A prediction model for coronary artery abnormalities in children with Kawasaki disease older than 5 years

OBJECTIVE

Reliably prediction models for coronary artery abnormalities (CAA) in children aged >5 years with Kawasaki disease (KD) are still lacking. This study aimed to develop a nomogram model for predicting CAA at 4 to 8 weeks of illness in children with KD older than 5 years.

METHODS

A total of 644 eligible children were randomly assigned to a training cohort (n = 450) and a validation cohort (n = 194). The least absolute shrinkage and selection operator (LASSO) analysis was used for optimal predictors selection, and multivariate logistic regression was used to develop a nomogram model based on the selected predictors. Area under the receiver operating characteristic curve (AUC), calibration curves, Hosmer-Lemeshow test, Brier score, and decision curve analysis (DCA) were used to assess model performance.

RESULTS

Neutrophil to lymphocyte ratio, intravenous immunoglobulin resistance, and maximum baseline z-score ≥ 2.5 were identified by LASSO as significant predictors. The model incorporating these variables showed good discrimination and calibration capacities in both training and validation cohorts. The AUC of the training cohort and validation cohort were 0.854 and 0.850, respectively. The DCA confirmed the clinical usefulness of the nomogram model.

CONCLUSIONS

A novel nomogram model was established to accurately assess the risk of CAA at 4-8 weeks of onset among KD children older than 5 years, which may aid clinical decision-making.

Sex differences in patients presenting with acute coronary syndrome: a state-of-the-art review

Cardiovascular conditions in the spectrum of acute coronary syndromes are characterized by sex differences with regard to pathophysiology, risk factors, clinical presentation, invasive and pharmacologic treatment, and outcomes. This review delves into these differences, including specific subsets like myocardial infarction with non-obstructed coronary arteries or Spontaneous Coronary Artery Dissection, and alternative diagnoses like Takotsubo cardiomyopathy or myocarditis. Moreover, practical considerations are enclosed, on how a sex-specific approach should be integrated in clinical practice: in fact, personal history should focus on female-specific risk factors, and hormonal status and hormonal therapy should be assessed. Moreover, physical and psychological stressors should be investigated, particularly in the event of Spontaneous Coronary Artery Dissection or Takotsubo cardiomyopathy.

Posttraumatic Stress Disorder After Spontaneous Coronary Artery Dissection: A Report of the International Spontaneous Coronary Artery Dissection Registry

BACKGROUND

Myocardial infarction secondary to spontaneous coronary artery dissection (SCAD) can be traumatic and potentially trigger posttraumatic stress disorder (PTSD). In a large, multicenter, registry-based cohort, we documented prevalence of lifetime and past-month SCAD-induced PTSD, as well as related treatment seeking, and examined a range of health-relevant correlates of SCAD-induced PTSD.

METHODS AND RESULTS

Patients with SCAD were enrolled in the iSCAD (International SCAD) Registry. At baseline, site investigators completed medical report forms, and patients reported demographics, medical/SCAD history, psychosocial factors (including SCAD-induced PTSD symptoms), health behaviors, and health status via online questionnaires. Of 1156 registry patients, 859 patients (93.9% women; mean age, 52.3 years) completed questionnaires querying SCAD-induced PTSD. Nearly 35% (n=298) of patients met diagnostic criteria for probable SCAD-induced PTSD in their lifetime, and 6.4% (n=55) met criteria for probable past-month PTSD. Of 811 patients ever reporting any SCAD-induced PTSD symptoms, 34.8% indicated seeking treatment for this distress. However, 46.0% of the 298 patients with lifetime probable SCAD-induced PTSD diagnoses reported never receiving trauma-related treatment. Younger age at first SCAD, fewer years since SCAD, being single, unemployed status, more lifetime trauma, and history of anxiety were associated with greater past-month PTSD symptom severity in multivariable regression models. Greater past-month SCAD-induced PTSD symptoms were associated with greater past-week sleep disturbance and worse past-month disease-specific health status when adjusting for various risk factors.

CONCLUSIONS

Given the high prevalence of SCAD-induced PTSD symptoms, efforts to support screening for these symptoms and connecting patients experiencing distress with empirically supported treatments are critical next steps.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04496687.

