Clinical results of percutaneous coronary intervention in chronic total occlusions of the right coronary artery.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTOs) of the right coronary artery (RCA) are a relatively common finding in the context of coronary angiography. However, the benefit of revascularization remains controversial. METHODS: A single-center retrospective cohort analysis prospectively collected outcomes of CTO patients undergoing percutaneous coronary intervention (PCI) in 2019 and 2020. Patients were divided into two groups according to the CTO vessel treated (left coronary artery [LCA]-CTO or RCA-CTO). The primary outcome was defined as the recurrence of angina and/or heart failure (HF) symptoms and secondary outcomes were myocardial infarction (MI) and all-cause mortality. RESULTS: A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome occurred in 28 (16.6%) patients and was significantly more frequent in RCA-CTO patients (19, 24.7%, p=0.010) in a mean follow-up of 18 months. This was mainly driven by recurrence of HF symptoms (12, 15.6%, p=0.013). Treated RCA-CTO was an independent predictor of the primary outcome (p=0.019, HR 2.66, 95% CI 1.17-6.05). MI and mortality rates were no different between groups (RCA-CTO with 1.3%, p=0.361 and 2.6%, p=0.673, respectively, on survival analysis). Left ventricular ejection fraction was an independent predictor of mortality (p=0.041, HR 0.93, 95% CI 0.87-0.99). CONCLUSIONS: Revascularization of CTO lesions by PCI was associated with low rates of symptom recurrence, and clinical outcomes showed no differences regardless of which artery was treated. Recanalization of RCA-CTO was less beneficial in reducing the recurrence of HF symptoms.

Diagnostic performance of a novel deep learning attenuation correction software for MPI using a cardio dedicated CZT camera. Experience in the clinical practice.

PURPOSE: To evaluate the diagnostic performance of a novel deep learning attenuation correction software (DLACS) for myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) cardio dedicated camera with invasive coronary angiography (ICA) correlation for the diagnosis of coronary artery disease (CAD) in a high-risk population. METHODS: Retrospective study of 300 patients (196 males [65%], mean age 68 years) from September 2014 to October 2019 undergoing MPI, followed by ICA and evaluated by means of quantitative angiography software, within six months after the MPI. The mean pre-test probability score for coronary disease according to the European Society of Cardiology criteria was 37% for the whole cohort. The MPI was performed in a dedicated CZT cardio camera (D-SPECT Spectrum Dynamics) with a two-day protocol, according to the European Association of Nuclear Medicine guidelines. MPI was retrospectively evaluated with and without the DLACS. RESULTS: The overall diagnostic accuracy of MPI without DLACS to identify patients with any obstructive CAD at ICA was 87%, sensitivity 94%, specificity 57%, Positive Predictive Value 91% and Negative Predictive Value 64%. Using DLACS the overall diagnostic accuracy was 90%, sensitivity 91%, specificity 86%, Positive Predictive Value 97% and Negative Predictive Value 66%. CONCLUSION: Use of the novel DLACS enhances performance of the MPI using the CZT D-SPECT camera and achieves improved results, especially avoiding artefacts and reducing the number of false positive results.

Jailed pressure wire technique for coronary bifurcation lesions: structural damage and clinical outcomes.

INTRODUCTION AND OBJECTIVES: The use of a pressure wire as a jailed wire to evaluate side branch results during provisional stenting seems feasible. However, safety concerns exist due to the mechanical damage of the wire and the lack of prospective data evaluating the prognosis of patients treated using this technique. This study sought to evaluate the structural damage of the pressure wire in patients treated using the jailed pressure wire technique and to assess mid-term clinical outcomes. METHODS: We enrolled 99 patients with single bifurcation lesions and provisional stenting as the strategy of choice. A jailed pressure wire was used to guide side branch intervention according to the instantaneous wave-free ratio (iFR). A total of 114 patients and the respective nonpolymer-coated jailed wires were used as historical controls. Guidewire damage was evaluated by stereomicroscopy. The primary endpoint was significant microscopic damage. Major adverse cardiac events were evaluated at 2-year follow-up. RESULTS: Significant microscopic damage was more frequent in pressure wires than in nonpolymer-coated wires (53.5% vs 22.8%, P<.001). There were no fractures in either group. There were fewer side branch interventions in the pressure wire group (postdilation/kissing balloon, 32.3% vs 56.1%, P=.001; stenting, 0.0% vs 2.6%, P=.104). The 2-year rate of major adverse cardiac events was similar between the 2 groups (HRadj, 0.42; 95%CI, 0.10-1.73; P=.229). CONCLUSIONS: Pressure wires were less resistant to jailing than conventional nonpolymer-coated wires. Patients treated with iFR-guided provisional stenting required fewer side branch interventions but had similar 2-year clinical outcomes than patients treated with the angiography-guided technique.

