Variant origin and course of left circumflex coronary artery.

Variant origin of left circumflex coronary artery (LCx) from right aortic sinus is a well-recognized coronary variation, usually without any clinical consequences. However, the variant origin and trajectory of the artery may have major implications during percutaneous coronary intervention, coronary artery surgery, aortic and mitral valve replacement procedures. We observed a variant LCx in a heart specimen belonging to 45-year-female with no history of hypertension, diabetes mellitus and coronary artery disease. The artery arose along with the right coronary artery from a common ostium in right aortic sinus and depicted a retroaortic course. The vessel was located at the level of aortic annulus and 6.6 mm above mitral valve annulus. The degree of luminal stenosis in variant LCx was higher than that in right coronary artery (RCA) and left anterior descending artery (LAD). Appropriate anatomical knowledge of the location and course of variant LCx is important for successful coronary interventions and valve replacement procedures.

Diagnostic and prognostic significance of ischemic electrocardiographic changes with regadenoson-stress myocardial perfusion imaging.

BACKGROUND: The diagnostic and prognostic value of regadenoson-induced ST-segment depression (ST↓) is not defined. Due to the low incidence of ST↓ ≥1.0 mm with vasodilator stress, a lower threshold to define ischemic ECG response may provide improved clinical utility. METHODS: We conducted a retrospective cohort study of patients who underwent regadenoson-stress SPECT myocardial perfusion imaging (MPI) followed by coronary angiography within 6 months. Ischemic ST↓ was defined as ≥0.5 mm. The prevalence of angiographically severe coronary artery disease (CAD) and the rates of major adverse cardiac events (MACE) including cardiac death, myocardial infarction, and coronary revascularization were determined. RESULTS: In a diagnostic cohort of 629 subjects, 117 (18.6%) had ST↓ ≥0.5 mm. Severe CAD was more prevalent in the ST↓ ≥0.5 vs ST <0.5 group (13.7% vs 5.3%, P = .001). Among patients with normal MPI (n = 229), the prevalence of severe CAD was higher in the ST↓ ≥0.5 group (8.2% vs 2.2%, P = .04). Adjusting for clinical and imaging covariates, ST↓ ≥0.5 mm was independently predictive of severe CAD [odds ratio = 3.37, 95% confidence interval (CI) = 1.67-6.83, P = .001], and provided incremental diagnostic value (Chi square increment = 10.3, P = .001). In an outcome cohort of 748 subjects, after adjusting for clinical and imaging covariates, ST↓ ≥0.5 mm was associated with increased MACE rate in the entire cohort [hazard ratio = 1.41, CI 1.01-1.96, P = .04] and in the subgroup of patients with normal MPI [hazard ratio = 2.2, CI 1.11-4.39, P = .02], and provided incremental prognostic value (Chi square increment = 3.9, P = .049). A diagnostic ST↓ threshold of 0.5 mm provided greater discriminatory capacity than a 1.0 mm cutoff (P = .03). CONCLUSIONS: Among patients selected to undergo coronary angiography, regadenoson-induced ST↓ ≥0.5 mm was associated with higher rates of severe CAD and MACE, irrespective of MPI finding.

Impact of same-admission percutaneous coronary intervention on periprocedural outcomes of transcatheter aortic valve implantation.

Background: Current guidelines recommend percutaneous coronary intervention (PCI) prior to transcatheter aortic valve implantation (TAVI) if significant coronary artery disease is present, but whether PCI should be done in the same admission as TAVI is not determined. Methods: We retrospectively analyzed the National Inpatient Sample from 2016 to 2019 to compare TAVI with and without same-admission PCI and compare in-hospital outcomes after propensity score matching. Results: Among 170,030 hospitalizations for TAVI, 4425 (2.6%) had same-admission PCI performed. After propensity score matching, 4425 hospitalizations were allocated to those with and without same-admission PCI. No difference in in-hospital mortality (odds ratio [OR] 1.59, 95% confidence interval [CI] 0.81-3.12) was observed between the two groups. However, TAVI with same-admission PCI was associated with higher odds of cardiac arrest (OR 2.25, 95% CI 1.02-4.98), cardiogenic shock (OR 2.21, 95% CI 1.29-3.79), and acute myocardial infarction (OR 3.23, 95% CI 2.11-4.93). It was also associated with longer length of stay and more expensive hospital cost. Conclusion: TAVI with same-admission PCI was associated with higher odds of periprocedural complications and higher immediate cost. Our findings should be interpreted in the context of the same-admission PCI and TAVI cohort potentially being sicker and the isolated TAVI control group may or may not having obstructive coronary artery disease.