An Unusual Presentation of SCAD in a Young Male Soldier

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of myocardial infarction and sudden cardiac death in young individuals without significant cardiovascular risk factors. The etiology of SCAD appears to be multifactorial and is often precipitated by physical and emotional stress superimposed on underlying arteriopathy, connective tissue disorders, systemic inflammatory disorders, genetic factors, and hormonal influences. There are no current societal guidelines to stratify young soldiers' risk of developing SCAD. Diagnosis typically requires invasive coronary artery angiography which is largely unavailable in stations with limited medical resources. Furthermore, young patients with SCAD often present with atypical cardiac symptoms, such as heartburn leading to the misdiagnosis of gastroesophageal reflux disease and a delay in diagnosis and management. We present a 21-year-old active duty male who was transferred from Okinawa, Japan to a tertiary military medical center for evaluation of hypercoagulable conditions after CT revealed non-obstructing portal venous thrombosis extending to right hepatic vein, splenic vein thrombosis with splenic infarct, and bilateral wedge-shaped renal infarct. Extensive work-up ultimately revealed mid-left anterior descending spiral dissection with transmural infarct of inferior, anteroseptal, and inferoseptal wall resulting in the formation of left ventricular thrombus, subsequently causing thromboembolism to multiple organs. This case demonstrates the ramifications of SCAD when diagnosis and management are delayed and serve as a poignant reminder for all providers to include SCAD in the differential diagnosis for young soldiers with atypical chest pain.

Coronary artery evaluation during ECG-gated CT of the thoracic aorta: Do not consider it a negligible clinical information

A CT angiography, performed for ascending aorta study, revealed, incidentally, an anomalous origin and course of right coronary artery. Anomalies in the origins and course of the coronary arteries are critical information that should not be missed, because they can worsen the patient's prognosis.

Swine Model of Coronary Artery Dissection

Coronary artery dissection (CAD) is the intimal tearing of the coronary arterial wall and can be iatrogenic, spontaneous, or traumatic in origin. CAD is a rare but challenging condition that can cause significant hemodynamic compromise. Management strategies for CAD, such as the use of mechanical circulatory support devices, are available in the clinical setting. However, the incidence, etiology, and optimal management of CAD are not well-defined, emphasizing the need for adequate animal models in preclinical studies. Large animal models provide the human-like conditions necessary for testing and development of potential treatment strategies. In this chapter, we describe a method for the creation of a CAD swine model.

Current challenges in treatment and management of spontaneous coronary artery dissection

Though an infrequent cause of acute coronary syndrome, spontaneous coronary artery dissection is an increasingly recognized cardiovascular condition predominantly seen in middle-aged females. Its pathophysiology is defined by separation of coronary arterial wall layers which cause acute coronary syndrome-like presentations with relatively high recurrence rates. Overall, there is a lack of reported literature and understanding of the short- and long-term management for spontaneous coronary artery dissection. Therapeutic approaches include, but are not limited to, percutaneous coronary intervention, surgical revascularization, antithrombotic therapy, and beta-blocker therapy. There is a significant absence of randomized control trials to help guide both interventional and medical management for spontaneous coronary artery dissection. This review is aimed to review the current literature regarding risk factors and considerations for the short- and long-term management of spontaneous coronary artery dissection.

Right Coronary Artery with an Intramural and Interarterial Course as a Unique Cause of Myocardial Ischemia: The Unroofing Method Might Still Be the Best Solution

A 39-year-old man was admitted because of cardiac arrest. Emergent coronary angiography revealed a preserved coronary blood flow; however, multiple-row detector computed tomography (MDCT) revealed that the proximal right coronary artery (RCA) was running inside the aortic wall, creating proximal stenosis without atherosclerotic changes. Surgical intervention with unroofing was performed; however, postoperative stenosis of the proximal RCA required additional coronary artery bypass grafting (CABG). Intraoperative findings during CABG did not reveal hematoma or coronary dissection. However, MDCT one year after CABG depicted improvement of the RCA and graft stenoses, suggesting that the post-unroof stenosis may have been caused by an inflammatory reaction after surgical intervention.