Association between physical activity and coronary artery calcification estimated by computed tomography: A systematic review.

BACKGROUND: The relationship between physical activity and coronary artery calcification (CAC) was evaluated in different studies during the last years, although the results were conflicting. OBJECTIVE: The main objective of the present systematic review was to assess the association between different levels of physical activity and CAC score estimated by computed tomography (CT). METHODS: This systematic review was performed according to PRISMA guidelines. A literature search was performed to detect studies that evaluated the association between physical activity and CAC score. The levels of physical activity evaluated were those reported by the original publications. The CAC score was estimated by CT and was reported in Agatston units. RESULTS: Twenty six studies including 89,405 subjects were considered eligible for this research. The studies developed in the general population showed different results regarding the association between physical activity and CAC score: no association (7 studies), a positive association (4 studies), an inverse relationship (6 studies), a U-shaped relationship (2 studies), or different results depending on the subgroup evaluated (2 studies). In the largest studies, a positive association was observed. When we analyzed the studies that evaluated athletes, four studies showed a positive association between exercise intensity and CAC. CONCLUSION: This systematic review showed disparate results regarding the association between physical activity and CAC score. The largest studies and most studies developed in athletes suggest that intense physical activity could be associated with high CAC score, although this hypothesis should be confirmed in future research.

Diagnostic performance of different cardiac stress protocols for myocardial perfusion imaging for the diagnosis of coronary artery disease using a cadmium-zinc-telluride camera with invasive coronary angiography correlation.

PURPOSE: To evaluate the diagnostic performance of three different cardiac stress protocols for myocardial perfusion imaging (MPI) using a cadmium-zinc-telluride (CZT) camera with invasive coronary angiography (ICA) correlation for the diagnosis of coronary artery disease in a high risk population. METHODS: Retrospective study of 263 patients (96 women and 167 males, mean age 68 years) from which 119 patients performed a bicycle stress test (BST), 113 pharmacological stress test (PST) and 31 a combination of the two (CST) between September 2014 and December 2018. The patients then underwent myocardial perfusion imaging (MPI), followed by ICA and evaluated by means of quantitative angiography software, within six months after the MPI. The mean pre-test probability score for coronary disease according to the European Society of Cardiology criteria was 36% for the whole population. The MPI was performed in a dedicated CZT cardio camera (D-SPECT Spectrum Dynamics) with a two-day protocol, according to the European Association of Nuclear Medicine guidelines. RESULTS: No significant difference was observed between the three stress protocols in terms of diagnostic accuracy (BST 85%, PST 88%, CST 84%). The overall diagnostic accuracy of MPI to identify patients with any obstructive CAD at ICA was 86%, Sensitivity 93%, Specificity 54%, PPV 90% and NPV 63%. CONCLUSION: The CZT D-SPECT camera achieves overall satisfactory results in the diagnosis of CAD, observing no significant differences in the diagnostic performance when the stress test was performed as a BST, PST or CST.

[Takotsubo cardiomyopathy associated with abnormal birth of the coronary arteries]. / Miocardiopatía de Takotsubo asociada al nacimiento anómalo de las arterias coronarias.

Background: Takotsubo cardiomyopathy (TM) is a form of non-ischemic cardiomyopathy. It is characterized by transient regional systolic dysfunction of the left ventricle that mimics acute myocardial infarction. The main objective of this article is to report the case of a patient with TM associated with abnormal birth of the left coronary trunk. Clinical case: A 76-year-old woman with typical angina at rest, with an electrocardiogram that showed dynamic changes in the T wave and elevation of biomarkers. Coronary angiography showed epicardial coronary arteries without significant lesions and abnormal birth of the left coronary trunk from the proximal segment of the right coronary artery. The patient progressed favorably, and the transthoracic echocardiogram showed no mobility disorders 3 months after the event. Conclusions: TM and abnormal birth of the coronary arteries are rare diseases whose simultaneous presentation is extraordinary. The diagnosis of both clinical entities is made by coronary angiography and echocardiogram, and their treatment is similar to that of patients with acute coronary syndrome. Abnormal birth of the left coronary trunk with retroaortic switch reaching the contralateral site has a good clinical prognosis and echocardiographic follow-up should be performed 4 weeks after the onset of the condition.

