Anomalous circumflex artery encircling the aortic annulus: implications for mitral valve repair.

Injury to coronary arteries during mitral surgery is a rare but life-threatening procedural complication, an anomalous origin and course of the left circumflex artery (LCx) increase this risk. Recognizing the anomaly by the characteristic angiographic pattern and identifying its relationship with the surrounding anatomical structure using imaging techniques, mainly transesophageal echocardiography (TOE) or coronary computed tomography angiography (CCTA), is of crucial importance in setting up the best surgical strategy. We report a case of anomalous origin of a circumflex artery (LCx) from the proximal portion of the right coronary artery (RCA) with a pathway running retroaortically through the mitro-aortic space. An integrated diagnostic approach using a multidisciplinary team with a cardiologist and an imaging radiologist allowed us to decide the surgical strategy. We successfully performed a mitral valvular repair using a minimally invasive minithoracotomic approach and implanting a complete semirigid ring.

Controlled antegrade and retrograde subintimal tracking (CART) for recanalisation of chronic total occlusions.

BACKGROUND: Controlled antegrade and retrograde subintimal tracking (CART) is rarely performed in contemporary chronic total occlusion (CTO) percutaneous coronary intervention (PCI). AIMS: We aimed to analyse the indications, procedural characteristics, and outcomes of CART at a high-volume CTO programme. METHODS: We included all patients undergoing a retrograde CTO PCI in which CART was performed at our institution between January 2019 and November 2023. The primary endpoint was technical success. RESULTS: Of 1,582 CTO PCI, the retrograde approach was performed in 603 procedures (38.1%), and CART was used in 45 cases (7.5%). The mean age was 69.1±10.3 years, 93.3% were male, and prior coronary artery bypass graft surgery was present in 68.9%. The most common target CTO vessel was the right coronary artery (48.9%). Anatomical complexity was high (Multicentre CTO Registry of Japan [J-CTO] score of 3.6±0.9). The most common collateral used for CART was a saphenous vein graft (62.2%). Advanced calcium modification was required in 15.6% of cases. CART was successful in 73.3%. Technical and procedural success was 82.2%. Coronary perforation was diagnosed in 4 subjects (8.9%), but only 1 patient (2.2%) suffered tamponade and required pericardiocentesis. No other in-hospital major adverse cardiac events were diagnosed. CONCLUSIONS: CART is a useful technique in selected, very complex CTOs tackled with the retrograde approach. Success rates were high, while complication rates were low, considering the high anatomical complexity and baseline patient risk.

Arterial switch operation in a child with commissural malalignment and unusual coronary anatomy.

The arterial switch operation has evolved to become the treatment of choice for transposition of the great arteries and is one of the greatest success stories in congenital heart surgery. The most crucial step of the operation is the coronary artery translocation; therefore, it is of paramount importance for surgeons to know every single detail about the morphology and spatial relationships of the coronary arteries and the roots of the great vessels. However, sometimes the surgeon may face unfavourable scenarios such as major commissural malalignment and anomalous coronary artery patterns and need to be prepared to carry out a successful coronary artery translocation. Herein, we demonstrate that the trapdoor technique is useful for transferring coronary arteries in a neonate with major commissural malalignment and unusual coronary anatomy during the arterial switch operation.

Experimental validation and clinical feasibility of 3D reconstruction of coronary artery bifurcation stents using intravascular ultrasound.

The structural morphology of coronary stents and the local hemodynamic environment following stent deployment in coronary arteries are crucial determinants of procedural success and subsequent clinical outcomes. High-resolution intracoronary imaging has the potential to facilitate geometrically accurate three-dimensional (3D) reconstruction of coronary stents. This work presents an innovative algorithm for the 3D reconstruction of coronary artery stents, leveraging intravascular ultrasound (IVUS) and angiography. The accuracy and reproducibility of our method were tested in stented patient-specific silicone models, with micro-computed tomography serving as a reference standard. We also evaluated the clinical feasibility and ability to perform computational fluid dynamics (CFD) studies in a clinically stented coronary bifurcation. Our experimental and clinical studies demonstrated that our proposed algorithm could reproduce the complex 3D stent configuration with a high degree of precision and reproducibility. Moreover, the algorithm was proved clinically feasible in cases with stents deployed in a diseased coronary artery bifurcation, enabling CFD studies to assess the hemodynamic environment. In combination with patient-specific CFD studies, our method can be applied to stenting optimization, training in stenting techniques, and advancements in stent research and development.

