coronary artery fistulas are abnormal communications between a coronary artery and a cardiac chamber or major vessel. A 62-year-old man was admitted to our hospital with sudden development of general weakness, dizziness and a sensation of compression in his chest. At presentation his blood pressure was 80/40 mmHg and heart rate was 65 beats/min. The ECG revealed sinus rhythm and 1–2 mm ST elevation in the anterior leads. The patient was taken to the catheterization laboratory for percutaneous coronary intervention. The left main and left circumflex coronary arteries were normal. Coronary angiography showed a communication between the left main and the diagonal branch of the left anterior descending and a fistula between the intercoronary connection and the left atrium. The other coronary arteries were normal. Laboratory test results, including cardiac troponin I and creatine kinase–MB levels, were normal. The angina symptoms disappeared and the ST elevation resolved within four hours. We report an interesting case of congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery presenting as an acute coronary syndrome. To the best of our knowledge, this is the first case in the literature involving a coronary artery fistula in an intercoronary communication.     

无保护左主干病变合并急性冠状动脉综合征介入与手术治疗对比研究

目的:探讨急性冠状动脉综合征(ACS)合并无保护左主干病变患者经桡动脉介入治疗(TRI)与冠状动脉旁路移植术(CABG)二者的疗效。方法:连续入选2008年3月至2010年12月,于北京安贞医院行经桡动脉介入治疗(n=236)或冠状动脉旁路移植术(n=354)的无保护左主干病变合并ACS患者。对于患者的临床基线特征及冠状动脉病变特征纳入倾向性评分模型进行匹配,得到154对患者。结果:平均随访时间27个月。经过倾向性评分模型进行校正,两组患者的基线资料及病变特征无显著差异。结果显示TRI与CABG两组全因病死率(4.5%vs.6.5%;P=0.454)及心肌梗死发生率(5.2%vs.7.8%;P=0.355)并差异无统计学意义。CABG组患者脑卒中发生率显著增加(零vs.2.6%;P=0.044),而TRI组靶血管重建率(TVR)显著增加(13.0%vs.5.2%;P=0.017)。两组患者复合终点(死亡/心肌梗死/靶血管重建),差异无统计学意义(7.1%vs.12.3%;P=0.124)。结论:对于ACS合并无保护左主干病变患者TRI与CABG的临床复合终点事件风险相似,然而尽管应用药物洗脱支架CABG组患者靶血管重建率仍显著低于介入治疗组。     

Spontaneous closure of post-intervention left anterior descending coronary pseudoaneurysm

Coronary pseudoaneurysms are an unusual finding during coronary angiography and there are very little data on their prognosis in the literature. We report the case of a 62-year-old man admitted with an anterior myocardial infarction who developed a pseudoaneurysm in the mid left anterior descending artery some days after a type I coronary perforation during coronary angioplasty. Spontaneous closure of the pseudoaneurysm was observed during hospital follow-up. Spontaneous closure of coronary pseudoaneurysms may be more common in clinical practice than previously thought, but few cases have been reported. As the natural history of post-intervention coronary pseudoaneurysms has been little investigated, reports of their occurrence may help to clarify their evolution.