Introducción: la miocardiopatía de Takotsubo (MT) es una forma de miocardiopatía no isquémica. Se caracteriza por la disfunción sistólica regional transitoria del ventrículo izquierdo que imita al infarto agudo de miocardio. El objetivo principal de este artículo es reportar el caso de una paciente con MT asociada al nacimiento anómalo del tronco coronario izquierdo. Caso clínico: paciente mujer de 76 años que presentó angina típica en reposo, con un electrocardiograma que evidenció cambios dinámicos en la onda T y elevación de biomarcadores. La coronariografía evidenció a las arterias coronarias epicárdicas sin lesiones significativas y el nacimiento anómalo del tronco coronario izquierdo proveniente del segmento proximal de la arteria coronaria derecha. La paciente evolucionó de manera favorable y el ecocardiograma transtorácico no mostró trastornos en la movilidad a los tres meses del evento. Conclusiones: la MT y el nacimiento anómalo de las arterias coronarias son enfermedades raras cuya presentación simultánea es extraordinaria. El diagnóstico de ambas entidades clínicas se realiza mediante la coronariografía y el ecocardiograma, y su tratamiento es similar al de los pacientes con síndrome coronario agudo. El nacimiento anómalo del tronco coronario izquierdo con cruce retroaórtico que alcanza el sitio contralateral tiene un buen pronóstico y se debe realizar seguimiento clínico y ecocardiográfico a las cuatro semanas del inicio del padecimiento.

Fibrinogen-to-albumin ratio is related to the severity of coronary artery disease in chronic kidney disease patients undergoing coronary angiography.

OBJECTIVES: This study was to explore the potential relationship between the fibrinogen-to-albumin ratio (FAR) and the presence and severity of coronary artery disease (CAD) in stage 3-5 predialysis chronic kidney disease (CKD) patients. DESIGN: This study included 978 patients undergoing coronary angiography (CAG). CAD was defined as the presence of obstructive stenosis>50% of the lumen diameter in any of the four main coronary arteries. Gensini scores (GSs), left main coronary artery (LMCA) and three-vessel coronary artery disease (TVD) were used to elevate the severity of CAD. RESULTS: The adjusted odds ratios of CAD were 3.059 (95% CI: 1.859-5.032) and 2.670 (95% CI: 1.605-4.441) in the third and fourth quartiles of FAR compared with the first quartile, respectively. Among 759 patients diagnosed with CAD, multivariate logistic regression analysis showed that FAR (at the 0.01 level) was significantly positively associated with the presence of LMCA (adjusted OR=1.177, 95% CI 1.067-1.299, P=0.001) or TVD (adjusted OR=1.154, 95% CI 1.076-1.238, P<0.001), and a higher GS (adjusted OR=1.152, 95% CI 1.073-1.238, P<0.001). CONCLUSIONS: FAR levels were independently associated with the presence and severity of CAD in stage 3-5 predialysis CKD patients.

Coronary artery bypass grafting in a child with Kawasaki disease.

Kawasaki disease (KD) with cardiac involvement can result in the development of coronary aneurysm, stenosis or thrombosis with significant cardiovascular implications. We report the case of a 23-month-old male with a late diagnosis of KD, in whom intravenous immunoglobulin treatment was not feasible. The patient's course was assessed by routine echocardiography. At the age of five years, angiographic assessment revealed an aneurysm of the anterior descending coronary artery measuring 17 mm×7 mm involving the first diagonal branch, 90% post-aneurysmal stenosis, and an aneurysm of the right coronary artery measuring 32 mm×6 mm. Due to the critical anatomy of the anterior descending artery the revascularization method of choice was coronary artery bypass surgery with an internal mammary artery graft, under cardiopulmonary bypass. There were no significant intraoperative or postoperative complications. This confirms coronary artery bypass grafting as a reliable treatment option for patients who present with coronary sequelae from KD, even at a very young age.

Predictor of in-stent restenosis in patients with drug-eluting stent (PRIDE)- a retrospective cohort study.