Attempted retrieval of guidewire fragment using the twisting wire technique causes coronary perfusion: Case report.

RATIONALE: Guidewire fracture is one of the biggest risks of percutaneous coronary intervention, twisting wire technique is very useful for retrieving the fractured wire, but the potential risks have been inadequately reported. Herein, we present a case of retrieval of guidewire fragments using the twisting wire technique that causes coronary perfusion. PATIENT CONCERNS: A 37-year-old male patient was admitted to our hospital for elective percutaneous coronary intervention of the left circumflex coronary artery. CLINICAL FINDINGS: For chronic total occlusion of the distal left circumflex coronary artery, antegrade recanalization by wire escalation, and parallel wire techniques were attempted. However, we shockingly found that the BMW guidewire, anchored in the right coronary artery, spontaneously fractured from the proximal right coronary artery, and a lengthy fragment of the guidewire remained in the coronary. DIAGNOSES, INTERVENTIONS, AND OUTCOMES: Many attempts were made to retrieve the remnant guidewire including the twisting wire technique, which leads to the perforation of the coronary. OUTCOMES: Finally, percutaneous retrieving procedures were stopped in favor of surgical extraction via a small coronary arteriotomy. This procedure was successful. LESSONS: To the best of our knowledge, the present case is the first reported spontaneous fracture of the guidewire. Leaving such a lengthy remnant guidewire in the artery, or leaving stenting over the wire, would impose a high risk of coronary thrombosis, perforation, and embolization. Yet, the perforation of the artery that occurred in this case, which could have had life-threatening consequences, resulted from our attempts to retrieve the guidewire using the twisting wire technique.

Performance of left internal thoracic artery-left anterior descending artery anastomosis by residents versus attendings and coronary artery bypass grafting outcomes.

OBJECTIVES: Performance of a technically sound left internal thoracic artery to left anterior descending artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We used prospectively collected data from the multicentre, randomized REGROUP (Randomized Endograft Vein Perspective) trial to investigate CABG outcomes based on whether a resident or an attending surgeon performed the LITA-LAD anastomosis. METHODS: This was a post hoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest from 2014 through 2017. The primary end point was major cardiac adverse events, defined as the composite of all-cause deaths, nonfatal myocardial infarctions or repeat revascularizations. RESULTS: Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%), by attending surgeons. Residents (compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs 37.4%, P < 0.001), performed fewer multiarterial CABGs (5.2% vs 14.6%, P < 0.001) and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs 10.9%, P < 0.001) and non-calcified landing zones (25.1% vs 21.6%, P < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), major cardiac adverse events occurred in 77 patients (22.4%) in the group treated by residents and 169 patients (22.8%) in the group treated by attendings (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; P = 0.99). Outcomes persisted on adjusted analyses. CONCLUSIONS: Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by the residents yielded clinical outcomes similar to those of the attendings.

Self-Practice Program for Beating-Heart Minimally Invasive Coronary Anastomosis Using a Homemade Low-Fidelity Simulator: A Proof of Concept.

OBJECTIVE: We evaluated the effectiveness of a consistent and structured self-practice coronary anastomosis program using a homemade low-fidelity beating-heart simulator. METHODS: An intermediary trainee was subjected to an 8-week structured self-practice program. The program was divided into 2 parts of nonbeating and beating practices with a minimum number of timed anastomoses. Each part was followed by an assessment using an objective skills assessment tool score. The beating-heart simulator was built using motorized toy blocks connected wirelessly to a smartphone application. This was coded to enable rate selection. A junior consultant was compared to the subject at the end of the program. Both were tasked to perform 1 coronary anastomosis for both off-pump coronary artery bypass (OPCAB) and minimally invasive CAB (MICS) setup. The primary outcomes were anastomotic time and score compared with the junior consultant. Secondary outcomes were progression of anastomotic time and score throughout the program. RESULTS: Overall performance of the studied subject approached the performance of the junior consultant in terms of time (OPCAB, 489 vs 605 s; MICS, 712 vs 652 s) and scores (OPCAB, 21 vs 20.7; MICS, 19 vs 20.6). There were inverse correlations between anastomosis time and number of practices for both nonbeating and beating anastomoses. Overall improvement was observed in terms of assessment scoring by 26.6%. CONCLUSIONS: A structured self-practice program using an affordable and accessible simulator was able to help trainees overcome the MICS anastomosis learning curve quicker when introduced earlier. This may encourage earlier adoption of MICS among surgeons.