Variance in coronary venous anatomy: a critical determinant in optimal candidate selection for cardiac resynchronization therapy.

BACKGROUND: Knowledge of coronary sinus (CS) anatomy and its variations is one of the important factors determining the final position of left ventricle pacing lead during cardiac resynchronization therapy. METHODS: Coronary venous system anatomy, including number, diameter, and opening angles of tributaries, was studied in 50 normal formalin-fixed adult cadaveric hearts. RESULTS: Thebesian valve (TV) and Vieussens valve were present in 64% and 60% cases, respectively. CS ostium coverage of ≥75% by TV was seen in 25% (8/32) cases. Number of prominent tributaries lying between anterior interventricular vein and middle cardiac vein varied from 1-4. In 28% of hearts, only one prominent tributary was present. Midlateral vein (average diameter 1.75 ± 0.66 mm) with an average distance of 43.5 ± 12.2 mm from coronary ostium was present in 58% (29/50) hearts, of which it formed an acute angle with CS axis in four (13.39%) cases. Posterolateral vein (average diameter 1.62 ± 0.45 mm) with an average distance of 33.4 ± 11.7 mm from coronary ostium was found in 72% (36/50) cases and formed an acute angle with CS in three (8.33%) cases. CONCLUSIONS: Restrictive TV covering ≥75% CS ostium (25% cases), presence of single prominent tributary (28% cases), and formation of acute angle of tributary with CS axis (1/4 cases with anterolateral vein, 4/29 cases with midlateral vein, 3/36 cases with posterolateral vein, and 3/28 cases with posterior veins of the left ventricle) can impede successful cannulation of CS.

Magnetocardiography for the diagnosis of coronary artery disease: a systematic review and meta-analysis.

BACKGROUND: Coronary artery disease (CAD) has a significant disease burden making early diagnosis and management imperative. Magnetocardiography (MCG) is a relatively new noninvasive technique that allows diagnosis of CAD by recording the magnetic fields generated by the electrical activity of the heart. METHODS: We searched MEDLINE and the Cochrane Central Register of Controlled Trials for prospective studies that evaluated the test characteristics (e.g., sensitivity, specificity, likelihood ratios) of MCG for detection of CAD. Studies were included if they evaluated either patients with stable CAD documented by angiogram or patients presenting initially with acute coronary syndrome and subsequently diagnosed with CAD. The quality of included studies was assessed using an adaptation of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. We performed meta-analyses of sensitivity, specificity and positive and negative likelihood ratios using Meta-DiSc software. RESULTS: Screening of titles and abstracts followed by full-text review yielded seven studies that met our inclusion criteria. Meta-analyses yielded a pooled sensitivity of 83% (95% confidence interval [CI] 80% to 86%) and a specificity of 77% (95% CI 73% to 81%). The pooled positive likelihood ratio was 3.92 (95% CI 2.30 to 6.66) and negative likelihood ratio was 0.20 (95% CI 0.12 to 0.35). Significant heterogeneity was present in all meta-analyses. CONCLUSIONS: The pooled test characteristics for MCG are similar to those of existing noninvasive modalities for diagnosing CAD. Our results suggest that MCG is a potential complementary or alternative tool for noninvasive detection of CAD.

Ruptured Sinus of Valsalva Aneurysm: Use of Multimodality Imaging in Delineating Structure and Function.

