Paweł Tyczyński

Comparison of Usefulness of Percutaneous Coronary Intervention Guided by Angiography plus Computed Tomography Versus Angiography Alone Using Intravascular Ultrasound End Points

The aim of our study was to assess the impact of coronary computed tomographic angiographic (CTCA) guidance on outcomes of percutaneous coronary intervention (PCI). The study was a randomized single-center trial. Consecutive eligible patients with CTCA-detected significant coronary lesions who were scheduled for PCI were randomized to an angiographically guided versus an angiographically plus computed tomographically guided (ACTG) group. In the ACTG group the operator preliminarily planned PCI based on computed tomographic angiogram. The coprimary end points were minimal stent area and minimal reference lumen area assessed in all patients with intravascular ultrasound performed after achieving optimal angiographic results. Seventy-one patients (50 men, mean age 65 ± 8 years) were randomized. After invasive angiography, PCI of 32 lesions (30 patients) in the ACTG and in 32 lesions (30 patients) in the angiographically guided group was performed. A stented segment length was longer and nominal stent diameter tended to be larger in the ACTG group (23.8 ± 6.7 vs 19.5 ± 6.5 mm, p = 0.01; 3.27 ± 0.44 vs 3.09 ± 0.41 mm(2), p = 0.110). Minimal stent area tended to be larger (6.62 ± 2.01 vs 5.80 ± 2.02 mm(2), p = 0.100) and the smallest peri-stent reference lumen area was significantly larger in the ACTG group (6.76 ± 3.01 vs 5.0 ± 1.62 mm(2), p = 0.006) with a smaller plaque burden (50 ± 16% vs 58 ± 13%, p = 0.025). In conclusion, CTCA analysis before PCI significantly influences treatment strategy and results in better lesion coverage as defined by intravascular criteria.

Comparison of Intravascular Ultrasound, Quantitative Coronary Angiography, and Dual-Source 64-Slice Computed Tomography in the Preprocedural Assessment of Significant Saphenous Vein Graft Lesions

The correlation between cardiac computed tomographic (CT) and intravascular ultrasound (IVUS) assessment of saphenous vein graft (SVG) lesions has not been studied. The aim of this study was to evaluate the accuracy of dual-source computed tomography in quantitative assessment of significant SVG lesions scheduled for percutaneous coronary intervention (PCI). Preintervention dual-source CT (DSCT) scans were performed in consecutive patients before PCI of the SVG lesion. All subjects underwent IVUS examination of the target lesion before stent implantation. Lesion characteristics were described using dual-source computed tomography, quantitative coronary angiography, IVUS, and visual estimation. Luminal areas and diameters, lesion lengths, and DSCT suggested stent dimensions were compared. Twenty-two SVG lesions were assessed in 22 patients. Minimal lumen area measured by IVUS was larger than by dual-source computed tomography (3.5 ± 1.2 vs 3.0 ± 1.2 mm(2), p = 0.04), although there was close correlation between measurements (R = 0.7, p = 0.007). Proximal and distal reference lumen diameters by IVUS and dual-source computed tomography were similar (3.3 ± 0.4 vs 3.4 ± 0.6 mm, p = 0.5, and 3.4 ± 0.6 vs 3.5 ± 0.6 mm, p = 0.4, respectively) and were well correlated (R = 0.85, p <0.0001, and R = 0.81, p <0.0001, respectively). Lesion length by IVUS averaged 18.3 ± 6.1 versus 17.6 ± 5.3 mm by dual-source computed tomography (p = 0.1). There was good correlation between mean reference lumen diameter by dual-source computed tomography and diameter of the implanted stent (R = 0.84, p = 0.0009) and a very good correlation between stent length and lesion length as assessed by dual-source computed tomography (R = 0.9, p <0.0001). In conclusion, DSCT measurements in SVGs correlate with IVUS so that DSCT scan data before PCI of an SVG lesion may be helpful in stent size selection.

