Surgical aspects of no-touch saphenous vein graft harvesting in cabg: clinical and angiographic follow-up at 3 months

Abstract With more than 800,000 coronary artery bypass grafting (CABG) operations annually worldwide and the saphenous vein being the most common conduit used, there is no question that improving saphenous vein graft patency is one of the most important tasks in CABG. This video describes the no-touch harvesting procedure of the saphenous vein on an 80-year old man with hypertension, hyperlipidemia and a previous myocardial infarction with percutaneous coronary intervention to the right coronary artery. He was complaining of exertional chest pain and was diagnosed with stable angina pectoris. The coronary angiography showed advanced three vessel disease with significant stenoses in the left anterior descending (LAD) artery, two marginal arteries (MAs) and the posterior descending artery (PDA), in addition to an occluded diagonal artery (DA). The patient received a triple sequential no-touch vein graft to the PDA and two MAs together with a double sequential no-touch vein graft to the DA and LAD. A vein graft was used to bypass the LAD due to the age of the patient and the low degree of stenosis in the LAD. The no-touch harvesting technique is described in detail in the film with complete narration. A follow-up of this patient was performed at three months both clinically and with a computed tomography angiography (CTA). No angina pectoris symptoms were reported by the patient and the wounds in the chest and lower limb were completely healed. The CTA showed patent no-touch saphenous vein grafts to all the distal anastomoses.

Does moderate coronary stenosis affect the fate of the left internal thoracic artery graft?

Abstract Introduction: In this study we try to observe the fate of the left internal thoracic artery grafts that were bypassed to left anterior descending artery with moderate stenosis identified with fractional flow reserve (FFR) technique. Doppler ultrasonography was chosen as a noninvasive screening method. Methods: A total of 30 patients who underwent coronary artery bypass grafting depending on results of the fractional flow reserve between January 2007 and January 2012, were subjected to transthoracic color Doppler ultrasonographic evaluation irrespective of the presence of symptoms, and the presence of a systolic-diastolic flow pattern was investigated using the supraclavicular approach. Results: The left internal thoracic artery graft was found to be functional in 63.3% of patients within a mean period of 35.1±19.7 months between coronary bypass and color Doppler ultrasonography. This period was found to be 29.4±19.6 months in the functional graft group, and 44.7±16.6 months in the dysfunctional graft group (P=0.046). Preoperative complaints of angina were reported to fall from 88.9% to 16.7% in the functional graft group, when compared to the postoperative period (P<0.001), but fell from 90.9% to 36.4% in the dysfunctional graft group (P=0.034). Conclusion: Functional left internal thoracic artery graft rates of the study population were found to be lower than the studies reported in the literature.

Factors Associated With Coronary Artery Disease Progression Assessed By Serial Coronary Computed Tomography Angiography / Fatores Associados com Progressão da Doença Arterial Coronariana Avaliada por Angiografia Coronariana por Tomografia Computadorizada Seriada

Abstract Background: Coronary computed tomography angiography (CCTA) allows for noninvasive coronary artery disease (CAD) phenotyping. Factors related to CAD progression are epidemiologically valuable. Objective: To identify factors associated with CAD progression in patients undergoing sequential CCTA testing. Methods: We retrospectively analyzed 384 consecutive patients who had at least two CCTA studies between December 2005 and March 2013. Due to limitations in the quantification of CAD progression, we excluded patients who had undergone surgical revascularization previously or percutaneous coronary intervention (PCI) between studies. CAD progression was defined as any increase in the adapted segment stenosis score (calculated using the number of diseased segments and stenosis severity) in all coronary segments without stent (in-stent restenosis was excluded from the analysis). Stepwise logistic regression was used to assess variables associated with CAD progression. Results: From a final population of 234 patients, a total of 117 (50%) had CAD progression. In a model accounting for major CAD risk factors and other baseline characteristics, only age (odds ratio [OR] 1.04, 95% confidence interval [95%CI] 1.01-1.07), interstudy interval (OR 1.03, 95%CI 1.01-1.04), and past PCI (OR 3.66, 95%CI 1.77-7.55) showed an independent relationship with CAD progression. Conclusions: A history of PCI with stent placement was independently associated with a 3.7-fold increase in the odds of CAD progression, excluding in-stent restenosis. Age and interstudy interval were also independent predictors of progression.