Burden of Rare Genetic Variants in Spontaneous Coronary Artery Dissection With High-risk Features

Importance

The emerging genetic basis of spontaneous coronary artery dissection (SCAD) has been defined as both partially complex and monogenic in some patients, involving variants predominantly in genes known to underlie vascular connective tissue diseases (CTDs). The effect of these genetic influences has not been defined in high-risk SCAD phenotypes, and the identification of a high-risk subgroup of individuals may help to guide clinical genetic evaluations of SCAD.

Objective

To identify and quantify the burden of rare genetic variation in individuals with SCAD with high-risk clinical features.

Design, Setting, and Participants

Whole-exome sequencing (WES) was performed for subsequent case-control association analyses and individual variant annotation among individuals with high-risk SCAD. Genetic variants were annotated for pathogenicity by in-silico analysis of genes previously defined by sequencing for vascular CTDs and/or SCAD, as well as genes prioritized by genome-wide association study (GWAS) and colocalization of arterial expression quantitative trait loci. Unbiased genome-wide association analysis of the WES data was performed by comparing aggregated variants in individuals with SCAD to healthy matched controls or the Genome Aggregation Database (gnomAD). This study was conducted at a tertiary care center. Individuals in the Canadian SCAD Registry genetics study with a high-risk SCAD phenotype were selected and defined as peripartum SCAD, recurrent SCAD, or SCAD in an individual with family history of arteriopathy.

Main Outcomes and Measures

Burden of genetic variants defined by DNA sequencing in individuals with high-risk SCAD.

Results

This study included a total of 336 participants (mean [SD] age, 53.0 [9.5] years; 301 female participants [90%]). Variants in vascular CTD genes were identified in 17.0% of individuals (16 of 94) with high-risk SCAD and were enriched (OR, 2.6; 95% CI, 1.6-4.2; P = 7.8 × 10-4) as compared with gnomAD, with leading significant signals in COL3A1 (OR, 13.4; 95% CI, 4.9-36.2; P = 2.8 × 10-4) and Loeys-Dietz syndrome genes (OR, 7.9; 95% CI, 2.9-21.2; P = 2.0 × 10-3). Variants in GWAS-prioritized genes, observed in 6.4% of individuals (6 of 94) with high-risk SCAD, were also enriched (OR, 3.6; 95% CI, 1.6-8.2; P = 7.4 × 10-3). Variants annotated as likely pathogenic or pathogenic occurred in 4 individuals, in the COL3A1, TGFBR2, and ADAMTSL4 genes. Genome-wide aggregated variant testing identified novel associations with peripartum SCAD.

Conclusions and Relevance

In this genetic study, approximately 1 in 5 individuals with a high-risk SCAD phenotype harbored a rare genetic variant in genes currently implicated for SCAD. Genetic screening in this subgroup of individuals presenting with SCAD may be considered.

A Spitting-Cobra-Like Coronary-Pulmonary Artery Fistula in a Patient With Angina

A 78-year-old woman with a history of hypertension, hyperlipidemia, and asthma was referred to her cardiologist for chest pain and dyspnea on exertion. After performing stress echocardiography, it was determined that closure of the fistula with coils was indicated. This case highlights that coronary fistula could be an unusual entity of angina, clinically improving after the occlusion procedure.

Nationwide observational study of incidence, management and outcome of spontaneous coronary artery dissection: a report from the Swedish Coronary Angiography and Angioplasty register

OBJECTIVES

The aim of this study was to conduct a nationwide all comer description of incidence, contemporary management and outcome in Swedish spontaneous coronary artery dissection (SCAD) patients. The incidence of SCAD as well as the management and outcome of these patients is not well described.

DESIGN

A nationwide observational study.

PARTICIPANTS AND SETTING

All patients with SCAD registered in the Swedish Coronary Angiography and Angioplasty Register from 2015 to 2017 were included. The index angiographies of patients with registered SCAD were re-evaluated at each centre to confirm the diagnosis. Patients with non-SCAD myocardial infarction (MI) (n=32 601) were used for comparison.

OUTCOME MEASURES

Outcomes included all-cause mortality, reinfarction or acute coronary reangiography.