Sinus of Valsalva aneurysm is a rare defect that can present with fatal complications in case of rupture. Heart failure symptoms are common due to high fraction of the resultant shunt. Multimodality imaging and invasive hemodynamic assessment is essential for comprehensive evaluation of the defect and guiding surgical planning. We describe the case of a 40-year-old woman who presented with heart failure symptoms and was found to have ruptured sinus of Valsalva aneurysm on transthoracic echocardiogram. Cardiac computed tomography angiography further characterized the defect and the associated anomalies. Right heart catheterization assessed the hemodynamic significance of the left to right shunt. Intraoperative findings highlighted the associated congenital anomalies including supracristal ventricular septal defect. The use of intraoperative transesophageal echocardiography proved essential in detecting worsening of the right ventricular outflow track infundibular dynamic obstruction post repair thus delineating the importance of maintaining adequate cardiac preload. This case highlights a stepwise approach in the anatomical characterization of sinus of Valsalva aneurysm using multimodality imaging and the use of hemodynamic assessment and intraoperative imaging to guide surgical planning.

Deep learning model to predict the need for mechanical ventilation using chest X-ray images in hospitalised patients with COVID-19.

OBJECTIVES: There exists a wide gap in the availability of mechanical ventilator devices and their acute need in the context of the COVID-19 pandemic. An initial triaging method that accurately identifies the need for mechanical ventilation in hospitalised patients with COVID-19 is needed. We aimed to investigate if a potentially deteriorating clinical course in hospitalised patients with COVID-19 can be detected using all X-ray images taken during hospitalisation. METHODS: We exploited the well-established DenseNet121 deep learning architecture for this purpose on 663 X-ray images acquired from 528 hospitalised patients with COVID-19. Two Pulmonary and Critical Care experts blindly and independently evaluated the same X-ray images for the purpose of validation. RESULTS: We found that our deep learning model predicted the need for mechanical ventilation with a high accuracy, sensitivity and specificity (90.06%, 86.34% and 84.38%, respectively). This prediction was done approximately 3 days ahead of the actual intubation event. Our model also outperformed two Pulmonary and Critical Care experts who evaluated the same X-ray images and provided an incremental accuracy of 7.24%-13.25%. CONCLUSIONS: Our deep learning model accurately predicted the need for mechanical ventilation early during hospitalisation of patients with COVID-19. Until effective preventive or treatment measures become widely available for patients with COVID-19, prognostic stratification as provided by our model is likely to be highly valuable.

Clinical predictors and outcomes of patients with pericardial effusion in chronic kidney disease.

BACKGROUND: Pericardial effusion is common in hospitalized patients with chronic kidney disease (CKD). We sought to identify predictors and prognostic impact of pericardial effusion in CKD patients. HYPOTHESIS: Clinical and biochemical parameters can predict pericardial effusion in CKD patients. METHODS: In a retrospective nested case-control design, we analyzed hospitalized adult patients with CKD stage 4, 5, or end-stage renal disease diagnosed with pericardial effusion. Controls were same-stage CKD patients without effusion. RESULTS: Among 84 cases and 61 controls, 44% and 34% were on dialysis, respectively. The mean creatinine was higher among cases versus controls (8.4±6.0 vs. 6.0±3.4 mg/dL, P = 0.002). Effusion was moderate to large in 46% of cases. Independent predictors of any pericardial effusion were serum potassium (OR: 1.95 per 1-mEq/L increment, 95% CI: 1.21-3.13, P = 0.006), serum corrected calcium (OR: 1.33 per 1-mg/dL decrement, 95% CI: 1.11-1.67, P = 0.015), and admission heart rate (OR: 1.29 per 10-bpm increment, 95% CI: 1.03-1.62, P = 0.027). Corrected calcium level was an independent predictor of moderate to large pericardial effusion (OR: 1.38 per 1-mg/dL decrement, 95% CI: 1.04-1.82, P = 0.023). Corrected calcium <8.0 mg/dL demonstrated 95% specificity for moderate to large effusion. Patients with effusion had no significant difference in the composite endpoint of mortality or cardiovascular rehospitalization (P = 0.408). CONCLUSIONS: In hospitalized CKD patients, hypocalcemia may be useful in identifying those with moderate to large pericardial effusion. In this population, pericardial effusion does not seem to be associated with adverse outcomes.

Spatial relationship of coronary sinus-great cardiac vein to mitral valve annulus and left circumflex coronary artery: implications for cardiovascular interventional procedures.