Resumo Fundamento: Angiografia coronariana por tomografia computadorizada (ACTC) permite fenotipagem não invasiva da doença arterial coronariana (DAC). Fatores relacionados à progressão da DAC têm valor epidemiológico. Objetivo: Identificar os fatores associados com a progressão da DAC em pacientes submetidos à avaliação sequencial por ACTC. Métodos: Nós analisamos retrospectivamente 384 pacientes consecutivos que apresentavam pelo menos duas avaliações por ACTC entre dezembro de 2005 e março de 2013. Devido às limitações na quantificação da progressão da DAC, os pacientes que haviam sido submetidos previamente à revascularização cirúrgica ou intervenção coronariana percutânea (ICP) entre as avaliações foram excluídos. A progressão da DAC foi definida como qualquer aumento no escore adaptado de estenose segmentar (calculado com utilização do número de segmentos afetados e gravidade da estenose) em todos os segmentos coronarianos sem stent (restenose intra-stent foi excluída da análise). Regressão logística stepwise foi utilizada para avaliar as variáveis associadas com a progressão da DAC. Resultados: De uma população final de 234 pacientes, um total de 117 (50%) pacientes apresentaram progressão da DAC. Em um modelo considerando os principais fatores de risco para DAC e outras características basais, apenas a idade (odds ratio [OR] 1,04, intervalo de confiança de 95% [IC95%] 1,01-1,07), intervalo entre avaliações (OR 1,03, IC95% 1,01-1,04) e ICP prévia (OR 3,66, IC95% 1,77-7,55) mostraram uma relação independente com a progressão da DAC. Conclusões: Uma história de ICP com implante de stent esteve independentemente associada a um aumento de 3,7 vezes na chance de progressão da DAC, excluindo a restenose intra-stent. Idade e intervalo entre avaliações também foram preditores independentes de progressão.

Intervencionismo coronario complejo con solapamiento de dispositivos biorreabsorbibles. Reporte de caso y revisión de nuevas perspectivas en el uso de dispositivos biorreabsorbibles guiado por tomografía de coherencia óptica / Complex coronary intervention with overlapping of bioresorbable scaffolds. Case report and new insights review in the use of bioresorbable vascular scaffolds guided by optical coherence tomography

Resumen La historia del intervencionismo percutáneo coronario ha tenido en los últimos años una evolución notable. Actualmente en México están disponibles los dispositivos vasculares biorreabsorbibles, los cuales tienen indicaciones precisas, y ofrecen una nueva opción en el intervencionismo coronario. En este trabajo presentamos el caso, y revisamos la evidencia publicada, para una nueva opción de intervención con estos dispositivos, un caso complejo con solapamiento de 3 dispositivos vasculares biorreabsorbibles guiado mediante tomografía de coherencia óptica.

Abstract In recent years, the history of percutaneous coronary intervention has had a remarkable evolution. Currently, in México are available the bioresorbable vascular scaffolds which have a very precise indications, and offer a new option in coronary intervention. We present the case and review of the published evidence, a new option for intervention with these devices, a complex case with 3 overlapping bioresorbable vascular scaffolds guided by optical coherence tomography.