BACKGROUND: It is a fact that coronary artery disease (CAD) is more prevalent in India as compared to western countries. The major risk factors associated with the early CAD are a high prevalence of diabetes mellitus, atherogenic lipid profile, smoking habits, sedentary lifestyle, low socioeconomic condition and high prevalence of obesity. Is this true for restenosis after drug-eluting stent (DES) implantation and factors associated with it? The main objective of the study was to determine the rate of in-stent restenosis (ISR) in patients with DES and risk factors associated with it from our region. METHODS: It was a single-center, retrospective cohort study in which 550 patients who underwent DES implantation were included. Patient's demographic data, coronary angiography findings, procedural characteristics and development of ISR were noted. RESULTS: Out of 550 patients, 31 developed ISR with a rate of restenosis of 5.63% and target lesion revascularization (TLR) of 5.63%. On multiple Cox-regression analysis, only diabetes mellitus (DM) (p=0.008, adjusted hazard ratio (HR): 2.757, 95% confidence interval (CI): 1.296-5.863), deployment of stent in the left anterior descending (LAD) artery (p=0.031, adjusted HR: 3.342, 95% CI: 1.115-10.017) and periprocedural complication during percutaneous coronary intervention (p=0.040, adjusted HR: 2.824, 95% CI: 1.049-7.603) were found to be significantly associated with increased risk of ISR. Kaplan-Meier survival analysis of event-free survival for restenosis showed patients with DM had significantly lower event-free survival compared to patients without DM (p=0.005 by log-rank test). CONCLUSIONS: In our study, the rate of restenosis after DES implantation was 5.63%. The presence of DM, the stent in the LAD territory and the periprocedural complication is strongly associated with the development of ISR.

Complete atrioventricular block as an initial manifestation of aortic dissection: A case report.

The right coronary artery involvement occurs in 1-2% of aortic dissection and may cause atrioventricular (AV) block due to obstruction of blood supply to the AV node. A 59-year-old man with a history of hypertension presented to the emergency department with chest pain and complete AV block. After the diagnostic approach, aortic dissection Stanford A was diagnosed. Aortic dissection must be suspected in hypertensive patients who present with AV block and chest pain.

La obstrucción de la coronaria derecha debida a extensión de disección aórtica ocurre en el 1 a 2% de los casos y puede ocasionar bloqueo auriculoventricular. En este caso se presenta a un paciente de 59 años con antecedente de hipertensión que acudió al servicio de urgencias por dolor precordial y bloqueo auriculoventricular completo. Tras el abordaje inicial se diagnosticó disección aórtica (Stanford A). Se debe sospechar la presencia de disección aórtica en pacientes con descontrol hipertensivo, bloqueo auriculoventricular completo y dolor torácico.

Impact of Percutaneous Coronary Revascularization of Severe Coronary Lesions on Secondary Branches.

INTRODUCTION AND OBJECTIVES: To analyze the percutaneous revascularization strategy for severe lesions in the secondary branches (SB) (diameter ≥ 2mm) of major epicardial arteries compared with conservative treatment. METHODS: This study analyzed patients with severe SB lesions who underwent percutaneous revascularization treatment compared with patients who received pharmacological treatment. The study examined the percentage of branch-related events (cardiovascular death, myocardial infarction attributable to SB, or the need for revascularization of the SB). RESULTS: We analyzed 679 SB lesions (662 patients). After a mean follow-up of 22.2±10.5 months, there were no significant differences between the 2 treatment groups regarding the percentage of death from cardiovascular causes (1.7% vs 0.4%; P=.14), nonfatal acute myocardial infarction (AMI) (1.7% vs 1.7%; P=.96), the need for SB revascularization (4.1% vs 5.4%; P=.45) or in the total percentage of events (5.1% vs 6.3%; P=.54). The variables showing an association with event occurrence on multivariate analysis were diabetes (SHR, 2.87; 95%CI, 1.37-5.47; P=.004), prior AMI (SHR, 3.54; 95%CI, 1.77-7.30; P<.0001), SB reference diameter (SHR, 0.16; 95%CI, 0.03-0.97; P=.047), and lesion length (SHR, 3.77; 95%CI, 1.03-1.13; P<.0001). These results remained the same after the propensity score analysis. CONCLUSIONS: The percentage of SB-related events during follow-up is low, with no significant differences between the 2 treatment strategies. The variables associated with event occurrence in the multivariate analysis were the presence of diabetes mellitus, prior AMI, and greater lesion length.

[Percutaneous management of pulmonary atresia with intact ventricular septum and critical pulmonary stenosis]. / Manejo percutáneo de la atresia pulmonar con tabique interventricular íntegro y la estenosis pulmonar crítica.

