Coronary artery aneurysms (CAAs) are uncommon and describe a localized dilatation of a coronary artery segment more than 1.5-fold compared with adjacent normal segments. The incidence of CAAs varies ...from 0.3 to 5.3%. Ever since the dawn of the interventional era, CAAs have been increasingly diagnosed on coronary angiography. Causative factors include atherosclerosis, Takayasu arteritis, congenital disorders, Kawasaki disease (KD), and percutaneous coronary intervention. The natural history of CAAs remains unclear; however, several recent studies have postulated the underlying molecular mechanisms of CAAs, and genome-wide association studies have revealed several genetic predispositions to CAA. Controversies persist regarding the management of CAAs, and emerging findings support the importance of an early diagnosis in patients predisposed to CAAs, such as in children with KD. This review aims to summarize the present knowledge of CAAs and collate the recent advances regarding the epidemiology, etiology, pathophysiology, diagnosis, and treatment of this disease.
Abstract Background Structural heart interventions have made major strides over the last years with the introduction of TAVR, percutaneous mitral valve repair and adult congenital heart disease ...procedures. Methods As part of the SCAI SHD Early Career Task Force committee, we complied a survey of 17 questions using a Survey Monkey website. We sent invitations twice by email to 183 European program directors of interventional cardiology fellowship programs in Europe. Results The most commonly performed procedures performed by the fellows were transseptal punctures, TAVR, BAV, PFO and BMV. For the rest of the structural procedures, each fellow performed < 10 procedures during their training. Conclusion Structural heart interventions training will keep expanding over the next years with the introduction of newer devices and techniques and accumulation of experience. Given the small number of the more rare structural procedures, it becomes apparent that we need to design national or international training networks to provide adequate training experience to all trainees.
BACKGROUNDOptimal management of patients with ostial left anterior descending artery stenosis remains an unresolved issue. METHODSPatients with ostial left anterior descending stenosis who underwent ...stent implantation were included in this study. Coronary records of all patients were monitored, and long-term clinical outcomes were recorded. The patients were divided into 2 groups according to the stenting method: focal left anterior descending stenting ostial stenting group and stenting from the left main coronary artery to the left anterior descending crossover stenting group. RESULTSOf the 97 eligible consecutive patients, 56 were treated with ostial stenting and 41 with crossover stenting. At a mean follow-up of 23.6 ± 12.6 months, non-fatal myocardial infarction (3.9% vs. 12.8%, P=.118), target lesion revascularization (5.9% vs. 12.8%, P=.252), and all-cause death (2.0% vs. 7.7%, P=.191) rates were not statistically significant. However, the rate of major adverse cardiovascular events defined as a composite of non-fatal myocardial infarction, target lesion revascularization, or all-cause death was significantly higher in the crossover stenting group (8.2% vs. 28.2%, P = .013). In the multiple regression analysis, left main coronary artery diameter (odds ratio = 4.506; 95% CI: 1.225-16.582, P = .024) and application of the crossover stenting technique (odds ratio = 5.126; 95% CI: 1.325-19.833, P = .018) were found to be the most effective predictors of major adverse cardiovascular events. CONCLUSIONIn our study, the ostial stenting group was associated with better clinical outcomes in the treatment of ostial left anterior descending stenosis. However, it is notappropriate to apply a single method to all patients with such lesions.
Myocardial crypts are discrete, narrow, blood filled invaginations within the left ventricular myocardium and high-take-off coronary artery are rare manifestations where coronary arteries originate ...above the sinotubuler junction.
A 41-year-old man with multiple coronary artery disease risk factors admitted to our outpatient department with progressive dyspnea and atypical chest pain. Physical examination revealed no pathological findings. His blood examination revealed only mild to moderately high IgE and LDL levels. Transthoracic echocardiography (TTE) was normal. His treadmill test was normal, yet in the 3rd stage of the test he had an atypically located chest pain which was relieved in the resting period. As he had multiple cardiovascular risk factors, we performed a coronary CT angiography to exclude coronary artery disease. Coronary CT angiography(CCTA) demonstrated multiple myocardial crypts, a muscular VSD like defect which were not detectable with TTE and a high take off left main coronary artery (LMCA). After CCTA, we repeated the TTE to investigate the crypts and VSD-like defect which were clear on CCTA, yet a precise TTE hardly showed crypts and didn't confirm a shunt between the left and right ventricle. We defined the defect as 'spontaneously closed muscular VSD'. None of these pathologies were clinically relevant with the patient's symptoms, thus pneumonology started a montelukast therapy for 1 year and we decided to follow up the patient, as multiple crypts may indicate an early phase hypertrophic cardiomyopathy.