Comparison of Full Lesion Coverage versus Spot Drug-Eluting Stent Implantation for Coronary Artery Stenoses

PURPOSE: The aim of this study was to evaluate and compare the long-term clinical outcomes of the spot drug-eluting stent (DES) implantation strategy, which is used to minimize implanted stent length and the number of stents, versus full lesion coverage for treatment of coronary artery stenoses. MATERIALS AND METHODS: We evaluated 1-year clinical outcomes of 1619 patients with stent implantation for a single coronary lesion. They were divided into two groups: those treated by full lesion coverage (n=1200) and those treated with the spot stenting strategy (n=419). The combined occurrence of 1-year target vessel failure (TVF), including cardiac death, target-vessel related myocardial infarction, or ischemia-driven target-vessel revascularization was evaluated. RESULTS: The spot DES implantation group had a shorter stent length (23.14+/-9.70 mm vs. 25.44+/-13.24 mm, respectively; p<0.001) and a fewer number of stents (1.09+/-0.30 vs. 1.16+/-0.41, respectively; p<0.001), even though the average lesion length was similar to the full lesion coverage group (21.36+/-10.30 mm vs. 20.58+/-10.97 mm, respectively; p=0.206). Spot DES implantation was superior to full DES coverage with respect to 1-year TVF (1.4% vs. 3.3%, p=0.044). Cox proportional hazard model analysis showed that the risk for 1-year TVF was almost 60% lower among patients who received spot DESs compared to those who received full DES coverage after adjustment for other risk factors (HR=0.40, 95% confidence interval=0.17-0.98; p=0.046). CONCLUSION: Minimizing stent length and the number of stents with overlapping by spot DES implantation may result in reduced rates of 1-year TVF, compared with full DES coverage.

Clinical outcomes of transradial unprotected left main coronary artery stenting in the elderly

To evaluate the long-term results in elderly patients undergoing percutaneous coronary intervention [PCI] with drug-eluting stents for unprotected left main coronary artery disease by transradial approach. This study took place in Qinhuangdao First Hospital, Hebei Medical University, Hebei, China between October 2006 and December 2009. Seventy-nine elderly patients with unprotected left main coronary artery [ULMCA] stenosis, aged >/= 70 years, that underwent drug-eluting stent were evaluated. The occurrence of major adverse cardiac events [MACE] [death, non-fatal myocardial infarction, stroke or target lesion revascularizations] was recorded after 3 years of follow-up. After 3 years follow-up, the MACE free survival rate was 72.2%. Cardiac deaths occured in 7.6% of patients. Myocardial infarction occurred in 5.1%, and target lesion revascularization in 13.9% of patients. Age and left main distal bifurcation were favorable predictors of MACE. Percutaneous coronary intervention can be performed with good angiographic and clinical results through a transradial approach in the elderly. The long term survival suggests that PCI in ULMCA patients >/= 70 years is safe and efficacious

Tomografía de coherencia óptica: Bases y aplicaciones de una nueva técnica de imagen intravascular

La angiografía es la técnica de referencia para el diagnóstico de la enfermedad arte rial coronaria. Sin embargo, la mayoría de los síndromes coronarios agudos involucran lesiones angiográficamente no significativas. Es también la técnica de elección para guiar la implantación de prótesis endovasculares y su seguimiento. La tomografía de coherencia óptica es una técnica de imagen interferométrica que penetra en los tejidos alrededor de 2-3 mm y ofrece una alta resolución axial. Es capaz de distinguir diferentes tipos de tejido, como fibroso, lipídico, necrótico o calcificado, reconoce características de las placas de ateroma que se han asociado con progresión rápida de la lesión y eventos clínicos adversos, como la delgada capa de fibroateroma, el espesor de la capa fibrosa, la infiltración de macrófagos y la formación de trombos. En la actualidad, existe un creciente interés en el valor de la tomografía de coherencia óptica en el área de intervención coronaria, donde la técnica ofrece ventajas significativas sobre las técnicas intravasculares de diagnóstico convencionales, como la ecografía intravascular. Su alta resolución permite reconocer las complicaciones periprocedimiento, como microdisección, malaposición e hiperplasia neointimal, haciendo de esta herramienta una de las técnicas más prometedoras en el diagnóstico intravascular.

