1
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Muneeb M, Nuzhat N, Khan Niazi A, Khan AH, Chatha Z, Kazmi T, Farhat S. Assessment of the Dimensions of Coronary Arteries for the Manifestation of Coronary Artery Disease. Cureus 2023; 15:e46606. [PMID: 37937019 PMCID: PMC10625989 DOI: 10.7759/cureus.46606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/09/2023] Open
Abstract
INTRODUCTION The size of the coronary artery influences the effective outcome of therapeutic measures like coronary artery bypass graft (CABG) surgery, percutaneous coronary interventions (PCI), and diagnosis of coronary artery disease. Patients' age, gender, BMI, anatomical variations, and increased left ventricular size all have an effect on coronary artery parameters. OBJECTIVE This study aims to compare the average size of the coronary arteries of the Pakistani population in both sexes for manifestation of coronary artery disease. METHODOLOGY For the analysis of the coronary arteries, 100 patients of both sexes, male and female, were taken. X-ray angiography was performed for two-dimensional images of coronary arteries. For diameter measurement, images were visualized on quantitative coronary angiography (QCA) in different views (caudal and cranial views). The diameters of the left main coronary artery (left main stem/LMS), left anterior descending (LAD), left circumflex (LCx), and right coronary artery (RCA) were measured on angiograms. Data about the dimensions of the coronary artery was gathered through quantitative angiography. Data analysis was done through SPSS version 26 (IBM Corp., Armonk, NY). RESULTS There is a notable distinction in the average diameters among the proximal LAD (3.12), mid-LAD (2.40), and distal LAD (1.29). A statistically significant difference is evident among mid-LCx, distal LCx, and proximal LCx (p-value < 0.001). Likewise, the average diameter of the distal RCA (1.89) was smaller when compared to the mid-RCA (3.19) and proximal RCA (3.78). However, there was no significant difference in the average diameter among mid-LMS, distal LMS, and proximal LMS (p-value = 0.09). CONCLUSION The average diameter of distal RCA was smaller when compared to mid-RCA and proximal RCA. The average size of proximal LAD and proximal LCx was comparatively larger than mid- and distal LAD and LCx. The findings of current research will be beneficial for the diagnosis and management of coronary artery disease patients.
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Affiliation(s)
- Muhammad Muneeb
- Interventional Cardiology, Shalamar Medical and Dental College, Lahore, PAK
| | - Nasia Nuzhat
- Applied Physics, University of Engineering and Technology, Lahore, PAK
| | | | - Ammar H Khan
- Cardiovascular Surgery, Imran Idrees Hospital, Sialkot, PAK
| | - Zanib Chatha
- Interventional Cardiology, Shalamar Medical and Dental College, Lahore, PAK
| | - Tahseen Kazmi
- Community Medicine, Central Park Medical College, Lahore, PAK
| | - Saira Farhat
- Community Medicine, Central Park Medical College, Lahore, PAK
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2
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Showkathali R, Yalamanchi RP. Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review. Interv Cardiol 2023; 18:e20. [PMID: 37435600 PMCID: PMC10331562 DOI: 10.15420/icr.2023.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 07/13/2023] Open
Abstract
The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.
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3
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Gunawardena TD, Corballis N, Merinopoulos I, Wickramarachchi U, Reinhold J, Maart C, Sreekumar S, Sawh C, Wistow T, Sarev T, Ryding A, Gilbert TJ, Clark A, Vassiliou VS, Eccleshall S. Drug-Coated Balloon vs. Drug-Eluting Stents for De Novo Unprotected Left Main Stem Disease: The SPARTAN-LMS Study. J Cardiovasc Dev Dis 2023; 10:jcdd10020084. [PMID: 36826580 PMCID: PMC9963161 DOI: 10.3390/jcdd10020084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
The objective of this study is to compare the outcomes of patients treated with drug-coated balloons (DCBs) or second-generation drug-eluting stents (DESs) for de novo unprotected left main stem (LMS) disease. Previous studies comparing the treatment of LMS disease suggest that the mortality for DES PCI is not worse than CABG. There are limited data from studies investigating the treatment of de novo LMS disease with DCB angioplasty. We compared the all-cause and cardiac mortality of patients treated with paclitaxel DCB to those with second-generation DES for de novo LMS disease from July 2014 to November 2019. Data were analysed using Kaplan-Meier analyses and propensity-matched analyses. A total of 148 patients were treated with either a DCB or DES strategy. There was no significant difference in all-cause mortality in the DCB group (19.5%) compared to the DES group (15.9%) (HR 1.42 [0.61-3.32], p = 0.42). Regarding cardiac mortality, 2 (4.9%) were recorded for the DCB group and 7 (6.5%) for the DES group (HR 1.21 [0.31-4.67], p = 0.786); for target vessel myocardial infarction, there were 0 (0%) for the DCB group and 7 (6.5%) for the DES group; and for target lesion revascularisation, there were 3 (7.3%) in the DCB group and 9 (8.3%) in the DES group (HR: 0.89 [0.24-3.30]). p = 0.86. These remained not significant after propensity score matching. We found no difference in the mortality outcomes with DCB angioplasty compared to second-generation DES, with a median follow-up of 33 months. DCB can therefore be regarded as a safe option in the treatment of LMS disease in suitable patients.