INTRODUCTION: Pulmonary atresia with intact ventricular septum and critical pulmonary stenosis in newborns encompasses a wide spectrum of disease, including cases with significant right ventricular hypoplasia and coronary artery to right ventricle fistulae, which may be considered a contraindication for decompression of the right ventricle. The aim of this study was to review the middle- and long-term outcomes of these patients over 20 years and identify differential factors between both groups, including patients with coronary artery fistulae. PATIENTS AND METHODS: We performed a descriptive retrospective study by identifying all patients that received a diagnosis of pulmonary atresia with intact ventricular septum and critical pulmonary stenosis between January 1996 and January 2018. We collected and analysed data regarding right ventricular morphology, surgical management, percutaneous intervention and medium- and long-term outcomes. RESULTS: 51 patients were admitted. A total of 9 patients (17.6%) died during the followup. None of the deceased patients had coronary artery to right ventricle fistulae. The median length of follow up in the 42 survivors was 8.9 years (1-16). The functional class based on the latest revision of the New York Heart Association classification was 1.2 for the overall sample. Survivors of critical pulmonary stenosis had a functional class of 1.1, and survivors of pulmonary atresia with intact ventricular septum a functional class of 1.6. There were no differences based on the presence or absence of coronary artery to right ventricle fistulae. CONCLUSIONS: Coronary artery to right ventricle fistulae may not be a contraindication for biventricular strategy. Patients with critical pulmonary stenosis had better outcomes compared to patients with pulmonary atresia with intact ventricular septum. The aggressive strategy of opening the pulmonary valve early on was associated with a good overall survival and correlated to a good functional class.

Right single coronary artery as an incidental finding in Takotsubo syndrome and acute heart failure: Case report and review of the literature.

INTRODUCTION: Single coronary artery (SCA) with no associated congenital heart disease is a rare congenital anomaly. Most cases are asymptomatic and incidental findings, but SCA can cause ischemia, congestive heart failure, and sudden cardiac death (SCD). CASE REPORT: A 44-year-old woman presented with Takotsubo cardiomyopathy and cardiogenic shock. Selective cannulation of the left coronary artery (LCA) was not possible on coronary angiography (CA); an SCA was revealed arising from the right sinus, continuing distally as the circumflex artery and thereafter as the left anterior descending artery. Coronary computed tomography angiography (CCTA) confirmed left main atresia and no coronary stenosis. Cardiac magnetic resonance imaging (MRI) showed diffuse myocardial edema and no perfusion defects. The patient's clinical course was favorable under conservative management. DISCUSSION: Our paper describes an incidental finding of right SCA. We report a Lipton type R-I, in which a dominant right SCA supplies the entire myocardium. It is the rarest SCA presentation, with an incidence of 0.0008%; only 15 cases have been reported in the literature, all of which were studied by CA. Of these 15, one had SCD, five angina, one ventricular arrhythmia and one complicated acute coronary syndrome. CCTA confirmed the diagnosis in seven patients, MRI in one and transesophageal echocardiography in another. Nine patients had coronary lesions. Two underwent coronary artery bypass grafting, one percutaneous intervention and 11 conservative treatment. CONCLUSION: Right SCA with congenital absence of the LCA is one of the rarest coronary artery anomalies. In a significant percentage of patients it is associated with ischemia and can be life-threatening. CCTA and MRI are the modalities of choice for diagnosis and risk stratification.

Revascularización miocárdica completa con injertos arteriales en un paciente con dextrocardia / Complete coronary artery bypass grafting in a patient with dextrocardia

Introducción: la dextrocardia es una rara anomalía cardiaca congénita. Aunque la incidencia de enfermedad coronaria es similar a la población en general, son pocos los casos documentados en la literatura. La disposición anatómica en esta anomalía constituye un desafío a la hora de planificar la técnica quirúrgica y los injertos a utilizar. Presentación del caso: paciente de 59 años con enfermedad coronaria de 2 vasos que fue sometido a una cirugía de revascularización arterial completa.

Introduction: dextrocardia is a rare congenital heart abnormality. Although the incidence of coronary heart disease is similar to that in the general population, few cases have been documented in the literature. Anatomic variants in this anomaly are a challenge when planning the surgical technique and the choice of graft configuration to be used. Case presentation: a 59 -year- old patient with 2-vessel coronary artery disease who underwent coronary artery bypass grafting

Anomalous aortic origin of the left coronary artery / Origen aórtico anómalo de la arteria coronaria izquierda