BACKGROUND: The spatial relationship of the coronary sinus-great cardiac vein (CS-GCV) to free posterior portion of the mitral valve annulus (MVA) and left circumflex coronary artery (LCx) has gained importance with the advent of cardiovascular interventional procedures such as percutaneous transvenous mitral annuloplasty (PTMA) and mitral isthmus (MI) ablation. METHODS: In 50 normal (nondilated cardiomyopathy, or non-DCM) and 20 dilated cardiomyopathy (DCM) cadaveric hearts, the diameter and distance from the MVA of CS-GCV and its spatial relationship to LCx along the free posterior portion of the MVA were studied. RESULTS: The diameter of the CS-GCV increased from the beginning to termination in both non-DCM and DCM cases. The CS-GCV was located farthest from the MVA in the vertical plane in the middle of its course and in the horizontal plane at its beginning. The LCx was located above the CS-GCV in direct contact with the epicardial aspect of MI in 12% non-DCM and 15% DCM cases and was wedged between the CS-GCV and MI in 20% non-DCM and 15% DCM cases. CONCLUSIONS: Knowledge of the separation between the CS-GCV and MVA in the horizontal and vertical planes could help in selecting suitable candidates and the preprocedural prediction of success of PTMA. Awareness of the spatial relationship of LCx with CS-GCV in MI would help to reduce the risk of incomplete MI block due to a heat sink effect or damage to the LCx by direct thermal injury during MI ablation.

Terminal branching pattern of the right coronary artery in left-dominant hearts: a cadaveric study.

BACKGROUND: Left coronary dominance has been reported to be associated with increased mortality and severity in case of myocardial ischemia involving left coronary artery. The present cadaveric study was proposed to objectively study and document the termination and branching pattern of the right coronary artery in left-coronary-dominant hearts in relation to the blood supply to the posterior surface of the right ventricle. METHODS: Seventy-five cadaveric hearts were studied. The coronary vessels were injected with colored cellulose acetate butyrate and dissected. The coronary dominance was determined. In left-dominant hearts, branches and termination of the right coronary artery were studied. RESULTS: Left coronary dominance was found in 13% of the specimens. The number of ventricular branches was found to be present as 0, 1, 2, and 4 in two, four, two, and two of the cases, respectively. The average length of the ventricular branch was 12.7 mm with a range of 5-35 mm. The atrial branch was found in 50% of hearts, varying from 2 to 3 mm in length. In three hearts, the acute marginal artery did not give any posterior ventricular branch, while two, three, and five posterior ventricular branches were seen in four, two, and one heart(s), respectively. The length of the posterior ventricular arteries was between 5 and 15 mm. CONCLUSION: The RCA is an inconstant and unreliable source of posterior right ventricular perfusion in a significant percentage of population with left-coronary-dominant hearts. This might be the reason for the increased morbidity and mortality seen in the event of left coronary ischemia.

Diagnostic accuracy retrospectively of electrocardiographic findings and cancer history for tamponade in patients determined to have pericardial effusion by transthoracic echocardiogram.

Unexpected pericardial effusions are often found by frontline providers who perform computed tomography. To study the hypothesis that electrocardiographic findings and whether cancer is known or suspected importantly change the likelihood of tamponade for such providers, all unique patients with moderate or large pericardial effusions determined by transthoracic echocardiography during a 6-year period were retrospectively identified. Electrocardiograms were evaluated by blinded investigators for electrical alternans (total and QRS), low voltage (limb leads only, precordial leads only, and both), and tachycardia (>100 QRS complexes/min). Medical records were reviewed to determine whether cancer was known or suspected and whether tamponade was diagnosed. Tamponade was present in 66 patients (27% of 241) with moderate or large pericardial effusions. No tachycardia lowered the odds of tamponade the most (likelihood ratio 0.4, 95% confidence interval 0.3 to 0.6) but by a degree less than any single diagnostic element increased it when present. The combined presence of all 3 electrocardiographic findings and cancer increased the odds of tamponade 63-fold (likelihood ratio 63, 95% confidence interval 33 to 150), whereas their combined absence decreased the odds only fivefold (likelihood ratio 0.2, 95% confidence interval 0.2 to 0.3). In conclusion, electrocardiography findings and cancer rule in tamponade better than they rule it out. Combining these diagnostic elements improves their discriminatory power but not sufficiently enough to rule out tamponade in patients with moderate or large pericardial effusions.