Prediction of Coronary Atherosclerotic Ostial Lesion with a Damping of the Pressure Tracing during Diagnostic Coronary Angiography

PURPOSE: When performing coronary angiography (CAG), diagnostic catheter intubation to the ostium can cause damping of the pressure tracing. The aim of this study was to determine the predictors of atherosclerotic ostial stenosis in patients showing pressure damping during CAG. MATERIALS AND METHODS: In total, 2926 patients who underwent diagnostic CAG were screened in this study. Pressure damping was defined as an abrupt decline of the coronary blood pressure with a blunted pulse pressure after engagement of the diagnostic catheter. According to CAG and intravascular ultrasound (IVUS), we divided damped ostia into two groups: atherosclerotic ostial lesion group (true lesion group) and non-atherosclerotic ostium group (false lesion group). Clinical and angiographic characteristics were compared between the two groups. RESULTS: The overall incidence of pressure damping was 2.3% (68 patients and 76 ostia). Among the pressure damped ostia, 40.8% (31 of 76 ostia) were true atherosclerotic ostial lesions (true lesion group). The true lesion group had more frequent left main ostial damping and more percutaneous coronary interventions (PCIs) performed on non-ostial lesions, compared to the false lesion group. On multivariate logistic regression analysis, left main ostial damping [hazard ratio (HR) 4.11, 95% confidence interval (CI) 1.24-13.67, p=0.021] and PCI on non-ostial lesion (HR 5.34, 95% CI 1.34-21.27, p=0.018) emerged as independent predictors for true atherosclerotic ostial lesions in patients with pressure damping. CONCLUSION: Left main ostial damping and the presence of a non-ostial atherosclerotic lesion may suggest a significant true atherosclerotic lesion in the coronary ostium.

Impacto do tempo de oclusão na taxa de sucesso e nos resultados da intervenção coronária percutânea em obstruções totais crônicas / Impact of occlusion duration on the success rate and outcomes of percutaneous coronary intervention in chronic total occlusions

Estudos iniciais mostram que oclusões antigas ou com tempo indeterminado têm sido associadas a insucesso da intervenção coronária percutânea (ICP) e a pior prognóstico. Nosso objetivo foi determinar o impacto do tempo de oclusão no sucesso e nos resultados da ICP contemporânea na obstrução total crônica (OTC). Métodos: Analisamos uma coorte retrospectiva de pacientes consecutivos que realizaram ICP em OTC, e que foram comparados de acordo com o tempo de oclusão confirmado (TOC) < 12 meses, ≥ 12 meses, ou indeterminado (TOI).Resultados: Foram tratados 168 pacientes, 122 (72,6%) com TOC (80 < 12 meses, 42 ≥ 12 meses) e 46(24,7%) com TOI. A extensão da lesão foi de 17,0 ± 13,6 mm, em vasos de 2,90 ± 0,58 mm, e a abordagemanterógrada foi utilizada em 98,8% dos casos. Sucesso angiográfico foi obtido em 79,2% dos pacientes (80,0% vs. 73,8% vs. 82,6%; p = 0,73). A principal causa de insucesso foi a incapacidade de cruzar a lesão com o fio-guia (68,6%). O tempo de oclusão não teve impacto na taxa de eventos cardiovasculares hospitalares (4,8% vs. 7,1% vs. 6,0%; p = 0,73), explicados em sua quase totalidade pelos infartos do miocárdioperiprocedimento, ou nos eventos tardios (18,8% vs. 7,1% vs. 15,3%; p = 0,23). Na análise multivariada,comprimento da lesão ≥ 20 mm (odds ratio - OR = 7,27; intervalo de confiança de 95% - IC 95% 1,94-29,1; p = 0,003), calcificação (OR = 4,72; IC 95% 1,19-19,1; p = 0,02) e tortuosidade do segmento ocluído (OR = 15,98; IC 95% 2,18-144,7; p = 0,007) foram preditores de insucesso. Conclusões: O tempo de oclusão não está associado ao aumento da taxa de insucesso do procedimento ou a piores resultados da ICP em OTC...