Abstract We present an unusual case of an anomalous left coronary artery arising from the contralateral sinus of Valsalva: a 63-year-old male patient who consulted to our emergency department with 1-week history of progressive dyspnea on exertion with clinical signs of heart failure, associated with lung congestion on the chest X ray and elevated NT-proBNP levels (2000 pg/ml; normal value <150). Doppler echocardiography showed severe dilation of both left atrium and left ventricle, with severe deterioration of LV systolic function (Ejection fraction of 26%), global hypokinesia and a moderate mitral regurgitation with central jet. A cardiac cath eterization was performed, which evidenced an anomalous origin of the left main coronary artery from the right coronary sinus with a proximal lesion of nearly 50%. A coronary computed tomographic angiography confirmed the diagnosis of an anomalous origin with an intramyocardial path at the level of the interventricular septum, as sociated with moderate extrinsic compression. To determine the degree of functional ischemia presented by the left main coronary artery lesion we performed a fractional flow reserve evaluation, resulting in 0.75, which was ranked as significant. An angioplasty with implantation of a drug-eluting stent (with Everolimus) was performed successfully to the target lesion. The patient evolved favorably during hospitalization and was discharged from the medical center to continue outpatient follow-up. Patient remained asymptomatic at 1-month and 6 months, during clinical evaluation, without evidence of ischemia on noninvasive functional assessment.

Resumen Presentamos un raro caso de nacimiento anómalo de arteria coronaria izquierda en el seno de Valsalva contralateral. Se trata de un hombre de 63 años que consultó al servicio de emergencias de nuestro centro por disnea progresiva de una semana de evolución, con signos clínicos de insuficiencia cardíaca, aso ciado a signos de congestión en la radiografía de tórax, y valores de NT-proBNP elevados (2000 pg/ml; valor normal <150). El ecocardiograma Doppler evidenció dilatación grave de la aurícula y del ventrículo izquierdo, con deterioro grave de la función sistólica (fracción de eyección de 26%), hipoquinesia global e insuficiencia mitral moderada con jet central. Se realizó una cinecoronariografía que evidenció el nacimiento anómalo del tronco de arteria coronaria izquierda desde el seno coronario derecho, con una lesión cercana al 50%. Una angiotomografía coronaria confirmó el origen anómalo del vaso coronario, con trayecto intramiocárdico a nivel del septum interventricular asociado a compresión extrínseca moderada. Para determinar el grado de isquemia funcional que presentaba la lesión del tronco coronario izquierdo se evaluó la reserva de flujo fraccional, que arrojó un resultado de 0.75 el cual se consideró significativo, prosiguiendo a angioplastia con implante de stent liberador de droga (con Everolimus) a dicha lesión. El paciente evolucionó favorablemente durante la internación en el hospital, egresando de la institución para continuar seguimiento ambulatorio. Persistió asintomático en los controles realizados al mes y a los 6 meses, sin evidencia de isquemia en la evaluación funcional no invasiva.

Variant origin of the right coronary artery from the left main coronary artery together with aortic valve stenosis: report of a rare case / Origen variante de la arteria coronaria derecha a partir de la arteria coronaria izquierda junto con estenosis de la valva aórtica: reporte de un caso raro

SUMMARY: Variations in the origin of the right coronary artery have an incidence between 0.09 % and 0.92 %. Herein, we report a rare case of a coronary artery anomaly in which the right coronary artery originates from the left main coronary artery. This variant was found during routine coronarography, combined with an artificial aortic valve. Despite their rare occurrence, some variations in the origins of the coronary arteries can be life threatening and are associated with a higher risk of sudden cardiac death. They can also pose serious technical challenges and predispose to complications during coronary angiographic procedures. Thus, knowledge of such anomalies is paramount for managing the patients correctly.

Las variaciones en el origen de la arteria coronaria derecha tienen una incidencia entre el 0,09 % y el 0,92 %. En este documento, informamos un caso raro de una anomalía de la arteria coronaria en la que la arteria coronaria derecha se originaba en la arteria coronaria izquierda. Esta variante se encontró durante una coronariografía de rutina, combinada con una válvula aórtica artificial. A pesar de su rara aparición, algunas variaciones en los orígenes de las arterias coronarias pueden poner en peligro la vida y se asocian con un mayor riesgo de muerte súbita cardíaca. También pueden plantear serios desafíos técnicos y predisponer a complicaciones durante los procedimientos angiográficos coronarios. Por tanto, el conocimiento de dichas anomalías es fundamental para el manejo correcto de los pacientes.