RESULTS

This study found 147 SCAD patients, rendering an incidence of 0.74 per 100 000 per year and a prevalence of 0.43% of all MIs. The average age was 52.9 years, 75.5% were women and 47.6% presented with ST-segment elevation MI. Median follow-up time for major adverse cardiac event was 17.3 months. Percutaneous coronary intervention was attempted in 40.1% of SCAD patients and 30.6% received stent. The use of antithrombotic agents was similar between the groups and there was no difference regarding outcomes, 10.9% vs 13.4%, p=0.75. Mortality was lower in SCAD patients, 2.7% vs 8.0%, p=0.03, whereas SCAD patients more often underwent acute reangiography, 9.5% vs 4.6%, p<0.01.

CONCLUSION

In this nationwide, all comer Swedish study, the overall incidence of SCAD was low, including 25% men which is more and in contrast to previous studies. Compared with non-SCAD MI, SCAD patients were younger, with lower cardiovascular risk burden, yet suffered substantial mortality and morbidity and more frequently underwent acute coronary reangiography.

Spontaneous coronary artery dissection: insights from computed tomography coronary angiography follow-up

METHODS

Patients with SCAD on invasive coronary angiography who underwent a follow-up CTCA between 2010 and 2018 at our institute were included. CTCA was reported by two cardiologists-one with knowledge of the SCAD location, and a second blinded. Assessment of dissection healing were made and optimal timing of CTCA was also calculated.

RESULTS

A total of 32 patients with 38 non-contiguous SCAD lesions were included (mean age 50.5 ± 8.8 years, 65.6% women). The left circumflex artery was the most commonly affected vessel (34.2%), and 71.1% of lesions occurred in distal or branch vessels. Median time that CTCA was performed was 40.5 days from the index event, and 25 of 38 lesions had healed (65.8%). On blinded reporting, the sensitivity and specificity of CTCA for assessment of dissection healing was 72% and 53.8%, respectively. The optimal timing of CTCA to assess healing was 80 days (AUC 0.774, p=0.006; sensitivity 76.9%, specificity 84.0%). When early CTCA was performed (<80 days), 21 of 24 lesions (87.5%) were unhealed, whereas late CTCA (≥80 days) showed healing in 10 of 14 lesions (71.4%).

CONCLUSION

The usefulness of CTCA in diagnosing SCAD remains challenging due to limitations in spatial and temporal resolution, particularly in distal vessels. The optimal timing of CTCA to assess dissection healing was 80 days.

Risk of sudden cardiac death in a case of spontaneous coronary artery dissection presenting with thyroid storm

OBJECTIVE

Spontaneous coronary artery dissection (SCAD) is a spontaneous separation of the coronary artery wall whose etiology appears to be poorly understood. SCAD is a rare cause of acute coronary syndromes, and it is a life-threatening condition.

CASE REPORT

We report the case of a young woman who developed SCAD during a thyroid storm (TS).

RESULTS

To the best of our knowledge, this is the first reported case of SCAD during a TS, and it suggests a possible association between high levels of circulating thyroid hormones and SCAD susceptibility.

CONCLUSIONS

Early identification of SCAD predisposing factors is important to identify high-risk patients. In patients presenting to the emergency department because of chest pain with a history of dysthyroidism, early determination of thyroid hormones and troponin could prevent certain forms of sudden cardiac death.

Health status outcomes after spontaneous coronary artery dissection and comparison with other acute myocardial infarction: The VIRGO experience

Background

Data on health status outcomes after spontaneous coronary artery dissection (SCAD) are limited.

Methods and findings

Using the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study we compared patients with SCAD and other acute myocardial infarction (AMI) at presentation (baseline), 1-month, and-12 months using standardized health status instruments. Among 3572 AMI patients ≤ 55 years, 67 had SCAD. SCAD patients were younger (median age (IQR) 45 (40.5–51) years vs. 48 (44–52) in other AMI, p = 0.003), more often female (92.5% vs. 66.6%), have college education (73.1% vs. 51.7%) and household income >$100,000 (43.3% vs. 17.7% (All p<0.001). SCAD patients at baseline had higher mean ± SD Short Form-12 [SF-12] physical component scores [PCS] (48.7±10.2 vs. 43.8±12.1, p<0.001) and mental component scores [MCS] (49.6±12.4 vs. 45.4±12.5, p = 0.008), and at 12-months [PCS (50.1±9.0 vs. 44.3±12.3, p<0.001) and MCS (53±10.1 vs 50.2±11.0, p = 0.045)]. The Euro-Quality of Life Scale [EQ-5D] VAS and EQ-5D index scores were similar at baseline, but higher at 12-months for SCAD (EQ-5D VAS: 82.2±10.2 vs. 72.3±21.0, p<0.001; EQ-5D index scores; 90.2±15.3 vs. 83.7±19.8, p = 0.012). SCAD patients had better baseline Seattle Angina Questionnaire [SAQ] physical limitation (88.8±20.1 vs. 81.2±25.4, p = 0.017). At 12-months SCAD patients had better physical limitation (98.0±8.5 vs. 91.4±18.8, p = 0.007), angina frequency (96.4±8.8 vs. 91.3±16.8, p = 0.018) and quality of life scores (80.7±14.7 vs 72.2±23.2, p = 0.005). Magnitude of change in health status from baseline to 12-months was not statistically different between the groups. After adjustment for time and comorbidities there remained no difference in most health status outcomes.