Considering that a high take-off LMCA is a congenital anomaly, encountering multiple crypts which are also congenital pathologies, is plausible, as congenital anomalies may accompany eachother. Echocardiography is a very useful, practical imaging tool but regrettably may be suboptimal due to various patient and method related reasons. Target combination of different cardiovascular imaging tools like echocardiography, cardiac CT(CCT), may be utilized in order to ensure a comprehensive diagnosis particularly.
Right ventricular pacing resulted in abnormal ventricular depolarization and an activation pattern similar to left branch bundle block. In some circumstances, it may exacerbate symptoms of heart ...failure and increase hospital admission rates. The objective of this study was to assess the effects of long-term ventricular resynchronization therapy on echocardiographic parameters of left ventricular (LV) remodeling in patients with moderate to severe heart failure who were upgraded from single- to biventricular pacing. Twenty-six consecutive pacemaker-dependent patients (20 men; mean age 61 ± 20 years) who underwent placement of an LV lead to upgrade their conventional pacing system to biventricular pacing were included in the study. All patients had heart failure symptoms, received the maximum tolerated medical therapy, and were stable for ≥1 month before the upgrade. Echocardiography and electrocardiography were performed before the pacemaker upgrade and at follow-up (mean duration 15 ± 9 months). QRS duration decreased significantly from 176 ± 23 to 154 ± 19 ms (p <0.001). LV end-diastolic volume (p = 0.006) and LV end-systolic volume (p = 0.004) decreased at follow-up compared with baseline. The decrease in LV volumes observed during follow-up was accompanied by a significant increase in ejection fraction (39 ± 11% to 46 ± 10%; p = 0.001) and decrease in LV myocardial performance index (0.84 ± 0.18 to 0.68 ± 0.14; p = 0.001). The upgrade of conventional pacing to biventricular pacing resulted in significant prolongation of normalized LV filling time (p = 0.01) and shortening of isovolumic contraction time (p 0.002). In addition, biventricular pacing significantly (V-V interval = 0) reduced intra- (44 ± 11 vs 18 ± 12 ms; p <0.001) and interventricular dyssynchrony (78 ± 33 vs 49 ± 22 ms; p <0.001). In conclusion, these findings suggested that in patients with advanced heart failure and continuous right ventricular pacing, upgrading to biventricular system resulted in significant reverse LV remodeling in the long-term follow-up and improvement in overall synchronicity of ventricular function.
As adult patients with congenital heart disease (CHD) grow older, the risk of developing coronary artery disease (CAD) increases. We sought to estimate the prevalence of CAD in adult patients with ...CHD, the safety of coronary angiography in this setting, and the potential relation of CAD to clinical and hemodynamic parameters. Two hundred fifty adult patients with CHD (mean age 51 ± 15 years; 53% men) underwent selective coronary angiography in our center for reasons other than suspected CAD. Clinical and hemodynamic data were retrieved retrospectively from medical records and echocardiographic and angiographic databases, respectively. Significant CAD using quantitative coronary angiography was found in 9.2% of adult patients with CHD. No patient with cyanosis or age <40 years had significant CAD. Systolic and diastolic systemic ventricular dimensions were significantly higher in patients with CAD, even after adjustment for age (odds ratio OR for 10-mm increase 2.59, 95% confidence interval CI 1.29 to 5.21, p = 0.007; OR 2.31, 95% CI 1.24 to 4.31, p = 0.008, respectively). Systemic arterial hypertension and hyperlipidemia were strong predictors of CAD (OR 4.54, 95% CI 1.82 to 12.0, p = 0.001; OR 9.08, 95% CI 3.56 to 24.54, p <0.0001, respectively), whereas no relation to chest pain was found. Only 1 major adverse event was recorded during coronary angiography. In conclusion, the prevalence of significant CAD in a hospital adult CHD cohort was similar to that in the general population. This study supported the performance of selective coronary angiography in patients >40 years referred for cardiac surgery, with low risk of major complications. Traditional cardiovascular risk factors for CAD also applied to adult patients with CHD, in whom primary prevention of CAD was as important as in the general population.
