S. Tanveer Rab

Coronary angiographic scoring systems: an evaluation of their equivalence and validity.

BACKGROUND Multiple scoring systems have been devised to quantify angiographic coronary artery disease (CAD) burden, but it is unclear how these scores relate to each other and which scores are most accurate. The aim of this study was to compare coronary angiographic scoring systems (1) with each other and (2) with intravascular ultrasound (IVUS)-derived plaque burden in a population undergoing angiographic evaluation for CAD. METHODS Coronary angiographic data from 3600 patients were scored using 10 commonly used angiographic scoring systems and interscore correlations were calculated. In a subset of 50 patients, plaque burden and plaque area in the left anterior descending coronary artery were quantified using IVUS and correlated with angiographic scores. RESULTS All angiographic scores correlated with each other (range for Spearman coefficient [ρ] 0.79-0.98, P < .0001); the 2 most widely used scores, Gensini and CASS-70, had a ρ = 0.90 (P < .0001). All scores correlated significantly with average plaque burden and plaque area by IVUS (range ρ 0.56-0.78, P < .0001 and 0.43-0.62, P < .01, respectively). The CASS-50 score had the strongest correlation (ρ 0.78 and 0.62, P < .0001) and the Duke Jeopardy score the weakest correlation (ρ 0.56 and 0.43, P < .01) with plaque burden and area, respectively. CONCLUSIONS Angiographic scoring systems are strongly correlated with each other and with atherosclerotic plaque burden. Scoring systems therefore appear to be a valid estimate of CAD plaque burden.

Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass Grafting for the Treatment of Multivessel Coronary Artery Disease

BACKGROUND Hybrid coronary revascularization (HCR) combines a minimally invasive (3-cm anterolateral thoracotomy), sternal-sparing, off-pump left internal mammary artery-left anterior descending (LIMA-LAD) coronary artery anastomosis with percutaneous coronary intervention (PCI) to non-LAD coronary arteries. We compared outcomes of HCR versus traditional off-pump coronary artery bypass grafting (OPCAB) for the treatment of multivessel coronary artery disease (CAD). METHODS Between October 8, 2003 and April 23, 2010, 147 patients with multivessel coronary disease were treated with HCR at a US academic center. These were matched 4:1 to 588 contemporaneous patients treated with multivessel OPCAB by sternotomy using an optimal matching algorithm with 8 preoperative variables: age, gender, ejection fraction, presence of diabetes, myocardial infarction (MI), number of diseased vessels, left main coronary artery disease, and Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) score. In-hospital major adverse events (MACCE) and the need for repeated revascularization during follow-up were compared between groups. All-cause mortality was determined using the Social Security Death Index (SSDI). RESULTS Matching produced groups with similar coronary anatomy and statistically similar preoperative risk factors. The incidence of MACCE was similar between groups (3/147 HCR versus 12/588 OPCAB). During a median 3.2 years of follow up, the need for repeated revascularization was higher for HCR than for OPCAB (18/147 [12.2%] versus 22/588 [3.7%]; p < 0.001). The incidence of blood transfusion was higher for the OPCAB group. Estimated 5-year survival was similar between groups (OPCAB, 84.3% versus HCR, 86.8%; p = 0.61). CONCLUSIONS Hybrid coronary revascularization is a minimally invasive treatment for multivessel CAD. Although repeated revascularization was greater with HCR, both in-hospital and midterm outcomes were comparable with those of traditional OPCAB. Further investigation into the comparative effectiveness of this alternative strategy is warranted.

Coronary aneurysms after stent placement: a suggestion of altered vessel wall healing in the presence of anti-inflammatory agents.

Coronary aneurysms are rare after conventional angioplasty and have not been reported after coronary stenting. Coronary artery stent sites were examined by follow-up angiography at a median of 4 months in 29 patients who received the Cook stent (Gianturco-Roubin) for acute coronary closure. Nineteen patients were treated with glucocorticoids administered intravenously or orally, or both, with or without colchicine and results were compared with those in 10 patients who were treated with neither agent. Standard therapy for all patients included routine administration of aspirin and heparin before and warfarin sodium (Coumadin) and aspirin after stent placement. Most patients also received dipyridamole and lovastatin during the follow-up period. Compliance with medications was confirmed by telephone conversation with each patient. Six (32%) of the 19 stented arteries showed evidence of coronary artery aneurysm, defined as expansion of the lumen outside the margins of the stent. None of the patients in the control group (who did not receive steroids or colchicine) developed aneurysm. This pattern of altered vascular healing in stented coronary segments appears to be due to the addition of multiple anti-inflammatory drugs rather than to stent presence alone. This observation demonstrates the possibility of medical impairment of normal vascular remodeling after acute injury and stent placement, which may be of benefit in designing future trials on restenosis.