Conclusions

SCAD patients fare marginally better than other AMI patients on most health status instruments and have similar 12-month health status recovery. Better pre-event health status suggests a need to modify exercise prescriptions and cardiac rehabilitation protocols to better assist this physically active population to recover.

Factors Associated With Revascularization in Women With Spontaneous Coronary Artery Dissection and Acute Myocardial Infarction

In contrast to atherosclerotic acute myocardial infarction (AMI), conservative therapy is considered preferable in the acute management of spontaneous coronary artery dissection (SCAD) if clinically possible. The present study aimed to investigate factors associated with treatment strategy for SCAD. Women aged ≤60 years with AMI and SCAD were retrospectively identified in the Nationwide Readmissions Database 2010 to 2015 and were divided into revascularization and conservative therapy groups. The revascularization group (n = 1,273, 68.0%), compared with the conservative therapy group (n = 600, 32.0%), had ST-elevation AMI (STEMI) (anterior STEMI, 20.3% vs 10.5%; inferior STEMI, 25.1% vs 14.5%; p <0.001) and cardiogenic shock (10.8% vs 1.8%; p <0.001) more frequently. Multivariable logistic regression analysis demonstrated that anterior STEMI (vs non-STEMI, odds ratio 2.89 [95% confidence interval 2.08 to 4.00]), inferior STEMI (2.44 [1.85 to 3.21]), and cardiogenic shock (5.13 [2.68 to 9.80]) were strongly associated with revascularization. Other factors associated with revascularization were diabetes mellitus, dyslipidemia, smoking, renal failure, and pregnancy/delivery-related conditions; whereas known fibromuscular dysplasia and admission to teaching hospitals were associated with conservative therapy. Propensity-score matched analyses (546 pairs) found no significant difference in in-hospital death, 30-day readmission, and recurrent AMI between the groups. In conclusion, STEMI presentation, hemodynamic instability, co-morbidities, and setting of treating hospital may affect treatment strategy in women with AMI and SCAD. Further efforts are required to understand which patients benefit most from revascularization over conservative therapy in the setting of SCAD causing AMI.

Predictive Performance of the International Takotsubo Registry Score in the Diagnosis of Takotsubo Syndrome Among Women with Non-ST Segment Elevation Myocardial Infarction

Background: The International Takotsubo Registry (InterTAK) score was developed to assess the probability of takotsubo syndrome (TTS) and to distinguish it from acute coronary syndrome, which has a similar clinical presentation. A European Society of Cardiology (ESC) consensus statement suggests invasive coronary angiography may be deferred in patients with non-ST segment elevation myocardial infarction (NSTEMI) and high probability of TTS. We aimed to determine the predictive performance of the InterTAK score in a real-world population of NSTEMIs. Materials and Methods: The InterTAK score was retrospectively calculated for consecutive female patients with NSTEMI who underwent invasive coronary angiography at two academic medical centers in New York City from March 2016 to August 2018. Results: Among 375 women with NSTEMI, 15 (4%) had InterTAK score >70, indicating high probability of TTS. Ten (67%) met ESC TTS criteria for a noninvasive strategy, among whom seven had TTS, two had spontaneous coronary artery dissection (SCAD), and one had coronary artery disease requiring revascularization. A total of 48 women (13% of cohort) had a final diagnosis of TTS. The InterTAK score had an area under the receiver operating characteristics curve (AUC) of 0.82 (95% confidence interval, 0.75-0.88) for TTS, with 21% sensitivity and 98% specificity at score >70. Conclusions: In this real-world sample of consecutive female NSTEMI patients, the InterTAK score was predictive of TTS but a high score was rare, and use of the score to obviate invasive angiography could have resulted in delay of revascularization and missed diagnosis of SCAD for a small number of patients. The InterTAK score should be used in conjunction with other clinical variables for angiographic referral.

