Jan Z. Peruga

Arterial dysfunction in syndrome X: results of arterial reactivity and pulse wave propagation tests

Objective: To assess arterial distensibility using pulse wave velocity (PWV) measurements and its relation with endothelium dependent vasodilatation (EDV) in patients with cardiological syndrome X. Methods: The study group consisted of 92 patients: 52 with syndrome X (34 women, 18 men, mean (SD) age 45 (3) years) and 40 healthy volunteer controls (27 women, 13 men, mean (SD) age 41 (2) years) without risk factors of atherosclerosis and with negative ECG exercise test and normal proximal coronaries on transoesophageal echocardiography. Patients with arterial hypertension, diabetes mellitus, valvar disease, or cardiomyopathy were excluded. PWV measured by a Complior Colson device was calculated for each patient. EDV was assessed from two dimensional Doppler measurement using an Acuson Sequoia with 8 MHz linear transducer at rest, during postischaemic reactive hyperaemia, and after an oral dose of 400 μg of glyceryl trinitrate. Results: PWV was significantly higher in patients with syndrome X than in healthy subjects (9.3 (0.7) m/s v 8.2 (0.9) m/s, respectively, p < 0.001). Baseline brachial artery diameter was similar in the syndrome X and control groups (4.0 (0.6) mm v 4.08 (0.64) mm, NS). EDV was impaired in patients with syndrome X compared with controls (6.6 (3.0)% v 11.1 (3.9)%, p < 0.001). Endothelium independent vasodilatation was similar in both groups. In patients with syndrome X there was a positive correlation between PWV and the degree of EDV (r = 0.864, p < 0.001). The cut off value for PWV was 8.5 m/s, with a sensitivity of 62% and a specificity of 91%. Conclusions: EDV but not glyceryl trinitrate induced vasodilatation is decreased in patients with syndrome X. There is a strong correlation between PWV and the degree of endothelial dysfunction of peripheral arteries in patients with syndrome X. PWV assessment may be useful to identify abnormal vascular physiology in these patients.

Definition of flow parameters in proximal nonstenotic coronary arteries using transesophageal Doppler echocardiography.

Transesophageal echocardiography (TEE) enables the visualization of proximal coronary arteries. We investigated the feasibility of coronary flow evaluation using TEE, as well as to define flow parameters found in normal proximal coronary arteries. The subgroups of patients with normal proximal segments of coronary arteries were selected from the cohort of 210 patients undergoing routine coronary angiography. The left main coronary artery (LMCA), proximal segment of left anterior descending coronary artery (LAD), left circumflex artery (LCx), and right coronary artery (RCA) were analyzed separately in 147, 64, 53, and 70 patients, respectively. Proximal coronary arteries were evaluated in the transverse plane using a 5‐MHz TEE probe, and the flow in normal arteries was registered using pulsed‐wave Doppler. The registration of flow with pulsed‐wave Doppler was feasible in 88% of studies for the LMCA, 85% for the LAD, 58% for the LCx, and 65% for the RCA. Normal flow was laminar with distinct phasic character (diastolic predominance). Mean ± SD values of peak coronary flow velocity were (systole/diastole) for the LMCA, 36 ± 11171 ± 19 cm/sec; the LAD, 31 ± 9/67 ± 19 cm/sec; the LCx, 36 ± 13/75 ± 24 cm/sec; and the RCA, 25 ± 8/39 ± 12 cm/sec. Peak diastolic coronary flow velocity was most significantly correlated with heart rate. Doppler evaluation of proximal coronary flow is feasible using TEE in the majority of patients. The knowledge of normal flow values, which is different for the left and the right coronary artery, provides the background for proper interpretation of flow in diseased coronary arteries.

Circumflex Origin from Right Coronary Artery—The Anomaly That Should Not Be Omitted during Echocardiography—”Crossed Aorta” and “Bleb Sign” Presentation after Stents Implantation

Case Report: A 63-year-old man with hypertension and coronary artery disease treated with multiple stents implantation (three drug eluting stents in Cx, two in right coronary artery (RCA) and one in left anterior descending artery (LAD)) was directed to control echocardiography. Five-chamber apical view during TTE revealed the bright echo of the stent implanted to Cx which seemed to cross the aorta perpendicularly to aortic long axis suggesting retroaortic course of the coronary artery (TTE; Fig. 1; movie clip S1). In TEE long-axis aortic view, we observed cross section of retroaortically coursing Cx with hyperechogenic stent forming “bleb sign” in mitroaortic angle (TEE; Fig. 2; movie clip S2, S3). Three-dimensional (3D) imaging of mitroaortic continuity facing the ostium of left atrial appendage revealed the bulging of endothelium covering stented Cx artery (3DTEE; Fig. 3; movie clip S4). TEE with color Doppler documented the laminar flow in proximal part of solitary ostium of LAD and RCA (movie clip S5). RCA with anomalous Cx origin from its proximal part was found during angiography and angioplasty with stents implantation to both coronaries was performed (angiography; Fig. 4). Despite “bleb sign” may be observed in native arteries, implanted stents in presented patient made anomalous Cx hyperechogenic and easily noticed. Although the described anomaly is often