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Affiliation(s)
- Tharusha D. Gunawardena
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Natasha Corballis
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Correspondence: (N.C.); (V.S.V.)
| | - Ioannis Merinopoulos
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Upul Wickramarachchi
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Johannes Reinhold
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Clint Maart
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Sulfi Sreekumar
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Chris Sawh
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Trevor Wistow
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Toomas Sarev
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Alisdair Ryding
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Tim J. Gilbert
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Vassilios S. Vassiliou
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
- Royal Brompton Hospital, London SW3 6NP, UK
- Correspondence: (N.C.); (V.S.V.)
| | - Simon Eccleshall
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
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4
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Milzi A, Dettori R, Lubberich RK, Burgmaier K, Marx N, Reith S, Burgmaier M. Quantitative Flow Ratio Is Related to Anatomic Left Main Stem Lesion Parameters as Assessed by Intravascular Imaging. J Clin Med 2022; 11:jcm11206024. [PMID: 36294345 PMCID: PMC9604622 DOI: 10.3390/jcm11206024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 09/29/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Previously, an association between anatomic left main stem (LMS) lesion parameters, as described by intravascular ultrasound (IVUS) and fractional flow reserve (FFR), was shown. Quantitative flow ratio (QFR) is a novel, promising technique which can assess functional stenosis relevance based only on angiography. However, as little is known about the relationship between anatomic LMS parameters and QFR, it was thus investigated in this study. Methods: In 53 patients with LMS disease, we tested the association between anatomic assessment using OCT (n = 28) or IVUS (n = 25) on the one hand and functional assessment as determined by QFR on the other hand. LMS-QFR was measured using a dedicated approach, averaging QFR over left anterior descending (LAD) and circumflex (LCX) and manually limiting segment of interest to LMS. Results: The minimal luminal area of the LMS (LMS-MLA) as measured by intravascular imaging showed a consistent correlation with QFR (R = 0.61, p < 0.001). QFR could predict a LMS-MLA < 6 mm2 with very good diagnostic accuracy (AUC 0.919) and a LMS-MLA < 4.5 mm2 with good accuracy (AUC 0.798). Similar results were obtained for other stenosis parameters. Conclusions: QFR might be a valuable tool to assess LMS disease. Further studies focusing on patient outcomes are needed to further validate the effectiveness of this approach.
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Affiliation(s)
- Andrea Milzi
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
- Correspondence: ; Tel.: +49-241-8036098
| | - Rosalia Dettori
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Richard Karl Lubberich
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Kathrin Burgmaier
- Department of Pediatrics, Faculty of Medicine, University of Cologne, University Hospital of Cologne, 50931 Cologne, Germany
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Sebastian Reith
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Mathias Burgmaier
- Department of Internal Medicine I, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
- Faculty of Applied Healthcare Science, Deggendorf Institute of Technology, 94469 Deggendorf, Germany
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5
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Elsherif A, Nadir A, Ludman PF, Khan SQ. Retrieval of Entrapped Catheter-Mounted Axial Flow Pump From Mitral Subvalvular Apparatus Using a Snare Catheter. JACC Case Rep 2021; 3:1494-1498. [PMID: 34693349 PMCID: PMC8511436 DOI: 10.1016/j.jaccas.2021.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
Axial-flow ventricular assist devices are being increasingly used to support hemodynamically compromised patients undergoing percutaneous coronary intervention. Periprocedural valvular complications have been recognized in a few case reports. We present a unique case of entanglement of the Impella within he mitral subvalvular apparatus, retrieved successfully using a snare under fluoroscopic guidance. (Level of Difficulty: Advanced.)