The 24-h blood pressure measurement may predict mortality and cardiovascular events in hypertensive patients with coronary artery disease.

The aim of this prospective study was to evaluate the relationship between 24-h blood pressure (BP) values and cardiovascular events in hypertensive patients with coronary artery disease in the long-term observation. Two hundred and seventy-four patients (mean age 56.9±9.3 years, 197 male, 77 female) who underwent coronary and renal angiography were investigated. Baseline characteristics included clinical and biochemical evaluations, 24-h BP measurement and standardized auscultatory readings – clinic BP. The composite end-point of death from all causes, nonfatal acute myocardial infarction, coronary revascularization and stroke were assessed at mean 40 months follow-up. Patients with the composite end-point had higher mean 24-h systolic BP (SBP) and diastolic BP (DBP) levels (124/74 vs. 117/71 mmHg; P<0.001 and P<0.05 for SBP and DBP, respectively), higher mean daytime SBP and DBP (127/76 vs. 119/72 mmHg; P<0.001 and P<0.05 for SBP and DBP, respectively) and higher night-time SBP and DBP (121/69 vs. 111/65 mmHg; P<0.001 and P<0.05 for SBP and DBP, respectively) at baseline. There were no differences in systolic and diastolic clinic BP levels between patients with and without the combined end-point. Multivariate Cox model revealed that only a number of coronary arteries stenosed and 24-h systolic BP level were independent predictors of occurrence of the composite end-point. In conclusion, our results indicate that 24-h BP measurement made in hospital but not the clinic standardized auscultatory readings predicts cardiovascular risk.

Adrenomedullin concentrations at two time points following myocardial infarction and prediction of mid-term outcomes.

Introduction Adrenomedullin (ADM) is a vasopeptide with multiple actions in the cardiovascular system and a potentially powerful tool in comparison to some of the well-established unimodal biomarkers of risk stratification in myocardial infarction (MI). Previous studies on ADM in acute MI were based on single assessment. Therefore the aim of the study was to examine the relation between ADM plasma concentrations assessed at different time points following MI and outcomes. Material and methods The study included 127 patients with acute MI treated with percutaneous coronary intervention and 60 healthy individuals as controls. Adrenomedullin concentration was assessed at baseline in all study subjects and 48 h after admission in patients with MI. The primary endpoint consisted of all-cause death, nonfatal myocardial infarction, stroke and the need of target vessel revascularization at 6-month follow-up. Results Mean ADM plasma concentration on admission was higher in patients with MI than in controls (30.3 ±14.3 pmol/l vs. 14.6 ±4.7 pmol/l, p < 0.0001). There was no significant difference between ADM concentration after 48 h (30.6 ±12.3 pmol/l) and on admission. The primary endpoint occurred in 9.4% of patients with MI. Multivariable analysis showed that ADM concentration at 48 h after admission (OR = 2.121, 95% CI 1.180-3.810 for every increase of 10 pmol/l, p = 0.012) was the only independent predictor of the primary endpoint. Conclusions In patients with acute MI adrenomedullin plasma concentration assessed at 48 h after admission, but not ADM concentration at baseline, is an independent predictor of major adverse cardiovascular events at mid-term follow-up.

Reduced kidney function estimated by cystatin C and clinical outcomes in hypertensive patients with coronary artery disease: association with homocysteine and other cardiovascular risk factors.