Transthoracic and Three‐Dimensional Transesophageal Echocardiographic Presentation of Anomalous Circumflex Origin from Right Coronary Artery in Patient with Severe Mitral Stenosis

Case Description: The 76-year-old man with symptomatic mitral valve stenosis was evaluated before decision for valvuloplasty or surgery. Transthoracic echocardiography (TTE) revealed severe mitral stenosis and suggested anomalous circumflex coronary artery (Cx) with probable origin from right sinus of Valsalva (Fig. 1). Transesophageal examination (TEE) corroborated mitral valve area of 0.9 cm (Fig. 2). A small round structure, consistent with previously reported “bleb sign,” indicating shortaxis view of an anomalous circumflex artery origi-

Safety of non-invasive cardiovascular imaging techniques. Expert consensus statement of the Polish Clinical Forum for Cardiovascular Imaging

Polskie Kliniczne Forum Obrazowania Serca i Naczyn: Edyta Plonska-Gościniak, Magdalena Kostkiewicz, Piotr Lipiec, Tomasz Miszalski-Jamka, Andrzej Szyszka, Mieczyslaw Pasowicz, Andrzej Gackowski, Tomasz Kukulski, Miroslaw Dziuk, Cezary Kepka, Mariusz Skowerski, Zbigniew Gąsior, Jerzy Walecki, Piotr Szymanski, Katarzyna Mizia-Stec, Anna Klisiewicz, Piotr Hoffman, Piotr Podolec, Piotr Pruszczyk, Jaroslaw D. Kasprzak, Adam Torbicki

Acute coronary syndrome as the first manifestation of Takayasu’s disease

A 39-year-old woman was admitted to hospital due to typical angina pectoris of three months’ duration progressing to Canadian Cardiovascular Society class III. There was no previous medical history or family history of coronary artery disease. Coronary risk factors except for smoking were absent. On admission she presented tachycardia 92/min and with 2 mm ST segment depression in II, III, aVF leads on 12-lead electrocardiogram (Fig. 1A). Laboratory tests showed elevated: troponin T (0.8 ng/mL) and CK-MB white blood cell count (11,100/μ) and test C-reactive protein (CRP; 28 mg/L) with mildly elevated immunoglobulins (IdA, IgM, IgG) indicating an inflammatory process. Echocardiography showed normal left ventricular (LV) function with ejection fraction 62%. LV relaxation was abnormal and pulmonary vein flow suggested mild elevation of LV end-diastolic pressure. Coronary angiography revealed severe bilateral ostial stenosis — 95% in the right and 80% in the left coronary artery (Fig. 1B, C). Colour Doppler mapping of coronary ostia showed turbulent high-velocity (diastolic component > 1.5 m/s; Fig. 1E) flow suggestive of bilateral ostial coronary stenosis. Ultrasound examination of the aortic arch suggested additionally left subclavian stenosis and bilateral carotid lesions (Fig. 1F). The patient underwent 64-row computed tomography to define stenoses in other major arteries. The scan confirmed critical ostial stenotic right and left coronary artery (Fig. 1D) and revealed inflammatory thickening of ascending and descending aorta, significant stenosis of both carotid and both subclavian arteries, and noncritical involvement of left and right vertebral arteries (Fig. 1G). Additionally, the left renal artery had 85% proximal stenosis. According to her symptoms, the patient was treated with coronary angioplasty (percutaneous coronary intervention) with bare metal stenting 4.0 × 16 mm in the ostium of the right coronary and 4.5 × 12 mm into the left main coronary artery ostium without residual stenosis and good early result. Anti-inflammatory therapy with prednisolone was instituted starting from 60 mg per day, and during one month we observed the normalisation of inflammatory parameters such as white cell count, level CRP, and erythrocyte sedimentation rate. Our patient presented an uncommon form of Takayasu arteritis initially manifesting as coronary acute syndrome due to critical ostial left and right coronary artery stenosis, initially detected on electrocardiogram and angiogram. Further multimodality workup showed severe arteritis in all arch branches and additionally in the renal artery (type V, C+). Therefore, we decided to embrace the percutaneous strategy, which led to symptomatic improvement.