Initial studies have shown that old occlusions or those with indeterminate occlusion durationhave been associated with percutaneous coronary intervention (PCI) failure and a worse prognosis. This study aimed to determine the impact of occlusion duration on the success and outcomes of contemporary PCI on chronic total occlusion (CTO). Methods: The authors analyzed a retrospective cohort of consecutive patients submitted to PCI in CTO, who were compared according to the confirmed occlusion duration (COD) < 12 months, ≥ 12 months, orindeterminate occlusion duration (IOD).Results: A total of 168 patients were treated, 122 (72.6%) with COD (80 < 12 months, 42 ≥ 12 months) and 46(24.7%) with an IOD. Lesion extension was 17.0 ± 13.6 mm, in 2.90 ± 0.58 mm vessels, and the anterogradeapproach was used in 98.8% of cases. Angiographic success was attained in 79.2% of patients (80.0% vs. 73.8%vs. 82.6%; p = 0.73). The main cause of failure was the inability to cross the lesion with the guidewire (68.6%).Occlusion duration had no impact on in-hospital events (4.8% vs. 7.1% vs. 6.0%; p = 0.73), which were almostentirely explained by periprocedural myocardial infarction, or on late outcomes (18.8% vs. 7.1% vs. 15.3%;p = 0.23). At the multivariate analysis, lesion length ≥ 20 mm (odds ratio - OR = 7.27; 95% confidence interval- 95% IC 1.94-29.1; p = 0.003), calcification (OR = 4.72; 95% CI 1.19-19.1; p = 0.02), and tortuosity of theoccluded segment (OR = 15.98; 95% CI 2.18-144.7; p = 0.007) were predictors of failure...

Myocardial Contrast Defect Associated with Thrombotic Coronary Occlusion: Pre-Autopsy Diagnosis of a Cardiac Death with Post-Mortem CT Angiography

We report the case of a female who died of suspected acute myocardial infarction. Post-mortem CT angiography (PMCTA) was performed with intravascular contrast infusion before the standard autopsy, and it successfully demonstrated the complete thrombotic occlusion of a coronary artery and also a corresponding perfusion defect on myocardium. We herein describe the PMCTA findings of a cardiac death with special emphasis on the potential benefits of this novel CT technique in forensic practice.

Impacto clínico da isquemia e viabilidade miocárdicas após tratamento de oclusão coronária crônica no segmento proximal da artéria descendente anterior / Clinical impact of myocardial ischemia and viability after treatment of proximal left anterior descending artery chronic total occlusions

INTRODUÇÃO: A avaliação da isquemia e viabilidade miocárdicas é recomendável antes da intervenção coronária percutânea (ICP) em oclusões crônicas. Avaliamos os eventos cardiovasculares adversos tardios de pacientes com ICP da oclusão crônica no segmento proximal da artéria descendente anterior, comparando pacientes de acordo com a presença ou não de isquemia ou viabilidade miocárdicas. MÉTODOS: Os pacientes foram alocados nos grupos com isquemia/viabilidade miocárdicas (G1, n = 91) e sem isquemia/viabilidade miocárdicas (G2, n = 65) e avaliados os eventos clínicos combinados tardios (óbito, infarto do miocárdio, revascularização do vaso-alvo e insuficiência cardíaca congestiva). RESULTADOS: A maioria dos pacientes era do sexo masculino (68,1% vs. 69,2%; P = 0,56), com média de idade de 65,4 ± 10,4 anos vs. 63,5 ± 8,7 anos (P = 0,61), e quase um terço era de diabéticos (33% vs. 29,2%; P = 0,76). Os grupos não mostraram diferenças em relação ao perfil clínico-angiográfico, com exceção da fração de ejeção do ventrículo esquerdo (48,6 ± 13,7% vs. 39,5 ± 11,8%; P = 0,04) e do grau de circulação colateral para a artéria descendente anterior, mais evidente no G1 (P = 0,03). A incidência de eventos clínicos combinados em um período de três anos foi menor nos pacientes com isquemia/viabilidade miocárdicas (12,5% vs. 31,1%; P < 0,01). Os fatores que mais contribuíram para essa diferença foram a incidência de insuficiência cardíaca congestiva (3,3% vs. 15,3%; P = 0,02) e óbito (2,2% vs. 7,7%; P = 0,13). CONCLUSÕES: O tratamento de oclusão crônica no segmento proximal da artéria descendente anterior com stent farmacológico, em pacientes com evidência de isquemia ou viabilidade miocárdicas, reduz eventos clínicos a longo prazo.