Aims: To evaluate the association between serum cystatin C and homocysteine concentrations, cardiovascular risk factors and cardiovascular events in hypertensive patients with coronary artery disease (CAD). Methods: 260 patients with hypertension and CAD (mean age 56.9 ± 9.3) were included. During a mean 40-month follow-up the combined end-point of death from all causes, non-fatal myocardial infarction and stroke or coronary revascularization was assessed. Results: Subjects in the highest serum cystatin C quartile (>103.4 nmol/l) as compared with the lowest were older, were characterized by a higher frequency of multivessel CAD, higher levels of homocysteine (13.2 ± 5.2 vs. 11.4 ± 4.2 µmol/l; p < 0.01), fibrinogen and high-sensitivity C-reactive protein and by an increased intima-media thickness. Combined end-point occurred twice as frequently in the 4th quartile of serum cystatin C as compared with the 1st quartile (10.8 vs. 20.3%; p = 0.11). In an univariate analysis, but not in a multivariate model, cystatin C concentration predicted the combined end-point (Exp(B) = 1.096; p < 0.05). Conclusion: In hypertensive patients with CAD, serum cystatin C level was independently associated with the extent of CAD, homocysteine plasma level and traditional vascular risk factors. However, serum cystatin C concentration did not independently predict the combined end-point.

Left aberrant subclavian artery. Systematic study in adult patients

BACKGROUND Left aberrant subclavian artery (LASA), is a type of right aortic arch (RAA) branching, which takes-off distally to the right subclavian artery and usually crosses behind the esophagus to the left upper limb. Taking into account the rarity of RAA, LASA is much more rarely seen than the right aberrant subclavian artery (RASA) originating from the left aortic arch. However, RAA may be associated with much more frequent presence of LASA, than left aortic arch with RASA. Anatomical LASA characteristics were not described up to date. METHODS Individual patient records filed in the electronic database from a single high-volume tertiary cardiac center were retrospectively screened for the presence of RAA in the consecutive patients who underwent chest computed tomography from 2008 to 2016. RESULTS 14 patients with LASA were identified. Only 3 were free of coexisting intra- or extra-cardiac anomalies. The most common defect was tetralogy of Fallot (3 patients). One patient had five congenital defects. Kommerells diverticulum (KD) was present in 9 patients. In all patients the LASA course was retrotracheal and retroesophageal. In all but one patients esophageal modelling or compression by KD or LASA was present. CONCLUSIONS Knowledge of Kommerells diverticulum presence and morphology as well as the LASA course during preinterventional work-up of patients with congenital heart defects is critical, since it may have surgical implications during corrective procedures.

Early stent thrombosis. Aetiology, treatment, and prognosis.

Stent thrombosis (ST) is an uncommon but life-threatening complication after percutaneous coronary intervention (PCI), frequently manifesting as acute coronary syndrome (ACS) or even cardiac death. According to the academic research consortium (ARC), the definition includes definite, probable, or possible ST and is described in detail elsewhere [1]. Traditional classification categorises this complication into early (including acute and subacute ST, within 24 h and from 24 h to 30 days, respectively), late (from 30 days to 1 year), and very late (after 1 year). However, this classification does not include intraprocedural coronary thrombosis, which occurs in nearly 1% of patients [2] and is more common in the setting of ACS [3]. The majority of these events seem to occur within the first month after PCI. Among 21,009 patients treated with bare metal stents or drug eluting stents (DES) from the Dutch Stent Thrombosis Registry, 437 patients experienced ST and only 27% occurred late or very late [4]. Similar results were observed with bioresorbable vessel scaffolding (BVS) within large multicentre GOUST-EU registry (1189 patients included), where ST mostly clustered within 30 days [5]. A shift toward later ST occurrence was observed within the Japanese ST RESTART registry. This included patients treated with sirolimus eluting stents and comprised 611 patients with definite ST. Among them 47% occurred after 1 year [6]. The higher rate of late and very late ST in the Japanese registry may be associated with prolonged healing of the vessel after implantation of DES with potent antiproliferative sirolimus drug. Finally, a completely different pattern of ST timing was observed within the impressive number of 401,662 ACS patients from the CathPCI registry [7]. Among them, definite ST events were identified in 7315. Very late ST constituted as much as 61%, and only 19% of patients presented as early ST. The broad spectrum of risk factor categories is related to the patient (incl. clinical presentation), lesion, stent, and antiplatelet therapy (Table I). Among them, premature cessation of dual antiplatelet therapy (DAPT) seems to be the strongest single risk factor for ST. However, this seems only partially true for early ST, as the majority of patients experiencing ST within the first month remain on DAPT (88% in the Dutch ST Registry) [4]. Furthermore , as shown in the ST-elevation myocardial infarc-tion (STEMI) patient population from the HORIZONS-AMI study, there are differences between ST risk factors for acute, subacute, late, and very late ST …