Association of a Genetic Risk Score With Prevalent and Incident Myocardial Infarction in Subjects Undergoing Coronary Angiography

Background—Genome-wide association studies have identified multiple variants associating with coronary artery disease (CAD) and myocardial infarction (MI). Whether a combined genetic risk score (GRS) is associated with prevalent and incident MI in high-risk subjects remains to be established. Methods and Results—In subjects undergoing cardiac catheterization (n=2597), we identified cases with a history of MI onset at age <70 years and controls ≥70 years without prior MI and followed them for incident MI and death. Genotyping was performed for 11 established CAD/MI variants, and a GRS was calculated based on average number of risk alleles carried at each locus weighted by effect size. Replication of association findings was sought in an independent angiographic cohort (n=2702). The GRS was significantly associated with prevalent MI, occurring before age 70, compared with older controls (≥70 years of age) with no history of MI (P<0.001). This association was successfully replicated in a second cohort, yielding a pooled P value of <0.001. The GRS modestly improved the area-under–the–curve statistic in models of prevalent MI with traditional risk factors; however, the association was not statistically significant when elderly controls without MI but with s\ angiographic CAD were examined (pooled P=0.11). Finally, during a median 2.5-year follow-up, only a nonsignificant trend was noted between the GRS and incident events, which was also not significant in the replication cohort. Conclusions—A GRS of 11 CAD/MI variants is associated with prevalent MI but not near-term incident adverse events in 2 independent angiographic cohorts. These findings have implications for understanding the clinical use of genetic risk scores for secondary as opposed to primary risk prediction.

Hybrid Coronary Revascularization Versus Off-Pump Coronary Artery Bypass for the Treatment of Left Main Coronary Stenosis

BACKGROUND Coronary artery bypass grafting is standard of care for left main (LM) coronary artery stenosis. Hybrid coronary revascularization (HCR) is an alternative therapy, combining a minimally invasive, sternal-sparing, off-pump left internal mammary artery to left anterior descending coronary anastomosis with percutaneous coronary stent placement through the LM into the circumflex coronary artery. METHODS From October 8, 2003, to April 23, 2010, 27 patients with LM coronary disease had HCR at a US academic center. These patients were matched 3:1 to 81 contemporaneous patients treated with off-pump coronary artery bypass grafting through a sternotomy by an optimal matching algorithm using seven preoperative variables. In-hospital major adverse cardiac and cerebrovascular events and repeat revascularization during the study period were compared between groups. All-cause mortality was compared using the National Social Security Death Index. RESULTS Patency of the left internal mammary artery to left anterior descending coronary anastomosis was confirmed in all cases before LM stenting, which was successful in all patients. There was no perioperative death, stroke, or myocardial infarction among the HCR patients. Major adverse cardiac and cerebrovascular events were similar between groups. During a median of 3.2 years of follow-up, patients treated with HCR had a higher incidence of repeat revascularization than those treated with off-pump coronary artery bypass grafting (2 of 27, 7.4% versus 1 of 81, 1.2%; p = 0.09), but this was not statistically significant. The incidence of blood transfusion was higher with off-pump coronary artery bypass grafting (50 of 81, 61.7% versus 9 of 27 33.3%; p = 0.01). CONCLUSIONS Hybrid revascularization is a safe, feasible, and minimally invasive alternative to off-pump coronary artery bypass grafting for the treatment of LM coronary disease. Further investigation into the comparative effectiveness of this alternative strategy is warranted to identify optimal candidates for HCR.

Clinical and Angiographic Results After Hybrid Coronary Revascularization

BACKGROUND With hybrid coronary revascularization (HCR), minimally invasive left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) grafting is combined with percutaneous coronary intervention (PCI) of non-LAD vessels. The purpose of this study was to examine the short-term clinical and angiographic results in one of the largest HCR series to date. METHODS From 2003 to 2012, 300 consecutive patients (aged 64±12 years, female 31.7%, predicted risk of mortality 1.6%±2.1%) underwent HCR on an intent-to-treat basis at a single institution. After robotic or thoracoscopic LIMA harvest, off-pump LIMA to LAD grafting was performed through a 3- to 4-cm sternal-sparing, non-rib-spreading thoracotomy. PCI was utilized to treat non-LAD lesions either before, after, or concomitant with the surgical procedure. RESULTS Of the 300 patients undergoing HCR on an intent-to-treat basis, HCR was performed with surgery first in 192 patients (64.0%), PCI first in 56 (18.7%), and as a concomitant procedure in 21 (7.0%). Of the 31 patients (10.1%) who did not undergo HCR, 24 patients (8.0%) did not have PCI and thus were incompletely revascularized. For all patients, 30-day mortality, stroke, and nonfatal myocardial infarction occurred in 4 (1.3%), 3 (1.0%), and 4 (1.3%), respectively. Angiographic LIMA evaluation was performed in 248 patients and revealed a FitzGibbon A LIMA patency rate of 97.6% (242 of 248 patients). Repeat revascularization was required in 13 of 300 patients (4.3%). CONCLUSIONS Hybrid coronary revascularization represents an alternative approach for patients with multivessel coronary disease with excellent short-term outcomes. It provides a minimally invasive alternative to traditional coronary artery bypass graft surgery and may prove more durable than multivessel PCI.