Intramural atrial haematoma as a complication of the percutaneous atrial septal defect closure

Piotr Lipiec, Dominika Filipiak-Strzecka, Konrad Szymczyk, Jan Zbigniew Peruga, and Jarosław D. Kasprzak Department of Cardiology, Bieganski Hospital, Medical University of Lodz, Kniaziewicza 1/5, 91-347, Lodz, Poland; and Department of Radiology, Barlicki University Hospital, Medical University of Lodz, Kopcinskiego 22, 90-153, Lodz, Poland * Corresponding author. Tel: 148 2516216; Fax: 148 2516015. E-mail: dominika.filipiak@gmail.com

Outcomes of percutaneous coronary intervention in patients after previous coronary artery bypass surgery

BACKGROUND Patients after previous coronary artery bypass grafting (CABG) often require repeat percutaneous revascularisation due to poor patency rates of saphenous vein grafts (SVG) and higher risk of re-CABG. Few data are available to evaluate different percutaneous revascularisation strategies in patients after previous CABG. AIM To evaluate outcomes of percutaneous coronary intervention (PCI) in patients after previous CABG, including the effect of treatment on the quality of life and symptoms, and secondly to assess the relation between angiographic factors and treatment outcomes METHODS This was a prospective observational study which included 78 patients after previous CABG. Following coronary angiography, the patients were assigned to one of three groups: group A (n = 20), PCI of a SVG (PCI SVG); group B (n = 29), PCI of a native coronary artery (PCI NA); group C (n = 29), control group that received medical treatment (MT) only. Duration of follow-up was 12 months. RESULTS Compared to MT patients, patients treated with PCI had significantly higher Canadian Cardiovascular Society (CCS) class (2.75 vs. 2.41, p = 0.03) and more frequently had coronary angiography performed due to unstable angina (57% vs. 31%, p = 0.04). Patients in the PCI SVG group had significantly older SVG conduits compared to the PCI NA group (13.4 years vs. 8.2 years, p = 0.005). At 12 months of follow-up, we found a significant improvement in the EQ-5D index of the quality of life, and a significant reduction in CCS class in the PCI SVG group (0.66 vs. 0.7, p = 0.0003, and 2.75 vs. 1.9, p < 0.001, respectively) and in the PCI NA group (0.65 vs. 0.72, p < 0.001, and 2.75 vs. 2.17, p < 0.001, respectively), but no improvement in the MT group. Treatment outcomes did not differ significantly between the three groups (combined endpoint rate 20% vs. 13% vs. 27.5%, p = 0.37). In multivariate analysis, SVG age > 11 years was identified as a significant predictor of poor outcomes in patients treated with PCI after previous CABG. CONCLUSIONS PCI in patients after previous CABG does not improve prognosis but significantly improves the quality of life and reduces symptom severity.

TCT-501 Ultrasound examination of the forearm arteries morphology and anomalies in patients undergoing percutaneous coronary intervention via radial access.

A proven advantage of radial over femoral arterial access has led to an increase in the number of interventions performed via radial artery access. An ultrasound examination of the forearm arteries provides important information about the anatomy of the forearm vessels, and indirectly also about the

Conscious sedation for transcatheter implantation of atrial septal occluders with two- and three-dimensional transoesophageal echocardiography guidance — a feasibility and safety study

BACKGROUND General anaesthesia may have negative impact on patient mortality and morbidity, as well as overall procedure costs, in atrial septal occluder (ASO) implantation. AIM We sought to evaluate the safety, efficacy, and feasibility of conscious sedation for transcatheter implantation of ASOs. METHODS A total of 122 patients referred for transcatheter implantation of ASO were included. Mean patient age was 51 ± 15 years, and 43 (35%) patients were male. The initial dose of midazolam was 2 mg and fentanyl dose was 25 μg. Additional doses of midazolam and fentanyl were administered, if necessary. Patient responsiveness was assessed every 10 min, and the sedatives doses were titrated in order not to exceed grade 3 sedation in the Ramsey scale. RESULTS Atrial septal occluders were successfully implanted in the majority of patients (98.4%). In two (1.6%) cases the proce-dure failed because of too small patent foramen ovale (PFO) diameter (n = 1, 0.8%) or device instability (n = 1, 0.8%). The mean duration of procedure was 47.6 ± 28.4 min and was similar for ASD and PFO closure (p = 0.522). The overall mean dose of midazolam was 4.7 ± 2.2 mg (63.9 ± 32.5 μg/kg) and fentanyl was 30.0 ± 11.9 μg (0.43 ± 0.17 μg/kg). Median entrance dose of radiation at the patient plane was 25 (interquartile range: 16-57) mGy, and did not differ between ASD and PFO procedures (p = 0.614). The majority of patients were free of complications (91.0%). The following early complications were observed: transient ischaemic attack (n = 2, 1.6%), supraventricular arrhythmias (n = 4, 3.3%), left atrial thrombus formation (n = 1, 0.8%), symptomatic bradycardia (n = 1, 0.8%), and femoral venous bleeding (n = 5, 4.1%). After mean follow-up of 386 days residual shunt was observed in eight (6.6%) patients. CONCLUSIONS Conscious sedation for transcatheter implantation of ASO is a feasible, safe, and efficient technique, allowing successful PFO and ASD closure in the majority of patients.