Coronary angiography is the reference technique for the diagnosis of coronary disease. However, the majority of acute coronary syndromes involve angiographically non- significant lesions. It is also the technique of choice for guiding the implantation of endovascular prostheses and their later monitoring. Optical coherence tomography is an interferometric imaging technique that penetrates tissue approximately 2-3 mm and provides axial and lateral resolution. It is able to distinguish different tissue types, such as fibrous, lipid-rich, necrotic, or calcified tissue. Optical coherence tomography is able to recognize a variety of features of athe- rosclerotic plaques that have been associated with rapid lesion progression and clinical events, such as thin cap fibroatheroma, fibrous cap thickness, dense macrophage infiltration, and thrombus formation. Currently, there is growing interest in the value of optical coherence tomography in the area of coronary intervention, where the technique offers significant advantages over more widespread intravascular diagnostic techniques such as intravascular ultrasound. Its higher resolution permits to recognize periprocedural complications, such as microdissection of the coronary artery, stent malapposition, and neointimal hiperplasia, making this tool one of the most promising techniques in the intravascular diagnosis.

Comparing Two-Stent Strategies for Bifurcation Coronary Lesions: Which Vessel Should be Stented First, the Main Vessel or the Side Branch?

This study compared two-stent strategies for treatment of bifurcation lesions by stenting order, 'main across side first (A-family)' vs 'side branch first (S-family). The study population was patients from 16 centers in Korea who underwent drug eluting stent implantation with two-stent strategy (A-family:109, S-family:140 patients). The endpoints were cardiac death, myocardial infarction (MI), stent thrombosis (ST), and target lesion revascularization (TLR) during 3 years. During 440.8 person-years (median 20.2 months), there was 1 cardiac death, 4 MIs (including 2 STs), and 12 TLRs. Cumulative incidence of cardiac death, MI and ST was lower in A-family (0% in A-family vs 4.9% in S-family, P = 0.045). However, TLR rates were not different between the two groups (7.1% vs 6.2%, P = 0.682). Final kissing inflation (FKI) was a predictor of the hard-endpoint (hazard ratio 0.061; 95% CI 0.007-0.547, P = 0.013), but was not a predictor of TLR. The incidence of hard-endpoint of S-family with FKI was comparable to A-family, whereas S-family without FKI showed the poorest prognosis (1.1% vs 15.9%, retrospectively; P = 0.011). In conclusion, 'A-family' seems preferable to 'S-family' if both approaches are feasible. When two-stent strategy is used, every effort should be made to perform FKI, especially in 'S-family'.

Congenital hypopituitarism: Monitoring after coronary artery bypass grafting.

Cardiovascular disease in patients with congenital hypopituitarism is not rare; however, there is a lack of reports referring to cardiac interventions in such patients. We present a 76-year-old man with complete pituitary hormone deficiency, who presented with recurrent events of unstable angina. He had a significant stenosis of the left anterior descending artery and he underwent off-pump coronary artery bypass. Our aim is to present the successful management of this patient with congenital hypopituitarism who underwent cardiac surgery and to review the relevant literature.

Effect of oral sirolimus therapy on inflammatory biomarkers following coronary stenting