Hybrid coronary revascularization for the treatment of left main coronary stenosis: A feasibility study

Objective: To determine the feasibility of a hybrid coronary revascularization (HCR) approach for the treatment of left main (LM) coronary artery stenosis. Background: The recommended therapy for significant LM stenosis is coronary artery bypass grafting (CABG). Percutaneous coronary intervention (PCI) of unprotected LM lesions is reserved for patients at high risk for complications with CABG. HCR in LM disease has not been studied. Methods: Twenty‐two consecutive patients with LM stenosis >70% underwent staged HCR. Following a robotic or thoracoscopic‐assisted minimally invasive left internal mammary artery (LIMA) to left anterior descending artery (LAD) coronary bypass, PCI of the LM, and non‐LAD targets was performed after angiographic confirmation of LIMA patency. Intravascular ultrasound confirmed optimal stent deployment. Thirty‐day adverse outcomes and long term follow up was obtained. Results: In the 22 patients with LM lesions, 6 were ostial, 5 mid, and 11 distal. LIMA patency was FitzGibbon A in all cases. LM stenting was successful in all patients with drug‐eluting stents (DES) placed in 21 of 22 cases. Three patients underwent stent implantation in the right coronary artery. There were no 30‐day major adverse cardiac or cerebrovascular events. At a mean of 38.8 ± 22 months postprocedure, 21 patients were alive without reintervention; one death occurred at 454 days. Conclusions: HCR for LM coronary disease is a feasible alternative to CABG and unprotected LM PCI. This approach combines the long‐term durability of a LIMA‐LAD bypass with the less invasive option of PCI in non‐LAD targets with DES.

Computational Fluid Dynamics Simulations of Hemodynamics in Plaque Erosion

We investigated whether local hemodynamics were associated with sites of plaque erosion and hypothesized that patients with plaque erosion have locally elevated WSS magnitude in regions where erosion has occurred. We generated 3D, patient-specific models of coronary arteries from biplane angiographic images in 3 human patients with plaque erosion diagnosed by optical coherence tomography. Using computational fluid dynamics, we simulated pulsatile blood flow and calculated both wall shear stress (WSS) and oscillatory shear index (OSI). We also investigated anatomic features of plaque erosion sites by examining branching and local curvature in X-ray angiograms of barium-perfused autopsy hearts. Neither high nor low magnitudes of mean WSS were associated with sites of plaque erosion. OSI and local curvature were also not associated with erosion. Anatomically, 8 of 13 hearts had a nearby bifurcation upstream of the site of plaque erosion. This study provides preliminary evidence that neither hemodynamics nor anatomy are predictors of plaque erosion, based upon a very unique dataset. Our sample sizes are small, but this dataset suggests that high magnitudes of WSS, one potential mechanism for inducing plaque erosion, are not necessary for erosion to occur.

Catastrophic Systemic Embolization from a Left Atrial Myxoma

We report the fatal course of a left atrial myxoma: its systemic embolization to the coronary, cerebral, renal, and peripheral vascular beds in a 39-year-old woman resulted in rapid clinical deterioration, multiorgan failure, and death. Among reported cases of left atrial myxoma, this degree of embolic burden is exceedingly rare. In addition to reporting the patients case, we discuss the presentation and diagnosis of possible intracardiac sources of systemic emboli.

Percutaneous saphenous vein graft intervention with sequential embolic protection devices: complementing lesion anatomy with embolic protection device.

Saphenous vein graft (SVG) percutaneous coronary intervention (PCI) carries unique technical challenges requiring the utilization of embolic protection devices (EPDs) to reduce the adverse events associated with distal embolization. Distal embolization is a common and almost ubiquitous consequence of SVG PCI due to the soft and friable nature of the SVG lesions. We describe a case of revascularizing a SVG with tandem stenoses employing the use of two different EPDs that complemented their respective lesions location within the SVG.