Práticas clínicas aplicadas a pacientes com infarto do miocárdio sem obstrução de artéria coronária (minoca) / Clinical Practices Applied To Patients With Myocardial Infarction Non-obstruction Coronary Arteries (Minoca) / Prácticas clínicas aplicadas a pacientes con infarto e miocardio sin obstruccion arteria coronaria (MINOCA)

Objetivo: Identificar práticas clínicas com resultados favoráveis aos pacientes com diagnóstico de infarto agudo do miocárdio sem obstrução de artéria coronária. Método: Revisão integrativa da literatura pela base de dados National Library of Medicine e Biblioteca Virtual de Saúde de estudos publicados entre 2018 e 2022. Resultados:87,5% dos estudos encontrados destacaram estratégias farmacológicas e destes, 62,5% citaram o uso da dupla antiagregaçãoplaquetária como mais utilizada, apesar de nenhum estudo evidenciar benefícios. Os inibidores do sistema renina-angiotensina-aldosterona comprovaram benefícios em três estudos. 75% dos artigos apontaram que esse grupo de pacientes recebem menos medicamentos preventivos comparados aos pacientes com infarto por obstrução coronariana. Outros seis estudos, revelaram condução clínica variável desses pacientes. Conclusão: O uso de inibidores do sistema renina-angiotensina-aldosterona deve ser considerado por ser a única medicação com redução da mortalidade evidenciada. São necessários estudos maiores para orientar com mais segurança à condução do infarto do miocárdio sem obstrução de coronária.(AU)

Objective: To identify clinical practices with favorable results for patients diagnosed with acute myocardial infarction without coronary artery obstruction. Method: Integrative literature review using the National Library of Medicine and Virtual Health Library databases of studies published between 2018 and 2022. Results: 87.5% of the studies found highlighted pharmacological strategies and of these, 62.5% cited the use of dual antiplatelet therapy as the most used, despite no study showing benefits. Inhibitors of the renin-angiotensin-aldosterone system have shown benefits in three studies. 75% of the articles pointed out that this group of patients receive less preventive medication compared to patients with infarction due to coronary obstruction. Another six studies revealed variable clinical management of these patients. Conclusion: The use of renin-angiotensin-aldosterone system inhibitors should be considered as it is the only medication with proven reduction in mortality. Larger studies are needed to guide with more safety the management of myocardial infarction without coronary obstruction.(AU)

Objetivo: Identificar prácticas clínicas con resultados favorables para pacientes con diagnóstico de infarto agudo de miocardio sin obstrucción arterial coronaria. Método: revisión integrativa de la literatura utilizando las bases de datos de la Biblioteca Nacional de Medicina y la Biblioteca Virtual en Salud de estudios publicados entre 2018 y 2022. Resultados: el 87,5% de los estudios encontrados destacaron estrategias farmacológicas y de estos, el 62,5% citó el uso de la terapia antiplaquetaria dual como el más utilizados, a pesar de que ningún estudio muestra beneficios. Los inhibidores del sistema renina-angiotensina-aldosterona han mostrado beneficios en tres estudios. El 75% de los artículos señalaron que este grupo de pacientes recibe menos medicación preventiva en comparación con los pacientes con infarto por obstrucción coronaria. Otros seis estudios revelaron un manejo clínico variable de estos pacientes. Conclusión: Se debe considerar el uso de inhibidores del sistema renina-angiotensina-aldosterona, ya que es el único medicamento con reducción comprobada de la mortalidad. Son necesarios estudios más amplios que orienten con mayor seguridad el manejo del infarto de miocardio sin obstrucción coronaria.(AU)

Coronary artery abnormalities: Current clinical issues.

INTRODUCTION AND OBJECTIVE: Patients with anomalous coronary arteries arising from the opposite sinus of Valsalva (ACAOS), the left coronary artery (LCA) arising from the right sinus or the right coronary artery (RCA) from the left sinus with an interarterial course, may present from complete absence of symptoms to sudden cardiac death. Although there are guidelines on indications for surgery, controversy remains. METHODS: A retrospective review was performed of all adult patients diagnosed with ACAOS in our hospital between 2007 and 2016. Demographic, clinical, perioperative and follow-up data were collected from clinical records and summarized. A review of the published literature was performed with special emphasis on clinical presentation, surgical indications and results. RESULTS: Seven symptomatic patients underwent surgery (mean age 57.1±8.9 years, two male, five female); they recovered without complications and to date have had no recurrence of myocardial ischemia. One asymptomatic patient with an anomalous RCA has been medically followed without evidence of myocardial ischemia. A 75-year-old woman, diagnosed in 2008 with an anomalous LCA, was not referred for surgery and died suddenly six months after diagnosis. CONCLUSIONS: Surgery for coronary abnormalities is performed with low risk and all published series report full operative survival. The indications for surgery are well established for patients with interarterial anomalous LCA and symptomatic patients with interarterial anomalous RCA. However, there is some uncertainty concerning asymptomatic patients, particularly those with an anomalous interarterial RCA, for whom we propose a more assertive approach, if young or engaged in strenuous activities.