We studied the effect of oral sirolimus, administered to prevent and treat in-stent restenosis (ISR), on the variation of serum levels of inflammatory markers following coronary stenting with bare metal stents. The mean age of the patients was 56 ± 13 years, 65 percent were males and all had clinically manifested ischemia. Serum levels of high sensitivity C-reactive protein (hs-CRP) concentration were determined by chemiluminescence and serum levels of all other biomarkers by ELISA. One group of patients at high risk for ISR received a loading oral dose of 15 mg sirolimus and 5 mg daily thereafter for 28 days after stenting (SIR-G). A control group (CONT-G) was submitted to stenting without sirolimus therapy. The increase in hs-CRP concentration was highest at 24 h after stenting in both groups. A significant difference between SIR-G and CONT-G was observed at 4 weeks (-1.50 ± 5.0 vs -0.19 ± 0.4, P = 0.008) and lost significance 1 month after sirolimus discontinuation (-1.73 ± 4.3 vs -0.01 ± 0.7, P = 0.0975). A continuous fall in MMP-9 concentration was observed in SIR-G, with the greatest reduction at 4 weeks (-352.9 ± 455 vs +395.2 ± 377, P = 0.0004), while a positive variation was noted 4 weeks after sirolimus discontinuation (227 ± 708 vs 406.2 ± 472.1, P = 0.0958). SIR-G exhibited a higher increase in P-selectin after sirolimus discontinuation at week 8 (46.1 ± 67.9 vs 5.8 ± 23.7, P = 0.0025). These findings suggest that the anti-restenotic actions of systemic sirolimus include anti-proliferative effects and modulation of the inflammatory response with inhibition of adhesion molecule expression.

Cirurgia de revascularização do miocárdio usando apenas tomografia computadorizada como angiograma pré-operatório / Cirugía de revascularización del miocardio usando sólo tomografía computada como angiograma preoperatorio / Coronary artery bypass using only computed tomography as pre-operative angiogram

A cirurgia de revascularização do miocárdio (CRM) é um procedimento bem estabelecido com indicações atuais precisas. O advento e a disseminação dessa técnica foram possíveis após a introdução do angiograma coronário. Embora muitos métodos de avaliação tenham evoluído nos últimos anos, nenhum conseguiu substituir o angiograma coronário invasivo como exame pré-operatório. A tomografia computadorizada (TC) emergiu como uma alternativa ao angiograma coronário invasivo. O presente relato descreve dois casos de CRM realizadas usando-se apenas a TC como técnica de avaliação anatômica das artérias coronárias pré-operatória.

Coronary artery bypass graft (CABG) is a well established procedure with current precise indications. The advent and spread of this technique was possible after the introduction of the coronary angiogram. Although many evaluation methods have been developed in the past years, to date, none have been able to replace the invasive coronary angiogram as a pre-operative exam. Computed tomography angiography (CTA) has emerged as an alternative to invasive coronary angiogram. In this report we describe two CABG cases that were performed using only this technique as a pre-operative anatomic coronary arteries evaluation.

La cirugía de revascularización del miocardio (CRM) es un procedimiento bien establecido con indicaciones actuales precisas. El advenimiento y la divulgación de esta técnica fueron posibles después de la introducción del angiograma coronario. Aunque muchos métodos de evaluación hayan evolucionados en los últimos años, ninguno ha conseguido sustituir al angiograma coronario invasivo como examen preoperatorio. La tomografía computada (TC) surgió como una alternativa al angiograma coronario invasivo. El presente informe describe dos casos de CRM realizadas usando sólo la TC como técnica de evaluación anatómica de las arterias coronarias preoperatoria.

Qual o erro da angiografia na definição de isquemia miocárdica durante intervenções coronarianas percutâneas? / What is the angiography error when defining myocardial ischemia during percutaneous coronary interventions?