Is there still a place for thrombectomy

Malignancy is known to be a prothrombotic condition, and some antitumor drugs may amplify the hypercoagulable tendency. We present a female patient with cancer, who developed acute coronary syndrome (ACS) due to occlusive intracoronary thrombus without underlying atherosclerosis. A 59-year-old woman with metastatic breast cancer diagnosed 2 years ago, paraneoplastic syndrome and steroid diabetes was admitted to our institution due to chest discomfort. The patient was previously treated with chemotherapy (trastuzumab and methylprednisolone). The last course was administered 4 months ago. The antithrombotic treatment with enoxaparin had been discontinued 3 weeks before, when an intensive rehabilitation program for cerebellar syndrome was initiated. Based on ST-segment depression in V4–V6 leads in ECG and elevated troponin T up to 2923 ng/ml (UNL < 14), non-ST segment elevation myocardial infarction (NSTEMI) was diagnosed. Coronary angiography did not show any vessel wall irregularities. However, occlusive thrombus in the distal segment of the right coronary artery (RCA) was visualized, with distal TIMI 1 flow (Figures 1 A, ​,B).B). 5000 IU of unfractionated heparin was administered, manual thrombectomy was performed (Figure 1 C) and the TIMI 3 flow was restored (Figure 1 D). After successful thrombus evacuation there was no RCA stenosis on angiography. Thus, neither balloon angioplasty nor stenting was attempted. Echocardiography revealed akinesis of the inferior wall, modestly impaired left ventricular systolic function with ejection fraction of 50% and moderate mitral regurgitation secondary to perforation of the posterior mitral leaflet (probably old), which was decided to be left for conservative treatment. Antithrombotic treatment with 75 mg of clopidogrel and 1 mg/kg o.d. of enoxaparin was prescribed indefinitely. Figure 1 A – Angiography of the right coronary artery with distal filling defect (TIMI 1), strongly suggesting intracoronary thrombi. B – Magnification of the distal segment. C – Manual thrombectomy. D – Restored contrast flow (TIMI ... Breast cancer may itself induce a hypercoagulatory state, which can subsequently lead to thrombus formation within the venous system, pulmonary circulation, and more rarely within different arteries. Antithrombotic prophylaxis with low-molecular-weight heparin (LMWH) is recommended, and its withdrawal for any reason may exacerbate the hypercoagulable tendency. The role of thrombectomy as an adjunctive tool for primary percutaneous coronary intervention after ambivalent results of the four main randomized trials [see insightful comments of Musialek [1] on the limitations of these studies] remains uncertain. Surprisingly, neither thrombus burden nor the coronary flow before interventional treatment had any significant impact on the outcome in the TASTE trial [2]. However, the vast majority of the patients included in these trials had underlying atherosclerosis, in contrast to our patient. Secondly, an intact artery after successful thrombectomy does not need balloon angioplasty or stent implantation, unless relevant intraluminal abnormality is seen. As suggested by Souteyrand et al., deferred two-step treatment of ACS with optical coherence tomography (OCT) guidance may lead to stenting abstention in more than 30% of cases after large thrombus removal with thrombectomy [3]. Thrombus regression under optimal pharmacotherapy has also been confirmed by other OCT studies [4]. Stenting by itself may lead to thrombosis. Although the causal relation between malignancy and stent thrombosis is not statistically proven, several reports of such a complication have been published [5]. Furthermore, even in the era of drug-eluting stents, possible restenosis should be taken into account. Finally, stent implantation imposes a temporary regimen of double antiplatelet therapy. Combination of such pharmacotherapy with LMWH may not be the optimal option, as it increases the bleeding risk. In conclusion, recent ESC guidelines have downgraded the thrombectomy recommendations for STEMI patients to class IIb (or class IIa for stent thrombosis). However, in selected NSTEMI cases this therapy must not be forgotten, and not only as an adjunctive therapy, but even as a sole interventional tool.

