Regional wall motion abnormalities in transthoracic echocardiography in patients with significant coronary artery disease and coronary collateral circulation in adults.

BACKGROUND: Coronary collateral circulation is a common finding in patients with chronic total occlusions (CTOs) resulting from chronic coronary artery disease (CAD). Regional wall motion abnormalities (RWMA) on transthoracic echocardiography (TTE) can be used for the diagnosis of CAD. However, little work has been done to investigate the impact of collateral vessels on the diagnostic accuracy of resting TTE for CAD. METHODS: A retrospective chart review was conducted of adults who received a resting TTE and cardiac catheterization within 30 days over a 4-year period at the Temple Baylor Scott & White echocardiography laboratory. Exclusion criteria included catheterization without coronary angiography and prior history of CAD, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). We analyzed RWMA on TTE in patients with CAD and coronary collateral circulation on cardiac catheterization to assess for correlation. RESULTS: Of the 753 patients were included in this study, 453 had CAD, 272 had both CAD and RWMA, 111 had collateral circulation, and 73 had collateral circulation and RWMA. There was no significant difference in RWMA in patients with CAD with and without collateral circulation. There was no significant difference in the sensitivity (60.0 % vs 59.2 %) and specificity (78.4 % vs 73.9 %) after collateral-adjusted interpretation of RWMA and CAD (p = 0.3). DISCUSSION: Our results suggest the average coronary collateral system is of insufficient clinical significance to prevent the development of RWMA on resting TTE.

Acute Coronary Syndrome Revascularization Strategies With Multivessel Coronary Artery Disease.

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multivessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multicentered, retrospective observational study from a large hospital system in the United States. We abstracted data in patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG, or medical management (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and gender. There were 295 patients with CABG (median age 66 years [interquartile range 59.7 to 73.1]; 73% male), 1,559 patients with PCI (median age 68.3 years [interquartile range 60 to 76.6]; 69.1% male], and 307 patients with MM (median age 70 years [60.9 to 77.1] 74% male]. Patients revascularized with PCI had greater all-cause mortality at 1 year (14.1% vs 5.1%; hazard ratio 2.4, confidence interval [1.5 to 3.8], p <0.001) and similar mortality to MM (13.4%). CABG also showed a reduced 1-year MI rate compared with PCI (1.7% vs 3.9%; hazard ratio 0.36, confidence interval 0.21 to 0.61, p ≤0.001), with a similar 1-year rate of MI to MM (3.9%). In conclusion, CABG is associated with lower mortality than are PCI and MM, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

Management of ST-Elevation Myocardial Infarction in High-Risk Settings.

Despite the widespread adoption of primary percutaneous intervention and modern antithrombotic therapy, ST-segment elevation myocardial infarction (STEMI) remains the leading cause of death in the United States and remains one of the most important causes of morbidity and mortality worldwide. Certain high-risk patients present a challenge for diagnosis and treatment. The widespread adoption of primary percutaneous intervention in addition to modern antithrombotic therapy has resulted in substantial improvement in the short- and long-term prognosis following STEMI. In this review, we aim to provide a brief analysis of the state-of-the-art treatment for patients presenting with STEMI, focusing on cardiogenic shock, current treatment and controversies, cardiac arrest, and diagnosis and treatment of mechanical complications, as well as multivessel and left main-related STEMI.

Dissection of Ascending Aorta: A Complication of Transradial Artery Access of Coronary Procedure.

Iatrogenic acute dissection of ascending aorta following coronary angiography and percutaneous intervention is a rare complication. Most reports involve localized aortic dissections as a complication of cannulation of a coronary artery with propagation into the ascending aorta. It is usually treated by sealing the intima with a stent in the ostium of the coronary artery or conservative management, while extensive dissections may require a surgical intervention. We describe a case of the subclavian dissection extending into the ascending aorta that occurred during diagnostic catheterization using the radial approach. The patient was successfully treated utilizing conservative management.

Role of Percutaneous Chronic Total Occlusion Interventions in Patients with Ischemic Cardiomyopathy and Reduced Left Ventricular Ejection Fraction.

PURPOSE OF REVIEW: The purpose of this review is to examine current evidence on the benefit of chronic total occlusion (CTO) revascularization in patients with ischemic cardiomyopathy and propose a systematic approach on how and when to accomplish revascularization in these patients. RECENT FINDINGS: Coronary revascularization in patients with reduced ejection fraction (EF) is advocated for to improve left ventricular function and consequently clinical outcomes. Approximately 16-31% of angiograms in patients with advanced CAD are noted to have a concomitant coronary CTO. Its presence is a main predictor of worse outcomes. Over the past 15 years, advancements in interventional technologies and techniques have made it possible to treat CTO lesions percutaneously with success rates exceeding 90%. Different revascularization techniques have been organized into widely used algorithms for systematic CTO lesion crossing and treatment. Patients with reduced EF can be revascularized percutaneously with goal of complete functional revascularization. However, randomized prospective data is needed to justify the increased patient risks and healthcare costs associated with these procedures.

