Coronary endarterectomy in patients with diffuse coronary artery disease: assessment of graft patency with computed tomography angiography.

BACKGROUND: With a growing population of patients with advanced coronary artery disease (CAD), many of whom have undergone prior percutaneous coronary interventions, coronary endarterectomy (CE) allows for the extension of revascularization in patients with otherwise limited options. Whether adjunctive CE associated with standard surgery, combined with contemporary antiplatelet therapy, improves outcomes remains largely unknown. METHODS: We studied 147 consecutive patients who underwent 154 adjunctive CE procedures for advanced CAD between January 2015 and January 2018. We used computed tomography angiography (CTA) in a subgroup of 32 consecutive patients who underwent CE during coronary artery bypass grafting after June 2016 to assess graft and coronary patency. RESULTS: Patients (mean age 67 ± SD 10 yr) underwent CE of the right (102 patients), the left anterior descending (LAD, 22 patients) and the circumflex (17 patients) coronary arteries. Seven patients (5%) experienced a procedural myocardial infarction and there were no perioperative deaths. Among the 32 patients who underwent CTA 3 months after surgery, the mean patency of the endarterectomized coronary arteries and bypass grafts was 90% and 88%, respectively. All 6 arterial grafts on the LAD artery were patent. The mean survival rate and the mean rate of freedom from major adverse cardiovascular events was 95% ± 2% and 95% ± 6%, respectively. The patency rate was 100 % for patients evaluated at 3-year follow up. CONCLUSION: Coronary endarterectomy offers a surgical option for patients with diffuse CAD who may be unsuitable for coronary bypass alone. Grafts and endarterectomized coronary artery patency remain adequate and explain the excellent patient survival and the freedom rate from major adverse cardiovascular events.

2020 MR Safety for Cardiac Devices: An Update for Radiologists [Formula: see text].

Magnetic resonance imaging (MRI) is a unique and powerful diagnostic tool that provides images without ionizing radiation and, at times, can be the only modality to properly assess and diagnose some pathologies. Although many patients will need an MRI in their lifetime, many of them are still being unjustly denied access to it due to what were once considered absolute contraindications, including MR nonconditional pacemakers and implantable cardioverter-defibrillators. However, there are a number of large studies that have recently demonstrated that MRI can safely be performed in these patients under certain conditions. In addition, there are an increasing number of novel cardiac devices implanted in patients who may require an MRI. Radiologists need to familiarize themselves with these devices, identify which patients with these devices can safely undergo MRI, and under which conditions. In this article, we will review the current literature on MR safety and cardiac devices, elaborate on how to safely image patients with cardiac devices, and share the expertise of our tertiary cardiac institute.

Mycotic Coronary Aneurysm Associated With Biventricular Fistula.

The incidence of coronary artery aneurysm is between 1.4% and 4.9% based on autopsy or angiographic series. Mycotic coronary arteries aneurysms are very rare and represent less than 3% of all coronary aneurysms. We report the case of a patient who presented with multiple coronary mycotic aneurysms.

Pulmonary homograft dysfunction after the Ross procedure using decellularized homografts-a multicenter study.

OBJECTIVES: Pulmonary homograft dysfunction is a limitation after the Ross procedure. Decellularized pulmonary homografts can potentially mitigate this complication. The aim of this study was to examine the incidence, predictors, progression, and morphology of pulmonary homograft dysfunction using data from the Canadian Ross Registry. METHODS: From 2011 to 2019, 466 consecutive patients (mean age: 47 ± 12 years, 73% male) underwent a Ross procedure using a decellularized cryopreserved pulmonary homograft (SynerGraft SG; CryoKife, Kennesaw, Ga). Pulmonary homograft dysfunction was defined as any of the following: peak pulmonary gradient ≥30 mm Hg, pulmonary regurgitation >2, or pulmonary homograft reintervention. Patients meeting ≥1 of these criteria (n = 30) were compared with the rest of the cohort (n = 436). Median follow-up is 2.2 years (maximum = 8.5 years) and 99% complete (1176 patient-years). RESULTS: The cumulative incidence of pulmonary homograft dysfunction was 11 ± 2% at 6 years. Pulmonary homograft stenosis was the most frequent presentation (n = 28 patients, 93%). Morphologically, stenosis occurred most often along the conduit (59%). Overall, 4 patients required homograft reintervention. At 6 years, the cumulative incidence of homograft reintervention was 3 ± 1%. The instantaneous risk was greatest in the first year after surgery (3.5%/year) and decreased to <1%/year thereafter. Patient age <45 years was the only independent risk factor associated with pulmonary homograft dysfunction (hazard ratio, 3.1, 95% confidence interval, 1.1-8.6, P = .03). CONCLUSIONS: The use of decellularized cryopreserved pulmonary homografts results in a low incidence of dysfunction and reintervention after the Ross procedure. The risk is greater in the first postoperative year. Younger age is the only independent risk factor for pulmonary homograft dysfunction.

A Rare Case of Coronary Artery Dilatation and Giant Pseudoaneurysm.

Coronary artery fistula are anomalous connections with coronary vessels or cardiac chambers, potentially resulting in coronary dilatation and pseudoaneurysm formation. We present the case of a 68-year-old woman referred to our institution for a voluminous coronary pseudoaneurysm secondary to coronary artery fistula presenting as a nearly completely obstructive left atrial mass. (Level of Difficulty: Intermediate.).

Aortic regurgitation in patients with a left ventricular assist device: A contemporary review.

Aortic regurgitation (AR) developing while using a continuous-flow left ventricular assist device (CF-LVAD) affects 25% to 30% of patients within the first year of implantation and is increasingly being recognized as a cause of recurrence of symptomatic heart failure (HF). The underlying mechanisms are likely multifactorial, including changes in the leaflets of the aortic valve (AV), altered root biomechanics, and excessive left ventricular (LV) unloading, together promoting cusp remodeling and commissural fusion. Known risk factors for the development of AR while under support include advanced age, lower body surface area, systemic hypertension, large aortic root diameter, permanently closed AV, and duration of support. Further, variants in the anastomotic angle between the outflow graft and the ascending aorta have recently been recognized to induce structural changes in the aortic wall, contributing to the development and progression of AV disease. Nevertheless, it remains controversial as to whether AR on LVAD has an independent impact on prognosis, and no clear recommendation exists regarding its optimal diagnosis criteria and treatment. Herein we briefly review the literature and focus on the latest results regarding development of AR in patients supported with CF-LVADs. We also provide a structured echocardiographic approach for an accurate assessment of AV dysfunction in this challenging situation.