Changing Incidence and Mechanism of Pregnancy-Associated Myocardial Infarction in the State of California

Background The objective of this study was to evaluate the temporal trends in pregnancy-associated myocardial infarction (PAMI) in the State of California and explore potential risk factors and mechanisms. Methods and Results The California State Inpatient Database was analyzed from 2003 to 2011 for patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for acute myocardial infarction and pregnancy or postpartum admissions; risk factors were analyzed and compared with pregnant patients without myocardial infarction. A total of 341 patients were identified with PAMI from a total of 5 266 380 pregnancies (incidence of 6.5 per 100 000 pregnancies). Inpatient maternal mortality rate was 7%, and infant mortality rate was 3.5% among patients with PAMI. There was a nonsignificant trend toward an increase in PAMI incidence from 2003 to 2011, possibly attributable to higher incidence of spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome. PAMI, when compared with pregnant patients without myocardial infarction, was significant for older age (aged >30 years in 72% versus 37%, P<0.0005), higher preponderance of Black race (12% versus 6%, P<0.00005), lower socioeconomic status (median household income in lowest quartile 26% versus 20%, P=0.04), higher prevalence of hypertension (26% versus 7%, P<0.0005), diabetes (7% versus 1%, P<0.0005), anemia (31% versus 7%, P<0.0001), amphetamine use (1% versus 0%, P<0.00005), cocaine use (2% versus 0.2%, P<0.0001), and smoking (6% versus 1%, P=0.0001). Conclusions There has been a trend toward an increase in PAMI incidence in California over the past decade, with an increasing trend in spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome as mechanisms. These findings warrant further investigation.

Coronary Artery Fistulae

Coronary artery fistula is a rare anatomic abnormality of the coronary arteries that affects 0.002% of the general population and represents 14% of all anomalies of coronary arteries. Its clinical relevance focuses mainly on the mechanism of the coronary steal phenomenon, causing myocardial functional ischemia, even in the absence of stenosis; therefore, angina and effort dyspnea are common symptoms. The suggested diagnostic approach is driven by patients' symptoms, and it consists of a number of instrumental examinations like ECG, treadmill test, echocardiography, computed tomography scan, cardiac magnetic resonance, and coronary angiography. If it is not an incidental finding, coronary angiography is required in view of optimal therapeutic planning. Small fistulae are usually asymptomatic, and prognosis is excellent if they are managed medically with clinical follow-up and echocardiography every 2 to 5 years. Large/giant, symptomatic fistulae, on the contrary, should undergo invasive closure, via either transcatheter approach or surgical ligation, whose results are equivalent at long-term follow-up. Antibiotic prophylaxis for prevention of bacterial endocarditis is recommended in all patients with coronary artery fistulae who undergo dental, gastrointestinal, or urological procedures. Life-long follow-up is always essential to ensure that the patient does not undergo progression of the disease or further cardiac complications.

Pregnancy-associated Acute Myocardial Infarction (PAMI): Case Report

Cardiovascular diseases are recognised complications of pregnancy, however, pregnancy-associated acute myocardial infarction (PAMI) is uncommon. Pregnancy is known to increase risk of myocardial infarction even in the absence of traditional risk factors for atherosclerotic vascular disease. Our patient presented with acute chest pain two weeks after delivery and her electrocardiogram was in keeping with STelevation myocardial infarction (STEMI). Coronary angiography revealed coronary artery dissection and she was managed conservatively. Various pathophysiological mechanisms of PAMI have been described in literature including spontaneous coronary artery dissection (SCAD) found in our case. The diagnosis is often missed and earlier reported cases were diagnosed at autopsy. Therefore, we report this case as a learning tool. Also, there is a need for a high index of suspicion in pregnant patients presenting with features suggestive of aortic dissection, and its diagnosis should be thought of in peripartum women presenting with acute chest pain.

