Management of Coronary Artery Aneurysms at the Time of Surgical Revascularization.

BACKGROUND: Coronary artery aneurysms (CAAs) represent a rare pathology occurring in 1.5%-5% of routine coronary angiograms. Limited data exist on the management of CAA at the time of cardiac surgery. MATERIALS AND METHODS: A single-institution retrospective review was performed on 53 patients who underwent cardiac surgery in the setting of atherosclerotic CAA between 1993 and 2015. Patients were stratified based on treatment strategy: exclusion and distal bypass (n = 26) versus revascularization alone (n = 27). Comparisons were made with respect to mortality, need for further/concomitant interventions, and long-term cardiac function including myocardial infarctions and congestive heart failure. RESULTS: A total of 53 patients underwent cardiac surgery in the setting of CAA disease. Management strategies included ligation and bypass in 26 patients and distal bypass only in 27 patients (with four of the patients in this group undergoing coronary stenting across the aneurysm). There were no significant differences in patient demographics between the two groups. No significant difference was found in either 30-d (P = 0.74) or long-term mortality when exclusion of the CAA was performed compared with revascularization alone (P = 0.20). More exclusion procedures were performed earlier in the experience (median surgical date 2000), whereas revascularization alone predominated later in the experience (median surgical date 2007; P ≤ 0.001). CONCLUSIONS: The practice of CAA exclusion, while still performed in selected cases, has largely been supplanted in patients undergoing revascularization. Exclusion does not appear to offer any advantage over isolated revascularization, supporting the current trends in managing this rare condition.

The Influence of Diffuse Left Anterior Descending Artery Lesions on Outcomes of Coronary Artery Bypass Grafting.

BACKGROUND: Diffuse coronary lesions adversely influence the outcomes of coronary artery bypass grafting (CABG). This study aimed to investigate the influence of diffuse left anterior descending artery (LAD) lesions on the outcomes of CABG. METHODS: The data of 123 patients, who received elective isolated CABG with the left internal mammary artery bypassed to the LAD from January 2011 to June 2017, were collected. According to their lesions (≥50% diameter stenoses) ≤2cm or >2cm in the middle and distal segment of LAD, the patients were classified into a No Diffuse Lesion (NDL) group (69 patients) and a Diffuse Lesion (DL) group (54 patients). The rates of in-hospital mortality, 5-year all-cause mortality, and major cardiac events (MCEs) (i.e. myocardial infarction, angina, acute heart failure, and atrial fibrillation) were analyzed. RESULTS: According to the univariate analyses, the NDL group had fewer diffuse left circumflex artery (LCX) lesions (P = .001) and higher ventricular fibrillation (Vf) after aortic de-clamping (P = .03) than the DL group. According to the multivariate analyses, the in-hospital and 5-year all-cause mortality rates of the two groups did not significantly differ (P = .80 and P = .59). Otherwise, the DL group had a trend toward more MCEs (hazard ratio = 2.07, P = .061), but the difference clearly was insignificant after adjusting for diffuse LCX lesions and Vf after aortic de-clamping (P = .104). CONCLUSIONS: The results demonstrated that diffuse LAD lesions did not influence the risks of in-hospital mortality, 5-year all-cause mortality, or MCEs after CABG.

Utilization and outcomes of polytetrafluoroethylene covered stents in patients with coronary artery perforation and coronary artery aneurysm: Single center 15-year experience.