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Key Words
- ACS, acute coronary syndrome
- CA, coronary angiography
- CABG, coronary artery bypass graft
- CMR, cardiac magnetic resonance
- ECG, electrocardiogram
- LVEF, left ventricular ejection fraction
- MI, myocardial infarction
- PCI, percutaneous coronary intervention
- TEE, transesophageal echocardiography
- TTE, transthoracic echocardiography
- axial-flow pump
- double kiss crush stenting
- left main stem
- left ventricular assist device
- mechanical circulatory support
- mitral valve injury
- percutaneous coronary intervention
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Affiliation(s)
- Ahmed Elsherif
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Cardiology Department, Faculty of Medicine, Suez Canal University Hospital, Egypt
| | - Adnan Nadir
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Peter F Ludman
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sohail Q Khan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
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6
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Ullah H, Elakabawi K, Ke H, Ullah N, Ullah H, Shah SA, Khan HH, Khan MA, Guo N, Yuan Z. Predictors and 3-year outcomes of compromised left circumflex coronary artery after left main crossover stenting. Clin Cardiol 2021; 44:1377-1385. [PMID: 34269478 PMCID: PMC8495093 DOI: 10.1002/clc.23693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There are few predictors of decreased fractional flow reserve (FFR) in the left circumflex coronary artery (LCx) after left main (LM) crossover stenting. OBJECTIVES We aimed to determine the predictors for low FFR at LCx and possible treatment strategies for compromised LCx, together with their long-term outcomes. METHODS Altogether, 563 patients who met the inclusion criteria were admitted to our hospital from February 2015 to November 2020 with significant distal LM bifurcation lesions. They underwent single-stent crossover percutaneous coronary intervention (PCI) under intravascular ultrasound (IVUS) guidance with further LCx intervention based on the measured FFR. RESULTS The patients showed significant angiographic LCx ostial affection post-LM stenting, but only 116 (20.6%) patients had FFR < 0.8. The three-year composite major adverse cardiac events (MACE) rates were comparable between the high and low FFR groups (16.8% vs. 15.5; p = 0.744). In a multivariate analysis, low FFR at the LCx was associated with post-stenting minimal luminal area (MLA) of LCx (odds ratio [OR]: 0.032, p < .001), post-stenting LCx plaque burden (OR: 1.166, p < .001), poststenting LM MLA (OR: 0.821, p = .038), and prestenting LCx MLA (OR: 0.371, p = .044). In the low FFR group, those with compromised LCx managed with drug-eluting balloon had the lowest three-year MACE rate (8.1%), as compared to either those undergoing kissing balloon inflation (KBI) (17.5%) or stenting (20.5%) (p = 0.299). CONCLUSION Unnecessary LCx interventions can be avoided with FFR-guided LCx intervention. Poststenting MLA and plaque burden of the LCx, and main vessel stent length are poststenting predictors of low FFR.