Minimalist Management of Occlusive Spontaneous Coronary Artery Dissection With Workhorse Guidewire: The Prick-and-Wait Technique

We describe what could be a bailout strategy in the event of (1) failure to reach the distal true lumen, (2) slight improvement in the distal flow, but allowing clinical resolution of STEMI, or (3) a situation not suited to surgery. The "prick-and-wait" technique presented in this case led to a complete recovery.

Dobutamine stress cardiac MRI is safe and feasible in pediatric patients with anomalous aortic origin of a coronary artery (AAOCA)

BACKGROUND

Risk stratification in anomalous aortic origin of a coronary artery (AAOCA) is challenged by the lack of a reliable method to detect myocardial ischemia. We prospectively studied the safety and feasibility of Dobutamine stress-cardiac magnetic resonance (DSCMR), a test with excellent performance in adults, in pediatric patients with AAOCA.

METHODS

Consecutive DSCMR from 06/2014-12/2019 in patients≤20 years old with AAOCA were included. Hemodynamic response and major/minor events were recorded. Image quality and spatial/temporal resolution were evaluated. Rest and stress first-pass perfusion and wall motion abnormalities (WMA) were assessed. Inter-observer agreement was assessed using kappa coefficient.

RESULTS

A total of 224 DSCMR were performed in 182 patients with AAOCA at a median age of 14 years (IQR 12, 16) and median weight of 58.0 kg (IQR 43.3, 73.0). Examinations were completed in 221/224 (98.9%), all studies were diagnostic. Heart rate and blood pressure increased significantly from baseline (p < 0.001). No patient had major events and 28 (12.5%) had minor events. Inducible hypoperfusion was noted in 31/221 (14%), associated with WMA in 13/31 (42%). Inter-observer agreement for inducible hypoperfusion was very good (Κ = 0.87). Asymptomatic patients with inducible hypoperfusion are considered high-risk and those with a negative test are of standard risk.

CONCLUSIONS

DSCMR is feasible in pediatric patients with AAOCA to assess for inducible hypoperfusion and WMA. It can be performed safely with low incidence of major/minor events. Thus, DSCMR is potentially a valuable test for detection of myocardial ischemia and helpful in the management of this patient population.

Assessment of transfer of morphological characteristics of Anomalous Aortic Origin of a Coronary Artery from imaging to patient specific 3D Printed models: A feasibility study

BACKGROUND AND OBJECTIVE

This study aims to determine the accuracy of patient specific 3D printed models in capturing pathological anatomical characteristics derived from CT angiography (CTA) in children with anomalous aortic origin of a coronary artery (AAOCA).

METHODS & MATERIALS

Following institutional regulatory approval, a standardized protocol for CTA of AAOCA was utilized for imaging. Blood volume of the aorta and coronaries were segmented from the DICOM images. A total of 10 models from 8 AAOCA patients were created, including 2 post-operative models. Mechanical properties of Agilus30 a flexible photopolymer coated with a thin layer of parylene, polyurethane (PU) and silicone and native aortic tissue from a postmortem specimen were compared. AAOCA models with wall thicknesses of 2mm aorta and 1.5mm coronaries were 3D printed in Agilus30 and coated with PU. CT of the printed models was performed, and 3D virtual models were generated. Transfer of anatomical characteristics and geometric accuracy were compared between the patient model virtual models.

RESULTS

Dynamic modulus of Agilus30 at 2mm thickness was found to be close to native aortic tissue. Structured reporting of anatomical characteristics by imaging experts showed good concordance between patient and model CTA Comparative patient and virtual model measurements showed Pearson's correlation (r) of 0.9959 for aorta (n=70) and 0.9538 for coronaries (n=60) linear, and 0.9949 for aorta (n=30) and 0.9538 for coronaries (n=30) cross-sectional, dimensions. Surface contour map mean difference was 0.08 ± 0.29mm.

CONCLUSIONS

Geometrically accurate AAOCA models preserving morphological characteristics, essential for risk stratification and decision-making, can be 3D printed from a patient's CTA.

Women With Spontaneous Coronary Artery Dissection Are at Increased Risk of Iatrogenic Coronary Artery Dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period.