OBJECTIVES: Determine the outcomes of polytetrafluoroethylene (PTFE) covered stents for coronary artery perforation (CAP) and coronary artery aneurysm (CAA). BACKGROUND: PTFE covered stents have been used for treatment of potentially life-threatening CAP and CAA. The short and long-term outcomes of the PTFE covered stent for CAP and CAA have not been well studied. METHODS: We performed a retrospective study of PTFE covered stents that were placed in the patients from 2003 to 2017. Short term outcomes included in-hospital mortality, pericardial effusion, cardiac tamponade, and length of stay. Long-term outcomes included target lesion revascularization (TLR), in-stent restenosis (ISR), and long-term mortality. RESULTS: Fifty-three PTFE covered stents were placed in 32 patients of which there were 24 patients with a CAP with a mean age of 75 ± 8 years. Two patients died in-hospital, with no additional deaths at 30 days. The rate of ISR was 25%, with estimated rates of TLR of 2.6% (3 years) and 17.8% (5 years). The median survival was 55.6 months, with survival at 10 years estimated to be 30.9%. Eight patients received a PTFE covered stent for CAA with a mean age of 59 ± 15 years with no in-hospital or 30-day mortality. Median follow-up of 49 months showed no evidence of TLR. The all-cause mortality was 12% at 1 year and 38% at 3 years. CONCLUSIONS: PTFE covered stents is an effective option in patients with CAP and CAA. The long-term outcomes may be related to the pathology of the disease rather than the stent itself.

Prognostic significance, angiographic characteristics and impact of antithrombotic and anticoagulant therapy on outcomes in high versus low grade coronary artery ectasia: A long-term follow-up study.

OBJECTIVES: To assess the prognostic significance of high vs. low grade coronary artery ectasia (CAE) and the impact of antithrombotic or anticoagulant therapy on adverse cardiac outcomes. BACKGROUND: There is paucity of knowledge on the impact of angiographic characteristics in CAE or that of antithrombotic or anticoagulant therapy on outcomes. METHODS AND RESULTS: In this retrospective study, we reviewed angiograms and medical records of all cases of confirmed CAE (2001-2011). Extent of CAE was categorized using the Markis classification. Types 1 and 2 were categorized as high-grade and types 3 and 4 as low-grade CAE. Angiographic flow was recorded as normal or sluggish (

Clinical outcomes of patients with coronary artery aneurysm after the first generation drug-eluting stent implantation.

OBJECTIVES: We sought to investigate the long-term clinical outcomes of patients with coronary artery aneurysm (CAA) after drug-eluting stent (DES) implantation, compared with patients without CAA. BACKGROUND: CAA developed after DES implantation is a rare but associated with poor clinical outcome. METHODS: We retrospectively compared 78 patients with CAA after DES implantation with 269 patients without CAA who underwent DES implantation for complex lesions (controls). The primary endpoint was defined as major adverse cardiac events (MACE), the composite of all-cause death, nonfatal myocardial infarction (MI), and target lesion revascularization (TLR). RESULTS: Morphologically, CAAs were saccular (32%), fusiform (13%), or microform (55%). The stent types involved were Cypher (n = 56, 71.8%) and Taxus (n = 22, 28.2%). During a median follow-up period of 1164 days, the incidence of MACE was significantly higher in the CAA group (26.9 vs. 2.2%, P < 0.001); the difference was driven mainly by nonfatal MI (11.5 vs. 0%, P < 0.001) and TLR (20.5 vs. 1.9%, P < 0.001). The incidence of stent thrombosis was higher in the CAA group (12.8 vs. 0.74%, P < 0.001), irrespective of the maintenance of dual antiplatelet therapy. In the CAA group, Cox regression analysis showed significantly higher hazard ratios of CAA for MACE during the follow-up period. Further analyses after propensity-score matching of 65 pairs also showed similar results. CONCLUSIONS: The incidence of MACE was higher in patients with CAA compared with patients without CAA after DES implantation. This difference was driven by TLR and nonfatal MI and widened over time.

Coronary Artery Ectasia Predicts Future Cardiac Events in Patients With Acute Myocardial Infarction.