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Affiliation(s)
- Hameed Ullah
- Department of CardiologyFirst Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Karim Elakabawi
- Department of CardiologyFirst Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
- Department of CardiologyBenha UniversityEgypt
| | - Han Ke
- Department of CardiologyFirst Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Najeeb Ullah
- Department of Data Science (FIT)University of MonashMolbourneAustralia
| | - Habib Ullah
- Department of CardiologyDow University of health sciencesKarachiPakistan
| | - Sardar Ali Shah
- Department of CardiologyFirst Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | | | | | - Ning Guo
- Department of CardiologyFirst Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
| | - Zuyi Yuan
- Department of CardiologyFirst Affiliated Hospital of Xi'an Jiaotong UniversityXi'anChina
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7
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Hussain HI, Protty MB, Gallagher S, Al-Raisi S, Aldalati O, Farooq V, Sharp ASP, Anderson R, Kinnaird T. The impact of coronary perforation in percutaneous interventions involving the left main stem coronary artery in the United Kingdom 2007-2014: Insights from the British Cardiovascular Intervention Society database. Catheter Cardiovasc Interv 2021; 97:E179-E185. [PMID: 32333715 DOI: 10.1002/ccd.28933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/01/2020] [Accepted: 04/13/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is increasingly utilized for treatment of coronary disease involving the unprotected left main stem (ULMS). However, no studies to date have examined the outcomes of such interventions when complicated by coronary perforation (CP). METHODS Using the British Cardiovascular Intervention society (BCIS) database, data were analyzed on all ULMS-PCI procedures complicated by CP in England and Wales between 2007 and 2014. Multivariate logistic regressions were used to identify predictors of ULMS CP and to evaluate the association between this complication and outcomes. RESULTS During 10,373 ULMS-PCI procedures, CP occurred more frequently than in non-ULMS-PCI (0.9 vs. 0.4%, p < .001) with a stable annual incidence. Covariates associated with CP included number of stents used, female gender, use of rotational atherectomy and chronic total occlusion (CTO) intervention. Adjusted odds of adverse outcomes for ULMS-PCI complicated by CP were higher for peri-procedural complications including cardiogenic shock, tamponade, side-branch loss, DC cardioversion, in-hospital major bleeding, transfusion requirement, and peri-procedural myocardial infarction. There were also significantly increased odds for in-hospital major adverse cardiac events (MACCE, OR 8.961, 95% CI [4.902-16.383]) and 30-day mortality (OR 5.301, 95% CI [2.741-10.251]). CONCLUSIONS CP is an infrequent event during ULMS-PCI and is predicted by female gender, rotational atherectomy, CTO interventions or number of stents used. CP was associated with significantly higher odds of mortality and morbidity, but at rates similar to previously published all-comer PCI complicated by CP.
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Affiliation(s)
| | - Majd B Protty
- Department of Cardiology, University Hospital of Wales, Cardiff, UK.,Division of Immunity and Infection, Systems Immunity University Research Institute, Cardiff University, Cardiff, UK
| | - Sean Gallagher
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Sara Al-Raisi
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Omar Aldalati
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Vasim Farooq
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, UK.,University of Exeter, Exeter, Devon, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK.,Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK
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8
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Malaiapan Y, Leung M, White AJ. The role of intravascular ultrasound in percutaneous coronary intervention of complex coronary lesions. Cardiovasc Diagn Ther 2020; 10:1371-1388. [PMID: 33224763 DOI: 10.21037/cdt-20-189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intravascular ultrasound (IVUS) is a catheter-based coronary imaging technique. It utilises the emission & subsequent detection of reflected high frequency (30-60 MHz) sound waves to create high resolution, cross-sectional images of the coronary artery. IVUS has been the cornerstone of intracoronary imaging for more than two decades. When compared to the invasive coronary angiogram which studies only the silhouette of the contrast-filled artery lumen, IVUS also crucially images the vessel wall. Because of this capability, IVUS has greatly facilitated understanding of the coronary atherosclerosis process. Such insights from IVUS reveal how commonly and extensively plain angiography underestimates the true extent of coronary plaque, the characteristics of plaques prone to rupture and cause acute coronary syndromes (lipid rich, thin cap atheroma), and a realisation of the widespread occurrence of vessel remodelling in response to atherosclerosis. Similarly, IVUS has historically provided salutary mechanistic insights that have guided many of the incremental advances in the techniques of percutaneous coronary intervention (PCI). Examples include mechanisms of in-stent restenosis, and the importance of high-pressure post-dilatation of stents to ensure adequate stent apposition and thereby reduce the occurrence of stent thrombosis. IVUS also greatly facilitates the choice of correct diameter and length of stent to implant. Overall, a compelling body of evidence indicates that use of intravascular ultrasound in PCI helps to achieve optimal technical results and to mitigate the risk of adverse cardiac events. In this review, the role of intravascular ultrasound as an adjunct to PCI in complex coronary lesions is explored. The complex coronary situations discussed are the left main stem, ostial stenoses, bifurcation stenoses, thrombotic lesions, the chronically occluded coronary artery, and calcified coronary artery disease. By thorough review of the available evidence, we establish that the advantages of IVUS guidance are particularly evident in each of these complex CAD subsets. In particular, some consider the use of IVUS to be almost mandatory in left main PCI. A comparison with other intracoronary imaging techniques is also explored.
