Caught Between Heart and Limbs: Navigating the Treatment of Patients With CAD and PAD in an Overwhelmed Healthcare System.

Peripheral arterial disease (PAD) and coronary artery disease (CAD) are manifestations of atherosclerosis, affecting a substantial proportion of the population. Despite their interrelation, the prevalence of CAD in severe PAD varies, prompting the need to understand their complex relationship. This study retrospectively analyzes prospectively collected data from a high-volume vascular center to assess CAD prevalence, risk factors, and implications for patients undergoing vascular surgery. Among 667 arterial disease patients, 19.5% underwent coronary angiography, with CAD detected in 61.5% of cases. CAD varied across vascular beds. Decision-making around preoperative coronary angiography and revascularization remains complex, with benefits for high-risk patients still being debated. In accordance with current guidelines, the routine practice of coronary revascularization preceding vascular surgery is generally discouraged. This study underscores the need for risk stratification to identify patients who might benefit from coronary revascularization prior to vascular surgery while adhering to cost-effectiveness and avoiding unnecessary and time-consuming diagnostics in the majority of patients. Patient demographics, risk factors, and clinical presentation were analyzed alongside hospital stay, mortality, and complications. The study highlights the challenges in managing patients with concurrent CAD and PAD and calls for improved protocols for treating this high-risk group.

Correlation of structural defects in the ascending aortic wall to ultrasound parameters: benefits for decision-making process in aortic valve surgery.

BACKGROUND: Histopathological changes in the ascending aorta wall in patients with severe tricuspid aortic valve (TAV) stenosis were graded and correlated to echocardiographic parameters. Objective was to associate threshold echocardiographic values with structural defects in the ascending aorta providing a tool to improve decision-making process in cases when simultaneous aortic valve replacement (AVR) and ascending aorta replacement is considered. METHODS: Biopsies from 108 TAV stenosis patients subjected to AVR were graded into three grades according to severity of aortic wall changes. Echocardiographic parameters obtained preoperatively and correlated to grade, age, gender and risk factors, were diameters of ventriculo-aortic junction (AA), sinus Valsalva (SV), sinotubular junction (STJ), the largest diameter of the visualized ascending aorta (AscA) as well as indexes: sinus Valsalva (SVI), sinotubular junction (STJI), AscA/AA and STJ/AA. RESULTS: Two echocardiographic parameters portrayed grades with statistical significance: STJ (F = 5.417; p = 0.006 (p < 0.05)) and AscA (F = 3.924; p = 0.023 (p < 0.05)). By using multiple predictors in the setting of Regression analysis, statistically significant differences among grades were reached for AA, SV, STJ, AscA and SVI. With further ROC curves analysis, threshold values for different grades were recognized. Grade 2 is identified in patients with AscA > 3.3 cm, while Grade 3 is identified in patients with values of AscA > 3.5 cm, STJ > 2.9 cm and STJI > 1. CONCLUSIONS: Hemodynamic stress induced by TAV stenosis leads to elastic lamellae disruption in the aortic wall. Those changes could be graded and correlated with echocardiographic parameters of the aortic root and ascending aorta, providing a tool for decision to replace ascending aorta concomitantly with AVR.

Left ventricular geometry in normal and post-anterior myocardial infarction patients: sphericity index and 'new' conicity index comparisons.

BACKGROUND: Anterior myocardial infarction leads a sequence of structural changes that alter the size and the shape of the left ventricle. Efforts to assess shape have been made by global left ventricular (LV) chamber analysis (sphericity index, SI) but this analysis does not detect regional shape abnormalities like those at the apical level, which precede global ventricular dilatation. OBJECTIVE: The present study will introduce a new analysis of regional apical changes in 52 normal subjects and in 92 patients with previous anterior myocardial infarction. METHODS: All patients had transthoracic echocardiogram and multiple views were obtained (long axis, 4CH, 2CH and short axis view). From the 4CH view the long and the short axes were measured and their ratio was calculated (sphericity index). In the same view, the apical axis length was also measured and the ratio between apical and short axis length was calculated (apical conicity index, ACI). RESULTS: Patients had all the measured parameters significantly worse than normal, except the sphericity index which remained unchanged. Ventricular length and width increased following anterior MI but the ratio between the two measurements did not change. Conversely, apical conicity index is significantly different following anterior MI, thereby indicating anterior infarction produces a less conical shape. SI and ACI differed when correlations were made in the relationship of mitral valve function; SI correlates with the degree of mitral regurgitation (MR) and with the distance of papillary muscles, conversely ACI shows an inverse correlation with the determinants of mitral regurgitation. These observations reflect differences between apical versus global dilatation in ischemic cardiomyopathy, so that mitral function is better (lower tenting area and lower coaptation height) when the apex is markedly dilated in respect to the short axis (high conicity index). In contrast, mitral function is impaired (bigger distance between papillary muscles and higher degree of mitral regurgitation), when sphericity index is high. CONCLUSIONS: Sphericity index fails to detect regional apical shape abnormalities. To address this focal change, we introduce a simple new measure termed apical conicity index, which is abnormal in patients with myocardial infarction, and can be useful to evaluate changes induced by the subsequent surgical approach of ventricular re-shaping.