FUNDAMENTO: A angiografia vem sendo utilizada como padrão de referência para definição de doença arterial coronariana (DAC), embora suas limitações sejam conhecidas. O valor da medida do fluxo fracionado de reserva do miocárdio (FFR) na avaliação da DAC está bem estabelecido. OBJETIVO: O objetivo deste estudo é avaliar a acurácia da angiografia em definir as lesões isquêmicas e sua correlação com o FFR. MÉTODOS: Duzentos e cinqüenta pacientes foram incluídos no estudo (471 vasos). Todas as estenoses > 50 por cento pela estimativa visual da angiografia (EVA) foram avaliadas medindo-se o FFR. Se o FFR <0,75 a lesão foi tratada, se o FFR >0,75 a lesão não foi tratada. As lesões foram divididas em moderadas (<70 por cento - 327) e graves (125) pela QCA. Foram determinados o coeficiente de correlação entre o grau de estenose ( por centoDE), o FFR e a acurácia da EVA em definir se uma lesão era ou não isquêmica. RESULTADOS: Foi possível obter o FFR em 96 por cento das lesões. por centoDE e FFR médios de 56±8 por cento e 0,74 e 76±6 por cento e 0,48 para as lesões moderadas e graves respectivamente. Notou-se pobre correlação entre o por centoDE e o FFR, especialmente nas lesões moderadas (Spearman rho = - 0.33, p<0,0001). A acurácia da EVA comparada com FFR foi de 57 por cento e 96 por cento nas lesões moderadas versus graves. CONCLUSÃO: A angiografia coronária não é adequada para avaliar a importância funcional das lesões coronarianas, sendo necessário associá-la a um método funcional capaz de fazê-lo, especialmente nas lesões moderadas.

BACKGROUND: The angiography has been used as a reference standard to define coronary artery disease (CAD), although its limitations are well-known. The significance of the myocardial fractional flow reserve (FFR) in the assessment of CAD is well established. OBJECTIVE: The aim of this study was to evaluate the accuracy of angiography when defining ischemic lesions and its correlation with FFR. METHODS: Two hundred and fifty consecutive patients (471 arteries) were included in this study. All stenoses > 50 percent at the angiography visual estimate (AVE) were assessed by FFR measurements. When FFR was < 0.75, stenting was performed; when FFR was > 0.75, no interventional treatment was carried out. Offline quantitative coronary angiography (QCA) was performed in all stenoses, which were divided in intermediate (< 70 percent - 327) and severe (125). The correlation coefficients between the diameter of the stenosis ( percentDS) and FFR and the accuracy of VA of the angiography when assessing ischemia were determined. RESULTS: FFR could be obtained in 452 lesions (96 percent). Mean percentDS and FFR were 56 ± 8 percent and 0.74 and 76 ± 6 percent and 0.48 for moderate and severe stenoses, respectively. Concordance between QCA and FFR was poor, especially in intermediate stenoses (Spearman's rho = - 0.33, p<0.0001). Visual assessment resulted in an accuracy of 57 percent and 96 percent in intermediate and severe lesions, respectively. CONCLUSION: Neither the visual assessment of an angiogram nor QCA can accurately predict the significance of most intermediate coronary stenoses, which emphasizes the importance of associating it to a functional evaluation of the coronary circulation, resulting in an adequate treatment of these stenoses.

Revascularização da descendente anterior proximal com stents revestidos por fármacos / Proximal left anterior descending coronary artery revascularization with drug-eluting stents

OBJETIVO: Avaliar o prognóstico clínico dos doentes coronários submetidos a revascularização percutânea com implantação de stents revestidos com fármacos na descendente anterior proximal. MÉTODOS: Cento e setenta doentes consecutivos, com idade média de 65 anos, 49 (29 por cento) mulheres, receberam implante de pelo menos um stent revestido com fármaco, no nosso centro. O número total de stents revestidos com fármaco implantados foi 189, dos quais 115 (61 por cento) de sirolimus (CYPHER®) e 74 (39 por cento) de paclitaxel (TAXUS®). Em 100 (60 por cento) dos casos, estava presente doença coronário multivaso. Em 61 (36 por cento) dos doentes tratou-se outro segmento coronário para além da descendente anterior proximal. Efetuou-se um seguimento clínico durante um tempo médio de 11 ± 5 meses e controle angiográfico entre os seis e os nove meses. Obteve-se um endpoint final composto por morte, infarto agudo do miocárdio e pela necessidade de reintervenção sobre a descendente anterior. Analisou-se secundariamente a ocorrência de reestenose, a necessidade de reintervenção sobre o segmento proximal da descendente anterior e a trombose de stent. RESULTADOS: O procedimento teve êxito angiográfico imediato em todos os doentes. Registraram-se duas mortes, dois infartos agudos do miocárdio, e duas reintervenções coronárias percutâneas por trombose de stent no período intra-hospitalar. Aos seis meses de seguimento, observou-se mais uma morte cardíaca e identificaram-se três infartos do miocárdio; houve necessidade de três novos procedimentos de revascularização. Até ao final do seguimento, verificaram-se mais três mortes, três infartos do miocárdio e oito revascularizações da descendente anterior, duas delas por cirurgia. A sobrevivência livre de eventos cardíacos adversos maior foi de 91 por cento. A mortalidade cardíaca foi de 3 por cento. A reestenose binária no segmento proximal da descendente anterior foi de 4,1 por cento. A sobrevivência livre...