Abstract
Background
Paravalvular leak (PVL) is a common, serious complication related with prosthetic valve replacement. Although surgical closure reoperation is the choice of treatment, percutaneous ...device closure is a good alternative with good results in patients with very high surgical risk.
Case summary
In this case report, we present the percutaneous closure of PVL of mitral valve replacement (MVR), in a patient with cardiogenic shock who failed conservative medical treatment and was deemed inoperable due to recurrent operations. Successful closure of the PVL with the use of the four consecutive PVL closure devices was performed under general anaesthesia with guidance of 2D and 3D transoesophageal echocardiography. The procedure was performed with no complications and the patient has remained asymptomatic after 10 months following the PVL closure procedure with marked improvement in her NYHA class and echocardiographic values.
Discussion
Percutaneous PVL closure is a very challenging and high clinical skills requiring procedure, but has a good success and low complication rate in high-risk patients. It is not a standard procedure and the type and size of device should be tailored for each patient with a good 2D and 3D echocardiographic guidance.
The CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease and sex) score is a simple risk stratification algorithm to estimate stroke/thromboembolic ...risk in patients with non-valvular atrial fibrillation (AF). Higher pre-stroke CHA2DS2-VASc score is known to be associated with greater stroke severity and poorer outcomes. AF patients generally have higher CHA2DS2-VASc scores than non-AF patients. The Modified Thrombolysis in Cerebral Infarction (mTICI) score is the most widely used grading system to assess the result of recanalizing therapies in acute ischemic stroke (AIS). mTICI 2c and mTICI 3 are conventionally accepted as successful recanalization.
We investigated whether pre-stroke CHA2DS2-VASc score is associated with mTICI recanalization score in AIS patients with and without AF undergoing percutaneous thrombectomy.
One hundred fifty-nine patients with the diagnosis of AIS who were admitted within 6 h from symptom onset were included in the study (mean age: 65.7 ±12.9). All subjects underwent endovascular treatment. CHA2DS2-VASc scores of the participants were calculated. Subjects were grouped according to mTICI scores achieved after endovascular treatment. mTICI 2c and mTICI 3 were accepted as successful recanalization.
Successful reperfusion was observed in 130 (81.8%) of all patients who underwent endovascular treatment (mTICI flow ≥ 2c) and first-pass reperfusion was observed in 107 (67.3%) patients. When the patients with successful (mTICI flow ≥ 2c) and unsuccessful (mTICI flow ≤ 2b) reperfusion were divided into groups, no significant difference was observed between the patients in terms of comorbidities such as AF, hypertension, hyperlipidemia, coronary artery disease and cerebrovascular accident history. Patients with unsuccessful reperfusion were older than patients with successful reperfusion (71.4 ±11.2 vs. 64.5 ±13.01,
= 0.006), with a higher CHA2DS2-VASc score (4.1 ±1.5 vs. 3.04 ±1.6,
= 0.002). In addition, the duration of the procedure was longer in the unsuccessful reperfusion group (92.4 ±27.2 min vs. 65.0 ±25.1 min,
< 0.001). CHA2DS2-VASc score significantly correlated with successful recanalization (correlation coefficient; 0.243,
= 0.002). Multivariate logistic regression analysis revealed that only CHA2DS2-VASc score (OR = 1.43, 95% CI: 1.09-1.87,
= 0.006) and procedure time (OR = 1.03, 95% CI: 1.01-1.05,
< 0.001) were independent predictors of successful reperfusion. The receiver-operating characteristic (ROC) curve was used to determine the cut-off value for the CHA2DS2-VASc score that best predicts successful reperfusion. The optimal threshold was 3.5, with a sensitivity of 58.6% and specificity of 59.2% (area under the curve (AUC): 0.669,
0.005).
For the first time in the literature, we investigated and demonstrated that pre-stroke CHA2DS2-VASc score was associated with success of recanalization as assessed with mTICI 2c and mTICI 3 in a cohort of AIS patients regardless of AF presence who underwent endovascular treatment. Our findings deserve to be tested with large scale long term studies.
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