OBJECTIVE: Coronary artery ectasia (CAE) is an infrequently observed vascular phenotype characterized by abnormal vessel dilatation and disturbed coronary flow, which potentially promote thrombogenicity and inflammatory reactions. However, whether or not CAE influences cardiovascular outcomes remains unknown. APPROACH AND RESULTS: We investigated major adverse cardiac events (MACE; defined as cardiac death and nonfatal myocardial infarction [MI]) in 1698 patients with acute MI. The occurrence of MACE was compared in patients with and without CAE. CAE was identified in 3.0% of study subjects. During the 49-month observation period, CAE was associated with 3.25-, 2.71-, and 4.92-fold greater likelihoods of experiencing MACE (95% confidence interval [CI], 1.88-5.66; P<0.001), cardiac death (95% CI, 1.37-5.37; P=0.004), and nonfatal MI (95% CI, 2.20-11.0; P<0.001), respectively. These cardiac risks of CAE were consistently observed in a multivariate Cox proportional hazards model (MACE: hazard ratio, 4.94; 95% CI, 2.36-10.4; P<0.001) and in a propensity score-matched cohort (MACE: hazard ratio, 8.98; 95% CI, 1.14-71.0; P=0.03). Despite having a higher risk of CAE-related cardiac events, patients with CAE receiving anticoagulation therapy who achieved an optimal percent time in target therapeutic range, defined as ≥60%, did not experience the occurrence of MACE (P=0.03 versus patients with percent time in target therapeutic range <60% or without anticoagulation therapy). CONCLUSIONS: The presence of CAE predicted future cardiac events in patients with acute MI. Our findings suggest that acute MI patients with CAE are a high-risk subset who might benefit from a pharmacological approach to controlling the coagulation cascade.

Cardiac Events and the Maximum Diameter of Coronary Artery Aneurysms in Kawasaki Disease.

OBJECTIVES: To clarify the occurrence of cardiac events based on the maximal diameter of the maximal coronary artery aneurysm (CAA) in Kawasaki disease (KD). STUDY DESIGN: Two hundred fourteen patients (160 male and 54 female) who had had at least 1 CAA in the selective coronary angiogram less than 100 days after the onset of KD were studied. We measured the maximal CAA diameters in the major branches of the initial coronary angiograms. Death, myocardial infarction and coronary artery revascularization were included as cardiac events in this study. We divided the patients into three groups based on the maximal CAA diameter (large ≥8.0 mm; medium ≥6.0 mm and <8.0 mm; small <6.0 mm). Further, we also analyzed the cardiac events based on laterality of maximal CAA (bilateral, unilateral) and body surface area (BSA). RESULTS: Cardiac events occurred in 44 patients (21%). For BSA < 0.50 m2, the 30-year cardiac event-free survival in the large and medium groups was 66% (n = 38, 95% CI, 49-80) and 62% (n = 27, 95% CI, 38-81), respectively. For BSA ≥ 0.50 m2, that in large group was 54% (n = 58, 95% CI, 40-67). There were no cardiac events in the medium group for BSA ≥0.50 m2 (n = 36) and the small group (n = 56). In the large analyzed group, the 30-year cardiac event-free survival in the bilateral and unilateral groups was 40% (n = 48, 95% CI, 27-55) and 78% (n = 48, 95% CI, 63-89), respectively (P < .0001). CONCLUSIONS: The group with the highest risk of cardiac events was the patient group with the maximal CAA diameter ≥6.0 mm with BSA < 0.50 m2 and the maximal CAA diameter ≥8.0 mm with BSA ≥ 0.50 m2. At 30 years after the onset of KD, cardiac event-free survival was about 60%. Given the high rate of cardiac events in this patient population, life-long cardiovascular surveillance is advised.

Indications and immediate and long-term results of a novel pericardium covered stent graft: Consecutive 5 year single center experience.

BACKGROUND: The use of covered stent grafts during percutaneous coronary intervention (PCI) is a life saving solution to seal acute iatrogenic vessel rupture. However, the presence of an impenetrable mechanical barrier is also appealing during treatment of friable coronary plaques but the synthetic PTFE-membrane that might trigger excessive neointimal proliferation has limited its elective-use. Pericardium tissue may offer an appealing "natural" alternative. Aim of our study is to report the consecutive 5-year single center experience with the use of pericardium-covered stents (PCS) (ITGI-Medical, Israel) in a variety of emergency and elective applications. METHODS: Nineteen consecutive patients undergoing implantation of PCS at the Royal Brompton in the last 5-years. Reasons for PCS implantation included treatment of degenerated vein grafts, large coronary aneurysms, and acute iatrogenic vessel rupture. RESULTS: Angiographic success, defined as the ability of the device to be deployed in the indexed lesion with no contrast extravasation with residual angiographic stenosis <30% and a final thrombolysis in myocardial infarction (TIMI)-3 flow was achieved in all cases. Procedural success, defined as the achievement of angiographic success without any major adverse cardiovascular event (MACE) was achieved in 94.7% of patients. In-stent restenosis (ISR) was observed in 26.3% and all patients underwent successful target vessel revascularization with DES (mean time to restenosis 9.0 ± 4.0 months). At a mean follow-up of 32.5 ± 23.3 months no acute or late stent thrombosis was observed. CONCLUSION: PCSs were effective in the treatment of friable embolization-prone coronary plaques, sealing of acute iatrogenic vessel rupture and exclusion of large aneurysms with no thrombosis but high target lesion revascularization.