Subepicardial aneurysm: echocardiographic evaluation and evolution.

Subepicardial aneurysms (SEA) are an infrequent and serious form of subacute cardiac rupture complicating myocardial infarction. An early diagnosis and surgical repair may be life saving. SEA comprise an abrupt interruption of the myocardium, with a narrow neck and thin wall containing only the epicardium. It may progress to fatal cardiorrhexis. We describe the echocardiographic evolution of this type of cardiac rupture and the contribution of contrast-enhanced echocardiography. A possible pathophysiological mechanism is proposed.

Left main coronary artery extrinsic compression syndrome: a combined intravascular ultrasound and pressure wire.

The compression of the left main coronary artery (LMCA) secondary to pulmonary artery trunk dilatation is a relatively new entity that has been associated with severe pulmonary hypertension. It is associated with acyanogen congenital cardiopathies or idiopathic pulmonary arterial hypertension. The natural history is unknown and its treatment has been based more on the severity of the angiographic compression than on the objective demonstration of myocardial ischemia. We report a case of a woman with severe pulmonary arterial hypertension due to an atrial septal defect with extrinsic compression of the LMCA and a physiopathologic approach to guide its treatment.

Slow-flow phenomenon during carotid artery intervention with embolic protection devices: predictors and clinical outcome.

OBJECTIVES: The purpose of this research was to define the predictors of the "slow-reflow" phenomenon during carotid artery intervention with filter-type embolic protection devices (EPDs) and to determine its prognostic significance. BACKGROUND: During carotid artery intervention using filter-type EPDs, we have observed cases in which there is angiographic evidence of a significant reduction in antegrade flow in the internal carotid artery proximal to the filter device, termed "slow-flow." The predictors of this phenomenon and its prognostic significance are unknown. METHODS: Using a single-center prospective carotid intervention registry, patients with slow-flow were compared to patients with normal flow during carotid intervention with respect to clinical, procedural, and lesion characteristics, and the 30-day incidence of death and stroke. RESULTS: A total of 414 patients underwent 453 carotid artery interventions using EPDs. Slow-flow occurred in 42 patients (10.1%) undergoing 42 carotid interventions (9.3%), and most commonly occurred after post-stent balloon dilatation (71.4%). Multivariate logistic regression analysis identified the following predictors of slow-flow: recent history (<6 months) of stroke or transient ischemic attack (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.4 to 5.6, p = 0.004), increased stent diameter (OR 1.4, 95% CI 1.02 to 1.94, p = 0.044), and increased patient age (OR 1.05, 95% CI 1.01 to 1.09, p = 0.025). Among patients with slow-flow, the 30-day incidence of stroke or death was 9.5% compared to 2.9% in patients with normal flow (chi-square = 4.73, p = 0.03). This difference was driven by the disparity in the 30-day incidence of stroke (9.5% vs. 1.7%). CONCLUSIONS: Slow-flow during carotid intervention with EPDs is a frequent event that is associated with an excess risk of periprocedural stroke. The association of the phenomenon with clinically symptomatic carotid lesions and use of larger stent diameters suggests that embolization of vulnerable plaque elements may play a pathogenic role.

[P-selectin as endothelial reactivity marker in patients with pre-eclampsia]. / P-selectina como marcador de reactividad endotelial en pacientes con preeclampsia.

INTRODUCTION: Pre-eclampsia affects 5% of all pregnancies. The physiopathologic hallmark is altered endothelium function and platelet activation. Selectins are molecules involved with the regulation between these systems, P-selectin is a molecule expressed in platelet membrane. Our objective was to describe the role of P-selectin on endothelial reactivity in patients with pre-eclampsia compared with normal pregnancies. MATERIAL AND METHODS: Blood samples from 30 patients with severe pre-eclampsia (cases) were compared with patients with 30 normal pregnancies during labor (controls). Samples from both groups were analyzed using ELISA (Bender Med kit, Vienna, Austria) for determination of P-selectin. RESULTS: We compared main clinical, biochemical, and hematologic variables in both groups, identifying an outstanding difference in expression of P-selectin between them. CONCLUSIONS: P-selectin is a marker of endothelium activation in patients with severe pre-eclampsia.

Triple antiplatelet therapy does not increase femoral access bleeding with vascular closure devices.