OBJECTIVE: To assess the clinical prognosis of patients with coronary artery diseases undergoing percutaneous revascularization with drug-eluting stent implantation in the proximal left anterior descending coronary artery. METHODS: One hundred and seventy consecutive patients with mean age of 65 years, 49 of them females (29 percent), undergoing implantation of at least one drug-eluting stent in our medical center. The total number of drug-eluting stents implanted was 189, of which 115 (61 percent) were sirolimus-eluting (CYPHER TM) and 74 (39 percent) were paclitaxel-eluting stents (TAXUS TM). In 100 (60 percent) of the cases, multivessel coronary artery disease was present. In 61 (36 percent) patients another coronary artery segment was treated in addition to the proximal left anterior descending coronary artery. The mean clinical follow-up period was 11 ± 5 months, and angiographic controls were performed between 6 and 9 months. The final endpoint was a composite of death, acute myocardial infarction and need for reintervention on the anterior descending. The secondary endpoint included the occurrence of restenosis, need for reintervention on the proximal segment of the left anterior descending and stent thrombosis. RESULTS: The procedure achieved immediate angiographic success in all patients. Two deaths, two acute myocardial infarctions, and two percutaneous coronary reinterventions due to stent thrombosis were recorded during in-hospital stay. At the sixth month of follow-up, an additional cardiac death and three myocardial infarctions were observed; three repeat revascularization procedures were required. Up to the end of the follow-up, three additional deaths, three myocardial infarctions and eight revascularization procedures of the anterior descending, two of them surgical, were verified. Survival free from major adverse cardiac events was 91 percent. Cardiac mortality was 3 percent. Binary restenosis in the proximal segment...

Peculiarity of surgical tactics for management of ischemic heart disease in patients with left main coronary artery stenosis

The left main coronary artery disease has poor natural history. Sudden death, massive myocardial infarction, angina and poor quality of life indicate the ominous nature of the disease. Coronary artery bypass grafting remains the ultimate choice of its management. A relatively high mortality and morbidity of its surgical treatment described in literature leads to the actuality of this disease. This work is a part of our continuous effort for refinements in anesthetic and surgical techniques to reduce mortality and morbidity in such patients and is in the clinical practice at our institute for the last few years. During the period from February 1998 to October 2005, 74 patients underwent coronary artery bypass surgery for left main coronary artery stenoses, at Federal Postgraduate Medical Institute, Shaikh Zayed Hospital, Lahore. All patients presented with angina, unstable in 62.2%. An old myocardial Infarction was present in 52 [70.3%] patients. An emergent surgery was needed in 5[6.8%], urgent operation was performed in 45[60.8%] patients and elective procedure was done in 24[32.4%]. Average stay in the hospital was 9.0+2.7 days. There were 2 hospital deaths and one late non cardiac death. The post operative recovery was eventless in majority of the patients. The return of patients to their jobs improved significantly [P < 0.005] three months after operation. Our current surgical results are certainly improved than many previous studies on coronary artery bypass grafting for left main stem stenoses