Cardiac Complications in 38 Cases of Kawasaki Disease with Coronary Artery Aneurysm Diagnosed by Echocardiography.

BACKGROUND: The long-term prognosis of patients with Kawasaki disease (KD) complicated by coronary artery aneurysm (CAA) is unclear. The aim of this study was to evaluate the complications of KD with CAAs. METHOD: We retrospectively analyzed the clinical data and complications of 38 KD patients with CAAs who were treated and underwent regular follow-up with echocardiography between January 1989 and May 2013. RESULTS: During a period of 29 days to 19 years after disease onset, complications seen included coronary stenosis and occlusion (six patients), thrombosis (17 patients), myocardial infarction (six patients), and calcification of CAAs (seven patients). Rupture of giant CAAs occurred in two patients and caused sudden death in one of these patients at 29 days and in the other patient at 5 months after disease onset. A total of seven deaths occurred, with five deaths caused by myocardial infarction. Three of these had undiagnosed incomplete KD or had not received regular treatment, while two experienced sudden death after several asymptomatic myocardial infarctions. CONCLUSION: Cardiac complications of KD with CAAs include thrombosis, coronary stenosis, myocardial infarction, sudden death, and calcification. Although rare, rupture of giant CAAs is fatal and might occur earlier after the onset of disease. Mortality occurred primarily in the earlier cases when anticoagulant therapy was insufficient and in patients who did not receive regular treatment. Echocardiography can provide reliable information for assessing the progression and prognosis of this condition.

Long-term prognosis of patients with Kawasaki disease complicated by giant coronary aneurysms: a single-institution experience.

BACKGROUND: Some patients with Kawasaki disease develop giant coronary aneurysms and coronary stenosis, leading to ischemic heart disease. The aim of this study was to determine the long-term prognosis of patients with Kawasaki disease with giant aneurysms. METHODS AND RESULTS: From our institutional database, 76 patients (57 men and 19 women) who developed giant aneurysms after January 1, 1972, were identified. Information on patient demographics, catheter and surgical interventions, and most recent status was collected from medical charts and patients' contacts. From these data, we calculated the survival rate and cumulative coronary intervention rate. The average age at onset was 2.9±2.9 years, and the median observational period was 19 years. During this period, 7 patients died and 1 patient underwent a heart transplantation, resulting in 95%, 88%, and 88% survival rates at 10, 20, and 30 years after the onset of KD, respectively. On the other hand, catheter and surgical coronary interventions (median, 1 intervention; range, 1 to 7 interventions) were performed to alleviate coronary ischemia in 46 patients (61%) at 1 month to 21 years (mode at 1 month) after onset, resulting in 28%, 43%, and 59% cumulative coronary intervention rates at 5, 15, and 25 years after onset, respectively. CONCLUSIONS: The long-term survival of patients with Kawasaki disease complicated by giant coronary aneurysms is moderately good with multiple catheter and surgical interventions. Further research should focus on the prevention of coronary vascular remodeling and on the indications for and effectiveness of percutaneous and surgical coronary interventions.

Infected ("Mycotic") coronary artery aneurysm: Systematic review.