BACKGROUND: The use of arteriotomy closure devices (CDs) to achieve hemostasis after femoral artery access in percutaneous coronary intervention is steadily increasing. However, the safety information with these devices in the era of triple antiplatelet therapy is limited. METHODS: We reviewed prospectively collected data from the Do Tirofiban and ReoPro Give Similar Efficacy Outcomes Trial (TARGET), where all patients received aspirin, clopidogrel, and glycoprotein IIb/IIIa inhibitor therapy. At the treating physician's discretion, manual compression (MC) or a vascular hemostasis device was selected following femoral angiography. Patients receiving MC were to have sheaths removed 2 to 6 hours postprocedure when the activated clotting time was < or = 175 seconds. RESULTS: Of 4809 patients, 4736 had femoral access, and 985 of these had a CD (Perclose 47%, Angio-Seal 43%, VasoSeal 5%, and other 5%). The MC and CD groups were similar regarding most demographic characteristics, including age, systolic blood pressure, and weight, but those with MC were more often female, diabetic, and had history of peripheral vascular disease. Patients with a CD had a lower ischemic event rate suggesting they were a lower risk cohort overall. There were no differences in major bleeding at the access site (0.4% vs 0.5%, P =.588), minor bleeding at the access site (1.9% vs. 3.1%, P =.142) or transfusions (0.8% vs 1.0%, P =.513) between the MC and CD groups, respectively. CONCLUSIONS: In contemporary percutaneous coronary intervention practice, with appropriate patient selection, a CD can be safely utilized despite aggressive polypharmacy for procedural anticoagulation.

GuardWire emboli protection device is associated with improved myocardial perfusion grade in saphenous vein graft intervention.

BACKGROUND: Use of emboli protection devices (EPD) during saphenous vein graft percutaneous coronary intervention (SVG-PCI) has been proven to reduce major adverse cardiac events (MACE). However, the impact of EPD on the microcirculation using Thrombolysis in Myocardial Infarction myocardial perfusion grade (TMP) has not been fully characterized. We sought to analyze TMP after SVG-PCI with and without EPD and determine its impact on inhospital MACE. METHODS: From August 2001 to December 2002, 305 patients had SVG-PCI suitable for EPD; 210 (69%) had an angiogram appropriate for TMP evaluation. Of those, 46 (22%) had an EPD (GuardWire, Medtronic, Minneapolis, Minn) deployed during the coronary intervention. Both groups were similar with regard to most demographic and clinical features. RESULTS: A TMP score of 2.5 or 3 was obtained in 98% of the EPD group versus 85% of the unprotected SVG-PCI (P = .01). There was a trend towards reduction in MACE when using EPD (15% vs 27%, respectively, P = .07). Peak postprocedural creatine kinase-MB was somewhat lower in the EPD group (6.03 +/- 7.8 ng/mL vs 14.87 +/- 42 ng/mL, P = .17) Patients with a TMP grade of 2.5 or 3 had a statistically significant reduction in MACE (OR 0.36, 95% CI 0.14-0.87, P = .02). CONCLUSIONS: Compared with SVG-PCI without emboli protection, EPD significantly improved TMP and trended towards a reduction in MACE.

[IgM antiphospholipical antibodies in preeclampsia-eclampsia]. / Anticuerpo antifosfolípido IgM en preeclampsia-eclampsia.

BACKGROUND: Antiphospholipid antibodies are associated with thrombocytopenia and fetal loss, and have been reported elevated in patients with preeclampsia-eclampsia. Site: Preeclampsia-Eclampsia Research Unit, Instituto Materno Infantil del Estado de Mexico, Toluca, Mexico and the Specialty Hospital Research Unit, La Raza Medical Center, Mexico City, Mexico. OBJECTIVE: To determine the presence of anticardiolipin antibodies (IgG-IgM) as markers of acute endothelial damage in patients with preeclampsia. MATERIAL AND METHODS: A randomized case control study composed of two groups: Group A (cases), 18 patients with preeclampsia-eclampsia and group B (control), 18 normal pregnancies. Antiphospholipid (anticardiolipin) antibodies were determined in both groups in addition to with coagulation tests and clinical variables in mother and newborn in day of admission and nine weeks after obstetrical resolution. We excluded patients with anticoagulant or dialysis therapy, taking NSAIDs or who recently required transfusion or plasmaferesis. RESULTS: There were significant differences in levels of IgM and in weights and mortality among newborns between the two groups. In terms of maternal complications, we found HELLP syndrome as leading cause. We also observed in the case group significant differences in mean arterial pressure (MAP) and IgM levels between admission day and nine weeks later. Our results lead us to the conclusion that there must be exist immunologic mechanism that induces synthesis of anticardiolipin antibodies (IgM isotype) during acute state of the disease, accounting for vascular changes and prothrombotic state responsible for maternal and neonatal complications.