An unusual cause of ischemia after coronary bypass grafting!!

Coronary subclavian steal syndrome is an uncommon cause of ischemia recurrence after coronary artery bypass grafting. Endovascular treatment of subclavian artery stenosis or occlusion is increasingly common and appears to offer a safe and effective alternative to surgical revascularization. We report a case of recurrent angina after coronary artery bypass grafting for critical subclavian artery stenosis. The anomalous origin of the vertebral artery from the aortic arch was an indication for endovascular treatment. We discuss the diagnostic difficulties and the management pitfalls of subclavian artery angioplasty in this syndrome.

Experiência inicial com a extensão de cateter-guia ExpressmanTM em um centro terciário de cardiologia de alto volume / Initial experience with the ExpressmanTM guide catheter extension in a high-volume tertiary cardiology center

Introdução: As extensões de cateter-guia fornecem maior suporte em intervenções coronárias percutâneas complexas. O ExpressmanTM é uma nova extensão de cateter-guia, e nosso objetivo foi avaliar o impacto de seu uso no sucesso do procedimento e nas complicações ocorridas em um centro de referência de alto volume. Métodos: Analisamos os dados de todos os procedimentos consecutivos em que foi usada uma extensão de cateter-guia ExpressmanTM. A decisão de usar uma extensão de cateter-guia ficou a critério do operador. O sucesso do dispositivo foi definido como o posicionamento bem-sucedido da extensão de cateter-guia dentro do vaso coronário, e o sucesso do procedimento foi definido como <20% de estenose residual e fluxo TIMI 3, sem perda significativa de ramos laterais. Eventos adversos cardíacos e cerebrovasculares maiores foram definidos como a combinação morte por todas as causas, infarto do miocárdio, revascularização do vaso-alvo e acidente vascular cerebral. Resultados: Foram incluídos 34 procedimentos entre abril de 2022 e janeiro de 2023. A maioria dos pacientes era do sexo masculino (59%), e a média de idade foi 66,5 anos. O uso da extensão de cateter-guia não foi planejado antes do procedimento em 17 procedimentos (50%). Os motivos mais comuns para o uso da extensão de cateter-guia foram angulação ou tortuosidade do vaso-alvo e posição desfavorável do óstio coronário. O sucesso do dispositivo foi obtido em 88% e o da revascularização, em 91%. Houve três oclusões de ramo lateral. Durante o acompanhamento clínico intra-hospitalar, não ocorreram sangramento e nem eventos adversos cardíacos e cerebrovasculares maiores. Conclusão: O sucesso do dispositivo e do procedimento foi alto, e a taxa de complicações foi baixa. O uso da extensão de cateter-guia como técnica de resgate em anatomias complexas permitiu o sucesso do procedimento na maioria dos pacientes que, de outro modo, não poderiam ser tratados.

Background: Guide catheter extensions provide increased support in complex percutaneous coronary interventions. The ExpressmanTM is a novel guide catheter extension and the objective was to assess the impact of its use on procedural success and complications in a high-volume reference center. Methods: We analyzed data from all consecutive procedures in which the ExpressmanTM guide catheter extension was used. The decision to use a guide catheter extension was at operator's discretion. Device success was defined as the successful positioning of the guide catheter extension in the coronary vessel and procedural success was defined as <20% residual stenosis and TIMI 3 flow, with no loss of significant side branches. Major adverse cardiac and cerebrovascular events were defined as the composite of all-cause death, myocardial infarction, target vessel revascularization and stroke. Results: From April 2022 to January 2023, 34 procedures were included. The majority of the patients were male (59%) and the mean age was 66.5 years. Guide catheter extension use was not planned pre-procedure in 17 procedures (50%). The most common reasons for guide catheter extension use were target vessel angulation or tortuosity and unfavorable coronary ostium position. Device success was obtained in 88% and revascularization success in 91%. There were three side branch occlusions. During in-hospital clinical follow-up, no major adverse cardiac and cerebrovascular events or major bleeding occurred. Conclusion: The device success and procedural success were high and the rate of complications was low. Guide catheter extension use as bailout technique in complex anatomies allowed procedural success in the vast majority of otherwise untreatable patients.