METHODS

Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection.

RESULTS

Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51±11 and 51±10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in SCAD and control groups, respectively, despite a much lower rate of percutaneous coronary intervention in the SCAD group. No common factors could be identified regarding particular equipment or procedural factors associated with iatrogenic dissection.

CONCLUSION

The rate of iatrogenic dissection in women with SCAD during cardiac catheterisation is confirmed to be high and significantly higher than a contemporaneous age-matched group of women without SCAD. This observation likely indicates generalised coronary fragility in this disease, and emphasises the importance of the utmost care in the engagement, injection and intervention involving the coronary arteries in this disease. Development of a non-invasive coronary imaging modality or biomarker able to diagnose SCAD non-invasively would be a great advance in the care of patients with this condition, because it would avoid the need for invasive coronary angiography for diagnosis.

Study of the Prevalence of Congenital Coronary Anomalies of Origin from the Opposite or Non-coronary Sinus in patients undergoing Invasive Coronary Angiography

OBJECTIVES

1. To study the incidence and clinical features of patients with Congenital Coronary Anomalies of Origin from Oppossite or Non-coronary Sinus; 2. To study the course of these Anomalous Coronary Artery Origins with CT Coronary Angiography.

METHODS

A Cross Sectional Observation study was conducted at Department of Cardiology, in a tertiary Hospital for a period of 3 years. Patients undergoing Coronary Angiography (CAG) were screened and patients having Anomalous Coronary Origin from the Opposite or Non-Coronary Sinus of Valsalva were selected. CT Cronary Angiography was done in all such patients and the course of the anomalous artery was studied.

RESULTS

During the 3 years period of study, total of 5241 CAGs were conducted of which 42 (0.8%) patients were found to have Anomalous Coronary Artery Origin as per the inclusion criteria. Out of the 42 cases, Anomalous origin of RCA from Left Corornary Cusp was the commonest with 23(0.43%) cases, followed by Anomalous Origin of LCX from Right Coronary or RCC with 17 (0.32%) cases. Other anomalies of origin were quite rare (n=2) which included Anomalous origin of Left Main from RCA (n=1) and Dual origin of LAD (n=1). CT Coronary Angiography showed that of the 23 patients with Anomalous Origin of RCA from Left side,27.4% had Inter-Arterial course and 56.1% had Retro-Aortic course. Of the 17 patients with Anomalous Origin of LCX from Right sinus, 88.23% had Retro-Aortic course.

CONCLUSIONS

This study showed that anomalous origin of Coronary Artery from the opposite sinus is quite rare with RCA from Left Sinus and LCX from Right sinus comprised the vast majority of cases. Most of these anomalous Coronaries have on benign course as defined on CT Coronary Angiography. However, it is important to recognize to delineate the origin and course as it can have significant clinical, therapeutic and prognostic implications.

[Reconstruction Using a Saphenous Vein for Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery in an Adult;Report of a Case]

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is an uncommon congenital heart disease. Such anomaly causes myocardial ischemia, heart failure, and sudden death. Most of such cases require surgical intervention. We report a successful surgical correction for ALCAPA in an adult. A 31-year-old woman with progressive exertional dyspnea was referred to our institution because of abnormal electrocardiogram showing ST depression( V3-V6). Computed tomography revealed the left main trunk (LMT) arising at the right lateral wall of the main pulmonary trunk. Interposition of a saphenous vein graft was performed between the ascending aorta and the LMT. The postoperative course was uneventful.

[Emergency Patch Closure of Coronary Artery Fistula During the Neonatal Period;Report of a Case]

We describe surgical treatment of a coronary artery fistula (CAF) in a neonate. A 5-day-old male neonate was diagnosed with CAF at another hospital and was transferred to our hospital. Transthoracic echocardiography revealed a right coronary artery-to-right ventricle (RV) fistula. Emergency surgery was performed to treat progressive congestive heart failure due to a significant left-to-right shunt through the large CAF. Intraoperatively, we confirmed that the large CAF drained into the inlet of the RV through multiple openings. Intracardiac CAF closure was performed with a bovine pericardial patch. The neonate showed an uneventful postoperative recovery, and postoperative echocardiography revealed a trivial residual shunt with good left ventricular function without increased pulmonary artery pressure.