BACKGROUND: Infected coronary artery aneurysms (ICAA) represent a rare but potentially fatal complication of pre-existent atherosclerotic or non-atherosclerotic coronary artery disease, percutaneous coronary artery intervention, endocarditis or extracardiac infection. METHODS: A retrospective analysis of four cases in addition to 51 infected coronary artery aneurysms from the literature, for a total of 55 ICAA was performed. Clinical and morphological information including age, sex, clinical presentation, microbial cultures, size, location and associated abnormalities as well as patient outcome was reviewed. RESULTS: 83% of affected patients were adult males, with an average age of 55.24 years. The right coronary artery was the most commonly affected vessel (40%). In nearly 80% of the time, the responsible organism was either Staphylococcus aureus (53.3%), or Streptococcus (20%) infection. ICAA are typically large, on average 3.4 cm in diameter and can measure up to 9 cm. On contrast enhanced CT, imaging features include lobulated contour or saccular shape (54.2%) with thick wall or mural thrombus (87.5%). Associated abnormal appearance of the pericardium with either pericardial fluid, thickening or loculation is common (79.2%). CONCLUSION: ICAA are typically large, and characterized by a thick wall with a lobulated or saccular shape. Association with mediastinal, chest wall or pericardial abnormalities are common. This combination of findings, in the setting of fever, known infection, or recent coronary intervention should raise concern for ICAA.

Coronary artery ectasia: prevalence, angiographic characteristics and clinical outcome.

OBJECTIVE: Determine coronary artery ectasia (CAE) prevalence and clinical outcome in a large cohort of patients underwent coronary angiography. METHODS: In an 11-year period, between 2006 and 2017, 20 455 coronary angiography studies were performed at a large university centre. Patients diagnosed with CAE based on procedure report were included in the final analysis. RESULTS: CAE was diagnosed in 174 out of 20 455 studies (0.85% per total angiograms, 161 patients). Patients' average age was 59.6±11.2 years old with male predominance (90.7%). Diffuse ectasia morphology was most common (78.9%), followed by fusiform (16.1%) and saccular (5%). Mixed CAE and atherosclerotic heart disease (ASHD) was present in 75.2% of the patients and isolated CAE in 24.8%. The most common coronary artery involved was the right coronary artery (RCA) (79%). Following index angiography, all the isolated CAE group was managed conservatively, while 67% of the mixed CAE-ASHD group underwent coronary intervention. In an average follow-up of 6±3.6 years, adverse clinical event (a composite endpoint of any death, cerebrovascular accident, myocardial infarction, thromboembolic event, bleeding and stent thrombosis) occurred in 48.8% of the mixed CAE-ASHD group compared with 25% in the isolated CAE group (p<0.05). CONCLUSIONS: CAE is a rare phenomenon. The most common artery involved was the RCA, and the diffused type of CAE was the most frequent. Most patients with CAE have also concomitant ASHD, and those patients have higher mortality and complications rate, compared with isolated CAE disease.

Spontaneous coronary artery dissection: a Western Denmark Heart Registry study.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that associates with a high acute-phase mortality rate, whereas long-term outcome is less well described. OBJECTIVE: To describe the incidence, predictors, and prognosis of SCAD. DESIGN: Retrospective case-identification study from the Western Denmark Heart Registry and the database of the Forensic Institute at Aarhus University from 1999 through 2007. RESULTS: SCAD was documented in 22 of 32,869 (0.7 per thousand) angiograms in the angiographic registry. The SCAD incidence among cases of ACS was 22 of 11,175 (2.0 per thousand). None was seen in the forensic database. The mean age was 48.7 +/- 8.9 years (range: 37-71 years). Females constituted 17 of 22 (77%) patients and all had undergone one or more pregnancies; two cases occurred in the postpartum period. The left descending artery (LAD) was the predominant site of entry. The age distribution, prevalence of the cardiovascular risk factors, presence of coronary atherosclerosis, and entry of the dissection were comparable among genders. Treatment was percutaneous coronary intervention in 13 of 22 (59%), coronary artery bypass operation in 2 of 22 (9%), and medical treatment in 7 of 22 (32%) patients. The mean follow-up period was 3.6 +/- 2.9 years. One patient suffered from recurrent SCAD; another patient died suddenly. The MACE- (cardiac death, nonfatal myocardial infarction, and new revascularization) free survival was 81% after 24 months. CONCLUSION: SCAD is a rare disease that mainly affects younger women. Compared with earlier reports, the prognosis seems to be improved by early diagnosis and interventional treatment.