Coronary flow reserve measurement in the coronary sinus in pre and post CABG status

Coronary flow reserve [CFR] is defined as a maximal [hyperemic] to resting ratio of coronary blood flow. It is a physiologic parameter of coronary circulation and depends on the patency of the epicardial coronary arteries and integrity of the microvascular circulation.CFR measurement has many clinical applications including functional assessment of intermediate stenosis, detection of critical stenosis monitoring of coronary flow in the post angioplasty period, assessment of post infarct blood flow and assessment of coronary graft patency. The aim of this study was to measure CFR in the coronary sinus through the transthoracic echocardiographic approach, in patients who were candidate for coronary artery bypass graft surgery [CABG] before and one month after operation. The present study included 19 patients [mean age=56 +/- 9.1] including 15 males and 4 females, admitted for CABG. All patients had a sinus rhythm, normal wall thickness, normal RV systolic pressure, and tricuspid valvular regurgitation equal or less than grade 2. The antegrade phase of coronary flow in the coronary sinus moving into the right atrium was analyzed in two phases [systolic and diastolic]. Each wave was determined considering the peak velocity and velocity time integral [VTI]. The volumetric blood flow in the coronary sinus calculated at the baseline and then in hyperemic phase was used for determination of CFR both before and after CABG. There was a significant increase in the diameter of the coronary sinus after CABG [9.4 +/- 1.2mm] compared with that of before CABG values [8.6 +/- 1.05mm]. Also there was a trend of increasing the diameter in the hyperemic phase before and after CABG. The absolute increase in mean coronary sinus diameter was 0.5 mm before and 1.5 mm after CABG. Coronary flow reserve [CFR] was significantly higher after surgery, despite a significant increase in systolic velocity ratio [hyperemic/baseline] after CABG. This is also true for systolic velocity time integral [VTI] and diastolic VTI ratios, but there was an insignificant increase in diastolic velocity ratio. Our study in accordance with previous studies, denotes that transthoracic measurement of the coronary flow reserve can be used as a feasible and reproducible method to monitor the changes in cardiac perfusion after revascularization

Simultaneous kissing stents for the treatment of left main stenosis in cardiogenic shock

Significant narrowing of the left main coronary artery puts the patient at high risk, since occlusion of this vessel, if unprotected by collateral flow or a patent bypass graft to either the left anterior descending or circumflex artery, compromises flow to approximately 75% of the left ventricle. Percutaneous coronary intervention of left main coronary artery may be the only life saving procedure. There are limited data on the general use of percutaneous intervention [PCI] in patients with acute myocardial infarction [MI] due to left main disease. Small series have noted in-hospital mortality rates of 30 to 35 percent following PCI with or without stenting. Moreover, cardiogenic shock secondary to acute MI, in patients with left main coronary artery disease, carries a very high mortality. Treatment options are limited especially when emergent coronary artery bypass surgery is not an option. We report a case of emergency angioplasty of left main coronary artery with simultaneous kissing stent technique in cardiogenic shock

Implante de duplo stent eluído com sirolimus em bifurcação de tronco não-protegido de coronária esquerda, utilizando a técnica de stents simultaneous / Two sirolimus eluting stents implant in Y bifurcation of unprotected left main coronary through kissing stents technique

É relatado o caso de paciente com 81 anos, do sexo masculino, portador de insuficiência cardíaca congestiva grau IV e de lesão grave no terço distal de tronco não-protegido dacoronária esquerda, com a configuração de bifurcação em “Y”. O referido paciente foi submetido a angioplastia coronária com implante de dois stents eluídos com sirolimus, utilizando-se a técnica de stents simultâneos, com sucesso.

This report describes a case involving an 81-year-old male patient with congestive heart failure level Class IV and severe distal part of the unprotected left main coronary artery stenosis with configuration in “Y” bifurcation, who successfully underwent coronary angioplasty with two sirolimus eluting stents implant through kissing stents technique.