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Affiliation(s)
- Yuvaraj Malaiapan
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Michael Leung
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Anthony J White
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
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9
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Abstract
There have been several investigations comparing the efficacy of percutaneous coronary intervention and coronary artery bypass grafting surgery for treatment of left main stem disease. This includes the Evaluation of XIENCE versus Coronary Artery Bypass Graft Surgery for Effectiveness of Left Main Revascularizaton (EXCEL) trial, which has garnered significant controversy surrounding its experimental design and reporting of its results. The authors review the methodology, results, caveats and statements on the EXCEL trial. They also review the other trials in the management of left main stem disease comparing percutaneous coronary intervention with coronary artery bypass grafting, as well as the SYNTAX score and its role in future guidelines for revascularisation. These findings have significant implications for current practice, influencing the growing role for multidisciplinary team meeting and allowing clinicians and patients to make the right choice.
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Affiliation(s)
| | - Krishna Mani
- Department of Cardiac Surgery, St. George's Hospital London, UK
| | - Martin T Yates
- Department of Cardiac Surgery, St. George's Hospital London, UK
| | - Justin Nowell
- Department of Cardiac Surgery, St. George's Hospital London, UK
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10
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Botta L, Amodio C, Savini C, Pacini D. Images in cardiovascular medicine voluminous left main stem to pulmonary artery fistula: A conservative approach. J Card Surg 2020; 35:1098-1099. [PMID: 32176363 DOI: 10.1111/jocs.14483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The presence of a coronary arteriovenous fistula is almost rare in the adult population, even rare when associated with aortic valve insufficiency. Management and treatment options can vary and depend on a single patient. In our case, a large fistula with a rounded origin started from the roof of the left main stem, just attached to the wall of the aortic root, and finished with a very narrowed end in the pulmonary trunk. Due to its anatomical position and to the potential complications related to a proximal surgical closure as well as the incidental discovery in adult age (without signs or symptoms until the operation), we decided to have a conservative approach, leaving untouched the fistula. No intraoperative, perioperative, and follow-up signs of myocardial ischemia were observed.
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Affiliation(s)
- Luca Botta
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Ciro Amodio
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Carlo Savini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
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11
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Gershlick AH, Kandzari DE, Banning A, Taggart DP, Morice MC, Lembo NJ, Brown WM, Banning AP, Merkely B, Horkay F, van Boven AJ, Boonstra PW, Dressler O, Sabik JF, Serruys PW, Kappetein AP, Stone GW. Outcomes After Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting According to Lesion Site: Results From the EXCEL Trial. JACC Cardiovasc Interv 2019; 11:1224-1233. [PMID: 29976358 DOI: 10.1016/j.jcin.2018.03.040] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The authors sought to determine the extent to which the site of the left main coronary artery (LM) lesion (distal bifurcation versus ostial/shaft) influences the outcomes of revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). BACKGROUND Among 1,905 patients with LM disease and site-assessed SYNTAX scores of <32 randomized in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, revascularization with PCI and CABG resulted in similar rates of the composite primary endpoint of death, myocardial infarction (MI), or stroke at 3 years. METHODS Outcomes from the randomized EXCEL trial were analyzed according to the presence of angiographic core laboratory-determined diameter stenosis ≥50% involving the distal LM bifurcation (n = 1,559; 84.2%) versus disease isolated to the LM ostium or shaft (n = 293; 15.8%). RESULTS At 3 years, there were no significant differences between PCI and CABG for the primary composite endpoint of death, MI, or stroke for treatment of both distal LM bifurcation disease (15.6% vs. 14.9%, odds ratio [OR]: 1.08, 95% confidence interval [CI]: 0.81 to 1.42; p = 0.61) and isolated LM ostial/shaft disease (12.4% vs. 13.5%, OR: 0.90, 95% CI: 0.45 to 1.81; p = 0.77) (pinteraction = 0.65). However, at 3 years, ischemia-driven revascularization occurred more frequently after PCI than CABG in patients with LM distal bifurcation disease (13.0% vs. 7.2%, OR: 2.00, 95% CI: 1.41 to 2.85; p = 0.0001), but were not significantly different in patients with disease only at the LM ostium or shaft (9.7% vs. 8.4%, OR: 1.18, 95% CI: 0.52 to 2.69; p = 0.68) (pinteraction = 0.25). CONCLUSIONS In the EXCEL trial, PCI and CABG resulted in comparable rates of death, MI, or stroke at 3 years for treatment of LM disease, including those with distal LM bifurcation disease. Repeat revascularization rates during follow-up after PCI compared with CABG were greater for lesions in the distal LM bifurcation but were similar for disease isolated to the LM ostium or shaft.