Mycotic coronary aneurysms.

: Mycotic coronary aneurysm is a rare infective disease of arterial vessel walls. Their development could be linked to the presence of an infective endocarditis or could represent a primary infection at the site of an implanted intracoronary stent. Bacterial agents, particularly Staphylococcus aureus, are the most common etiological agents. Due to an aspecific clinical presentation and examination, diagnosis could be challenging. Multiple imaging techniques (both invasive and noninvasive) are often required to reach the final diagnosis. Prognosis is characterized by high morbidity and mortality rates and, in fact, a tempestive treatment is required, although, to date, scanty data concerning the optimal treatment choice are present in literature.

Coronary aneurysms in the acute patient: Incidence, characterization and long-term management results.

BACKGROUND: Coronary aneurysms (1.5 times dilation the reference-vessel) are uncommon and have been diagnosed with increasing frequency with coronary angiography. The incidence varies from 1.5% to 5%. Reported complications are multiple: thrombosis, distal embolization, rupture and vasospasm, causing ischemia, heart failure or arrhythmias. However, the natural history and prognosis remains obscure. We aimed to describe the characteristics of acute patients with coronary aneurysms. METHODS: Prospective coronariography registry of patients with the diagnosis of coronary aneurysm between 2002 and 2013. Among 51,555 consecutive coronary angiograms, 414 patients with aneurysms were reported, of which 256 were considered acute (82% NSTE-ACS). RESULTS: Predominantly male (80%, mean age 65.5years), cardiovascular risk factors were common (hypertension 65%, dyslipidemia 65%, obesity 25%, diabetes mellitus 28.5%, and smokers 67%). With frequent coronary stenoses (94%), mostly with one aneurysm (80%), it was observed more frequently in the anterior descending artery. After a median follow-up of 52months, 53 died (14 cardiac causes) and 42% presented a cardiovascular event. Complications from the aneurysm were found in 4. The duration of dual antiplatelet therapy, LVEF, age and peripheral vascular disease highlighted in the multivariate analysis of death. CONCLUSION: The presence of coronary aneurysms in patients undergoing coronary angiography with an acute event is low. Patients who present them also have a large burden of atherosclerotic risk factors. In the long-term, the probability of cardiovascular complications is high, but only a small proportion are due to the aneurysm itself. A more intense and prolonged antithrombotic treatment may result in lower mortality rates.

Histopathological aspects of cardiovascular lesions in Kawasaki disease.

Kawasaki disease (KD) is the commonest vasculitic syndrome. It affects medium-sized arteries, principally the coronary arteries. Histologically, coronary arteritis begins at 6 to 8 days after the onset of KD and the inflammation rapidly involves all layers of the artery. This results in severe damage to the structural components of the artery leading to arterial dilation. The inflammatory infiltrate in KD arteritis is characterized predominantly by infiltration of monocytes and macrophages. Activated neutrophils, monocytes and macrophages are believed to be involved in the initial stage of coronary arteritis. Inflammatory cell infiltration may continue for up to 25 days of disease following which the inflammatory cells gradually decline in number. Inflammatory lesions in the arteries are relatively synchronous as they evolve from an acute to the chronic stage. If a giant aneurysm remains or vessel recanalization occurs after thrombotic occlusion of an aneurysm, the remodeling of vascular structures may continue for a much longer time.

Epidemiology and risk factors of coronary artery aneurysm in Taiwan: a population based case control study.