BACKGROUND: Evaluation of myocardial ischemia and viability is recommended prior to percutaneous coronary intervention (PCI) for chronic total occlusions. We evaluated late adverse cardiovascular events of patients with PCI for proximal left anterior descending artery occlusions, comparing patients with or without myocardial ischemia or viability. METHODS: Patients were allocated to groups with myocardial ischemia/viability (G1, n = 91) and without myocardial ischemia/viability (G2, n = 65) and adverse cardiovascular events (death, myocardial infarction, target-vessel revascularization and congestive heart failure) were compared. RESULTS: Most patients were male (68.1% vs 69.2%; P = 0.56), with a mean age of 65.4 ± 10 years vs 63.5 ± 8.7 years (P = 0.61) and almost one third were diabetics (33% vs 29.2%; P = 0.76). No differences regarding the clinical and angiographic profile were observed, except for the left ventricular ejection fraction (48.6 ± 13.7% vs 39.5 ± 11.8%; P = 0.04) and the degree of angiographic collateral flow grade to the left anterior descending artery, which was more evident in G1 (P = 0.03). The 3-year follow-up incidence of composite adverse cardiovascular events was lower in patients with myocardial ischemia/viability (12.5% vs 31.1%; P < 0.01). The factors that contributed the most for this difference were the incidence of congestive heart failure (3.3% vs 15.3%; P = 0.02) and death (2.2% vs 7.7%; P = 0.13). CONCLUSIONS: Treatment of proximal left anterior descending artery chronic total occlusions in patients with evidence of myocardial ischemia or viability reduces the incidence of adverse cardiovascular events in the long term.

Quem vê coronária não vê coração / Coronary artery no mirror for the heart

Oclusão de uma ou mais artérias coronárias se associa, em geral, a importante comprometimento da função ventricular. Relata-se o caso de um paciente de 64 anos sem história ou eletrocardiograma de infarto agudo do miocárdio prévio, com oclusão proximal de duas importantes artérias coronárias e função ventricular preservada.

In general, occlusion of one or more coronary arteries is associated with significant weakening of the leftventricular function. This case study describes a 64-year old man with no history or electrocardiographic signs ofprior acute myocardial infarction, with proximal occlusion of two main coronary arteries and preserved left ventricular function.

Intervenção coronariana complexa e tardia pós-tratamento quimioterápico / Complex late coronary intervention after chemotherapy

A associação entre o uso de quimioterápicos e a ocorrência de síndromes coronarianas agudas (SCA) ou mesmo infarto agudo do miocárdio (IAM) é rara, todavia constitui complicação por vezes de natureza grave, surpreendendo pacientes em curso de tratamento de uma doença já debilitante. Relata-se um caso dessa ocorrência, representada por um lado pelo uso de paclitaxel (taxol) para o tratamento de câncer de ovário e, do outro, por uma lesão complexa, de bifurcação, tratada percutaneamente.

Although associations between chemotherapy and acutecoronary syndromes or even acute myocardial infarctions are rare, they may result in complications that might even be severe, surprising patients during treatments of diseases that are already debilitating. We present a case study of such an association, represented on the one hand by the use of paclitaxel (Taxol), with a complex coronary lesion (bifurcation) treated percutaneously on the other.