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Affiliation(s)
- Anthony H Gershlick
- University Hospitals of Leicester, University of Leicester, Leicester Biomedical Research Centre, Leicester, United Kingdom.
| | | | - Amerjeet Banning
- University Hospitals of Leicester, University of Leicester, Leicester Biomedical Research Centre, Leicester, United Kingdom
| | - David P Taggart
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Nicholas J Lembo
- Piedmont Heart Institute, Atlanta, Georgia; Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | | | - Adrian P Banning
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ferenc Horkay
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | | | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Patrick W Serruys
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Gregg W Stone
- Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
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Mahmood M, Altaf A, Salahuddin M, Khan M, Shah KA, Shah H. Prognosis of Percutaneous Intervention of a Left Main Coronary Artery Stenosis Without the Use of Intravascular Imaging. Cureus 2018; 10:e2857. [PMID: 30148010 PMCID: PMC6107041 DOI: 10.7759/cureus.2857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives The aim of this study was to assess the prognosis in patients with left main coronary artery stenosis one year after percutaneous coronary intervention (PCI). Methods Our study included 40 patients who underwent PCI for left main coronary artery stenosis without the use of intravascular ultrasound (IVUS). Patients were followed for a year, and the prognostic effect of PCI on a composite end-point of revascularization, new myocardial infarction, cardiac death, and on all-cause mortality was assessed in multivariable Cox analysis. Results The multivariable analysis showed a good prognosis in patients receiving PCI with a total event rate of 7.5%. The independent predictors for major adverse cardiac events (MACE) were diabetes (p = 0.02). Other prognostic factors included in the model were gender, age, smoking, body mass index (BMI), hypertension, the complexity of the vessel, and ejection fraction. Conclusion PCI for left main coronary artery stenosis without the use of IVUS has a good prognosis after one year of clinical follow-up.
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Affiliation(s)
- Mazhar Mahmood
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
| | - Afrasyab Altaf
- Cardiology, Tongji Hospital of Tongji University, Shanghai, CHN
| | - Momin Salahuddin
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
| | - Momin Khan
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
| | - Karamat A Shah
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
| | - Hammad Shah
- Department of Cardiology, Rehman Medical Institute, Peshawar, PAK
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Naganuma T, Fujino Y, Tahara S, Mitomo S, Basavarajaiah S, Nakamura S. Extremely Late Catch-Up Phenomenon After First-Generation Sirolimus-Eluting Stent in the Left Main Stem: Insights From Optical Coherence Tomography. JACC Cardiovasc Interv 2015; 8:e237-9. [PMID: 26718525 DOI: 10.1016/j.jcin.2015.06.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 06/19/2015] [Indexed: 11/22/2022]
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Abstract
Abstract: In the management of coronary artery disease (CAD) it is important to ensure that all patients are receiving optimal medical therapy irrespective of whether any intervention, by stents or surgery, is planned. Furthermore it is important to establish if a proposed intervention is for symptomatic and/or prognostic reasons. The latter can only be justified if there is demonstration of a significant volume of ischaemia (>10% of myocardial mass). Taking together evidence from the most definitive randomized trial and its registry component (SYNTAX), almost 79% of patients with three vessel CAD and almost two thirds of patients with LMS disease have a survival benefit and marked reduction in the need for repeat revascularisation with CABG in comparison to stents, implying that CABG is still the treatment of choice for most of these patients. This conclusion which is apparently at odds with the results of most previous trials of stenting and surgery but entirely consistent with the findings of large propensity matched registries can be explained by the fact that SYNTAX enrolled ‘real life’ patients rather than the highly select patients usually enrolled in previous trials. SYNTAX also shows that for patients with less severe coronary artery disease there is no difference in survival between CABG and stents but a lower incidence of repeat revascularisation with CABG. At three years, SYNTAX shows no difference in stroke between CABG and stents for three-vessel disease but a higher incidence of stroke with CABG in patients with left main stem disease. In contrast the PRECOMBAT trial of stents and CABG in patients with left main stem disease showed no excess of mortality or stroke with CABG in comparison to stents in relatively low risk patients. Finally the importance of guidelines and multidisciplinary/heart teams in making recommendations for interventions is emphasised.
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Affiliation(s)
- David P Taggart
- Nuffield Dept of Surgery, Oxford University NHS Hospitals, Oxford OX3 9DU, England, UK
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