OBJECTIVES: Coronary artery aneurysm (CAA) is usually an asymptomatic and rare disease. There are limited epidemiological data for CAA in Asian populations and in the rest of the world. DESIGN: A retrospective case control study. SETTING: A population based, database study from Taiwan's National Health Insurance Research Database, between 2005 and 2011. PARTICIPANTS: CAA patients identified using International Classification of Diseases, ninth revision, clinical modification (ICD-9-CM) code 414.11 with CAA examinations. OUTCOME MEASURES: The incidence rate and mortality rate of CAA were calculated. We also matched patients with non-CAA patients according to age, gender and index year at a 1:10 ratio to explore the risk factors for CAA using conditional logistic regression. RESULT: A total of 1397 CAA patients were identified between 2005 and 2011; 41.9% were paediatric patients and 58.1% were adults. The incidence rate and mortality rate of CAA in Taiwan were 0.87 and 0.05 per 105 person-years, respectively. The adjusted odds ratios (aOR) for coronary atherosclerosis, hypertension, dyslipidaemia and diabetes were 7.97, 2.09, 2.48 and 1.51, respectively. Of note, aortic dissection (aOR 6.76), aortic aneurysm (aOR 5.82) and systemic lupus erythematosus (aOR 4.09) were found to be significantly associated with CAA. CONCLUSION: In Taiwan, CAA patients were distributed across both paediatric and adult populations. Apart from cardiovascular risk factors, aortic diseases and systemic lupus erythematosus need to be investigated further in CAA patients.

Coronary artery aneurysm: a review.

Coronary artery ectasia (CAE) is found in 0.3-5% of patients undergoing coronary angiography. Atherosclerosis is the main cause, followed by Kawasaki disease and infectious emboli. The exact pathogenesis has not been diagnosed as yet, but an inflammatory process is underlying. Symptoms, if present, are usually related to myocardial ischemia. Angiography is the mainstay for diagnosis. The prognosis is generally favorable. Thromboembolic complications are rare with antiplatelet therapy, and spontaneous rupture generally is rare but occurs more commonly in Kawasaki disease. Management varies from antithrombotic therapy to surgical ligation. Controlling coronary heart disease risk factors sharply affects the prognosis in patients with CAE.

Multimodality Imaging for Spontaneous Coronary Artery Dissection in Women.

Spontaneous coronary artery dissection (SCAD) has gained attention as a key cause of acute coronary syndrome and sudden cardiac death among women. Recent advancements in cardiac imaging have improved identification and accelerated awareness of SCAD. Accurate diagnosis of SCAD through use of imaging is critical, as emerging evidence suggests that the optimal short- and long-term management strategies for women with SCAD differs substantially from that of women with atherosclerotic coronary disease. This review summarizes the application of both invasive and noninvasive imaging for the diagnosis, assessment, surveillance, and treatment of women affected by SCAD.

Does coronary angiography before emergency aortic surgery affect in-hospital mortality?

OBJECTIVES: To study the relationship between coronary angiography and in-hospital mortality in patients undergoing emergency surgery of the aorta without a history of coronary revascularization or coronary angiography before the onset of symptoms. BACKGROUND: In the setting of acute ascending aortic dissection warranting emergency aortic repair, coronary angiography has been considered to be desirable, if not essential. The benefits of defining coronary anatomy have to be weighed against the risks of additional delay before surgical intervention. METHODS: Retrospective analysis of patient charts and the Cardiovascular Information Registry (CVIR) at the Cleveland Clinic Foundation. RESULTS: We studied 122 patients who underwent emergency surgery of the aorta between January 1982 and December 1997. Overall, in-hospital mortality was 18.0%, and there was no significant difference between those who had coronary angiography on the day of surgery compared with those who had not (No: 16%, n = 81 vs. Yes: 22%, n = 41, p = 0.46). Multivariate analysis revealed that a history of myocardial infarction (MI) was the only predictor of in-hospital mortality (relative risk: 4.98 95% confidence interval: 1.48-16.75, p = 0.009); however, coronary angiography had no impact on in-hospital mortality in patients with a history of MI. Furthermore, coronary angiography did not significantly affect the incidence of coronary artery bypass grafting (CABG) during aortic surgery (17% vs. 25%, Yes vs. No). Operative reports revealed that 74% of all CABG procedures were performed because of coronary dissection, and not coronary artery disease. CONCLUSIONS: These data indicate that determination of coronary anatomy may not impact on survival in patients undergoing emergency surgery of the aorta and support the concept that once diagnosed, patients should proceed as quickly as possible to surgery.