Optimising Percutaneous Coronary Interventions: The Impact of Stent Type and Diameter on Long-Term Clinical Outcomes in Large Coronary Arteries.

Background and Objectives: Our study aimed to reveal the effect of using 4 mm bare-metal stents (BMS), 4 mm drug-eluting stents (DES), or 3 mm DES with 4 mm diameter balloon post-dilation strategies on long-term clinical outcomes and endpoints for large-diameter coronary artery percutaneous coronary intervention (PCI). Materials and Methods: In our study, patients who had undergone PCI were retrospectively screened between January 2014 and July 2020. The study included 350 patients and was divided into three groups; Group I (n = 134) included patients with direct 4.0 mm BMS implantation, Group II (n = 109) included patients with direct 4.0 DES implantation, and Group III (n = 107) included patients with 4mm NC post-dilatation after 3 mm DES implantation. Primary endpoints were determined as target lesion revascularisation, cardiac mortality, and myocardial infarction associated with the target vessel. Our secondary endpoint was all-cause mortality. Results: No differences were observed between the groups in terms of the baseline variables. Stent length was the highest in Group II and the shortest in Group III. There were no significant differences between the groups regarding major adverse cardiovascular events (MACE). Conclusions: Our study suggests that in percutaneous coronary interventions for non-complex lesions, there is no significant difference in MACE outcomes when directly implanting a 4 mm diameter DES, a 4 mm diameter BMS, or a 3 mm diameter DES, followed by post-dilation with an appropriately sized NC balloon when the target vessel diameter is in the range of 4 to 4.4 mm.

FFR-Guided Complete or Culprit-Only PCI in Patients with Myocardial Infarction.

BACKGROUND: The benefit of fractional flow reserve (FFR)-guided complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease remains unclear. METHODS: In this multinational, registry-based, randomized trial, we assigned patients with STEMI or very-high-risk non-STEMI (NSTEMI) and multivessel disease who were undergoing primary percutaneous coronary intervention (PCI) of the culprit lesion to receive either FFR-guided complete revascularization of nonculprit lesions or no further revascularization. The primary outcome was a composite of death from any cause, myocardial infarction, or unplanned revascularization. The two key secondary outcomes were a composite of death from any cause or myocardial infarction and unplanned revascularization. RESULTS: A total of 1542 patients underwent randomization, with 764 assigned to receive FFR-guided complete revascularization and 778 assigned to receive culprit-lesion-only PCI. At a median follow-up of 4.8 years (interquartile range, 4.3 to 5.2), a primary-outcome event had occurred in 145 patients (19.0%) in the complete-revascularization group and in 159 patients (20.4%) in the culprit-lesion-only group (hazard ratio, 0.93; 95% confidence interval [CI], 0.74 to 1.17; P = 0.53). With respect to the secondary outcomes, no apparent between-group differences were observed in the composite of death from any cause or myocardial infarction (hazard ratio, 1.12; 95% CI, 0.87 to 1.44) or unplanned revascularization (hazard ratio, 0.76; 95% CI, 0.56 to 1.04). There were no apparent between-group differences in safety outcomes. CONCLUSIONS: Among patients with STEMI or very-high-risk NSTEMI and multivessel coronary artery disease, FFR-guided complete revascularization was not shown to result in a lower risk of a composite of death from any cause, myocardial infarction, or unplanned revascularization than culprit-lesion-only PCI at 4.8 years. (Funded by the Swedish Research Council and others; FULL REVASC ClinicalTrials.gov number, NCT02862119.).

Native coronary artery or bypass graft percutaneous coronary intervention in patients after previous coronary artery bypass surgery: A large nationwide analysis from the Netherlands Heart Registration.

BACKGROUND: Patients with previous coronary artery bypass surgery (CABG) who require repeat revascularization frequently undergo percutaneous coronary intervention (PCI). We sought to identify factors associated with the decision to intervene on the native vessel versus a bypass graft and investigate their outcomes in a large nationwide prospective registry. METHODS: We identified patients who underwent PCI with a history of prior CABG from the Netherlands Heart Registration between 2017 and 2021 and stratified them by isolated native vessel PCI versus PCI including at least one venous- or arterial graft. The primary endpoint of major adverse cardiac events (MACE) was a composite of all-cause death and target vessel revascularization (TVR) at one-year post PCI. The key secondary endpoint was a composite of all-cause death, myocardial infarction (MI), and TVR at 30 days. RESULTS: Out of 154,146 patients who underwent PCI, 12,822 (8.3%) had a prior CABG. Isolated native vessel PCI was most frequently performed (75.2%), while an acute coronary syndrome (ACS) presentation was most strongly associated with graft interventions. The primary outcome of MACE at one-year post PCI occurred more frequently in interventions including grafts compared with native vessels alone (19.7% vs. 14.3%; adjOR 1.267; 95% CI 1.101-1.457); p < 0.001) driven by TVR. There was however no difference in mortality or the key secondary endpoint between the two groups. CONCLUSION: In this nationwide prospective registry, ACS presentation was strongly associated with bypass graft PCI. At one year after PCI, interventions including bypass grafts had a higher composite of MACE compared with isolated native vessel interventions.