Quadrifurcation of the left main coronary artery and acute coronary syndrome.

Percutaneous treatment of the left main coronary artery (LMCA) bifurcation for acute coronary syndrome (ACS) is complex and associated with poorer results as compared to simple lesions. When additional branches take off from the LMCA, percutaneous coronary intervention (PCI) may be challenging. We present two patients with ACS, in whom the culprit lesions were located at the LMCA quadrifurcation. Additionally, we propose modified Medina classification adopted for quadrifurcation lesions. Patient 1: A 65-year-old male patient was admitted due to recurrent chest pain for one week. Electrocardiogram showed ST segment depression in precordial leads. Maximal troponin T rise was 3172 ng/L (UNL < 14). Urgent angiography revealed LMCA quadrifurcation. Eccentric stenosis involved distal LMCA and ostia of the left circumflex coronary (LCx) artery and two intermedial branches (Fig. 1). TIMI 3 flow was preserved. The next day the patient underwent coronary artery by-pass grafting. Patient 2: An 82-year-old male patient with a history of chronic left bundle branch block and ST elevation ACS 12 years ago, treated with primary PCI of the left anterior descending coronary artery (LAD) was admitted due to recurrent chest pain for several hours. Troponin T rise on admission was 1866 ng/L. Angiography revealed LMCA quadrifurcation with critical stenosis in LCx ostium with TIMI 2 flow (Fig. 2). After predilatation of the LCx ostium up to 40 atm., a 2.5 × 12 mm everolimus eluting stent was implanted at 20 atm. Four branches originating from the LMCA are casuistic. Atherosclerotic involvement of the LMCA quadrifurcation makes PCI challenging, although not impossible. Only single reports of PCI for LMCA quadrifurcation are available. Surgical treatment seems to be the gold standard for such lesion location in stable patients. However, ACS may force the operator towards PCI, if the lesion involvement is technically favourable (as in the second patient). Next, classification of the LMCA quadrifurcation may aid the treatment strategy. As adopted from the Medina classification for bifurcation lesions, the quadrifurcation lesions may also be classified in similar way, giving a binary value (0 or 1) according to whether each of the consecutive quadrifurcation segments is compromised or not. The first digit corresponds to the LMCA, the second digit to the LAD, the third and fourth digits to the intermedial branches, and the last digit to LCx (Fig. 3). Theoretically, 32 anatomical scenarios of LMCA quadrifurcation involvement are possible. Finally, such modification of Medina classification may also serve for LMCA trifurcation or pentafurcation assessment (Fig. 4). Figure 1. A–D. Significant stenosis in the left main coronary artery quadrifurcation

Rescue extracorporeal membrane oxygenation for refractory cardiogenic shock

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used for bridge-to-recovery, bridge-to-decision or bridge to ventricular assist device (VAD) implantation or heart transplantation in patients with cardiogenic shock (CS). We report a case of iatrogenic left main coronary artery (LMCA) dissection and secondary cardiogenic shock in which mechanical cardiopulmonary support with portable ECMO was used to rescue the patient after urgent surgical revascularization. Extracorporeal membrane oxygenation has the potential to improve tissue perfusion without the adverse consequences of medical therapies, consisting primarily of inotropic agents and vasopressors, such as increased myocardial oxygen demand and ischemia, arrhythmogenicity and reduction of tissue microcirculation, creating the opportunity to reduce the high mortality rates currently associated with conventionally managed patients in CS.