Evaluation of post-dilatation on longitudinal stent deformation and postprocedural stent malapposition in the left main artery by optical coherence tomography (OCT): an in vitro study.

BACKGROUND: The diameter of the ostial and proximal left main coronary artery can be greater than 5.0 mm. However, the diameters of the mostly available coronary drug-eluting stents (DESs) are ≤ 4.0 mm. Whether high-pressure dilatation can increase the diameter of stents from 4.0 to 5.0 mm and whether post-dilatation leads to longitudinal stent deformation (LSD) of 4.0-mm-diameter stents have rarely been studied. Therefore, this study aims to evaluate LSD and stent malapposition of six types of commercially available 4.0-mm-diameter stents in China in a 5.0-mm-diameter artificial blood vessel model by optical coherence tomography (OCT) in vitro. METHODS: The left main coronary artery was simulated by a truncated cone-shaped silicone tube. The internal diameters were 4.0 mm at one end of the silicone tube and 5.0 mm at the other end. Six different types of coronary stents widely used in China were selected for this study. Each stent was respectively implanted into the simulated blood vessel and dilated to a diameter of 4.2 mm according to the stent-balloon pressure compliance table. The stents were subjected to post-dilatation with a 5.0 × 15-mm noncompliant balloon. The LSD ratio of the longitudinal axis of each stent and stent malapposition were measured through OCT, and any fractures of the stents were determined. RESULTS: None of the six types of stents fractured following post-dilatation. The longitudinal axes of the BuMA and Excrossal stents were slightly shortened, while the other stents were elongated after high-pressure post-dilatation. All stents expanded to a diameter of 5.0 mm without incomplete stent apposition, except for the Nano Plus stent, which remained malapposed after high-pressure post-dilatation. CONCLUSION: All 4.0-mm-diameter stents can be expanded to a diameter of 5.0 mm by noncompliant balloon post-dilatation without stent strut fracture. Most stents were found to be well apposed after high-pressure post-dilatation. However, LSD was observed after post-balloon dilatation. Stent malapposition might be positively correlated with the percentage change in stent length.

Self-Apposing Stents in Coronary Chronic Total Occlusions: A Pilot Study.

OBJECTIVES: This pilot study assessed the 12-month angiographic and clinical outcomes of self-apposing (SA) stents in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BACKGROUND: Self-apposing (SA) stents may decrease incomplete strut apposition and stent strut coverage that are common after CTO PCI. METHODS: We compared 20 patients who underwent CTO PCI using SA drug-eluting stents (DESs) with 20 matched control patients who underwent CTO PCI using balloon-expandable (BE)-DESs. All patients were followed up clinically for 12 months and had coronary angiography with optical coherence tomography at the end of the follow-up period. The primary end points were stent strut malapposition and strut coverage. The secondary end point was composite major adverse cardiovascular events (MACEs) at 12 months. RESULTS: Both groups had high prevalence of diabetes mellitus, and most of the treated lesions were complex, with 62% having a J-CTO score of ≥3. All CTO PCI techniques were allowed for recanalisation, and 75% of the procedures were guided by intravascular ultrasound. At 12 months, the SA-DES group had fewer malapposed struts (0% [interquartile range (IQR) 0%-0%] vs 4.5% [IQR 0%-20%]; p<0.001) and uncovered struts (0.08% [IQR 0%-1.6%] vs 8.2% [IQR 0%-16%]; p<0.001). However, they showed significantly higher rates of MACEs due to clinically-driven target lesion revascularisation (45% vs 15%; p=0.038). CONCLUSIONS: In this pilot study, compared with conventional BE-DESs, SA-DESs used in CTO PCI were associated with fewer malapposed and uncovered stent struts but also with significantly higher rates of in-stent restenosis and MACEs, mainly caused by clinically driven target lesion revascularisation.