Aortic Stenosis With Coronary Artery Disease: SAVR or TAVR-When and How?

The growing number of candidates for transcatheter aortic valve replacement (TAVR) has increased the interest in the concomitant presence of coronary artery disease (CAD) and severe aortic stenosis (AS), prompting the need to define the appropriate revascularization strategy for each case. The reported prevalence of concurrent AS and CAD has varied over the years on the basis of the CAD definition and the population evaluated. Revascularization for treating CAD in patients with severe AS involves additional interventions that could impact outcomes. The addition of coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) has demonstrated favourable effects on long-term prognosis, while the impact of adding percutaneous coronary intervention (PCI) to TAVR may depend on the CAD complexity and the feasibility of achieving complete or reasonably incomplete revascularization. Furthermore, the comparison between SAVR+CABG and TAVR+PCI in low-intermediate surgical risk and low-intermediate complex CAD patients did not reveal differences in all-cause mortality or stroke between the groups. However, there is some evidence showing a lower incidence of major cardiovascular events with the SAVR+CABG strategy for patients with complex CAD. Thus, SAVR+CABG seems to be the best option for patients with low-intermediate surgical risk and complex CAD, and TAVR+PCI for high surgical risk patients seeking complete and/or reasonable incomplete revascularization. After deciding between TAVR+PCI or SAVR+CABG, factors such as timing for PCI, low ejection fraction, coronary reaccess, and valve durability must be considered. Finally, alternative methods for assessing CAD severity are currently under evaluation to ascertain their real value for guiding revascularization in patients with severe AS with CAD.

High frequency of coronary artery ectasia in obstructive sleep apnea.

STUDY OBJECTIVES: Patients with obstructive sleep apnea (OSA) have a greater risk of developing coronary artery disease. However, the frequency of specific coronary artery vascular phenotypes, such as coronary artery ectasia (CAE), which has a frequency of 5% in the general population, has not been studied in patients with OSA. This study aimed to estimate CAE frequency in patients with OSA who underwent coronary angiography. METHODS: A retrospective cross-sectional study was performed. The results of each polysomnography were reviewed, classifying OSA severity according to the apnea-hypopnea index. Each coronary angiography was reviewed. CAE was defined and classified according to the scales described in the literature. Two groups of patients were classified and compared (OSA/CAE group vs OSA/non-CAE group). RESULTS: We identified the frequency of CAE in 185 patients with OSA who underwent coronary angiography. The frequency of CAE was 18.4% in these patients. ST-elevation myocardial infarction as the indication for coronary angiography was significantly greater in the OSA/CAE group than the OSA/non-CAE group (26.5% vs 9.9%; P = .02); 62% of the patients having severe OSA (apnea-hypopnea index ≥ 30 events/h). These patients in the OSA/CAE group had a significantly higher median apnea-hypopnea index than in the OSA/non-CAE group (72.5 events/h vs 53.5 events/h, respectively; P = .039). The CAE severity was not directly related to the OSA severity. CONCLUSIONS: The frequency of CAE in patients with OSA is higher than that reported for the general population. The severity of OSA is related to the presence of CAE but not to its severity. CITATION: del Portillo JH, Hernandez BM, Bazurto MA, Echeverri D, Cabrales J. High frequency of coronary artery ectasia in obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):433-438.

Stent liberadores de medicamento en enfermedad coronaria prematura en jóvenes conhipercolesterolemia familiar homocigota y trasplante hepático previo / Drug-eluting stents in premature coronary disease in young people with homozygous familial hypercholesterolemia and prior liver transplantation

Resumen La hipercolesterolemia familiar es una enfermedad genética que se caracteriza por niveles muy elevados de colesterol y lipoproteínas de baja densidad en suero, xantomas tendinosos y aterosclerosis prematura. La forma heterocigota es la más común; alcanza una prevalencia de aproximadamente 1 de cada 300 a 500 personas en el mundo, en tanto que la homocigota, autosómica dominante, es la forma más rara, con una prevalencia de 1 en 1 millón de personas. Esta se caracteriza por hipercolesterolemia severa, que conlleva enfermedad cardiovascular prematura y a menudo no responde al tratamiento tradicional por la falta de receptores para c-LDL funcionales. Los niveles de c-LDL pueden superar seis a diez veces los valores normales, en cuyo caso el trasplante de hígado se ha convertido en el tratamiento de elección para los pacientes que no responden a tratamientos farmacológicos de rutina. Se presentan dos casos con hipercolesterolemia familiar homocigota en jóvenes de 14 y 15 años, con antecedente de trasplante de hígado y enfermedad coronaria severa en vasos principales (descendente anterior y coronaria derecha) a quienes se les hizo implante exitoso de stent liberador de medicamento.

Abstract Familial hypercholesterolemia is a genetic disorder characterised by very high cholesterol and low-density lipoproteins serum levels, tendon xanthomas and premature atherosclerosis. Heterozygous form is the most common, with a prevalence of approximately 1 out of 300 to 500 people worldwide, whereas the homozygous, autosomal dominant, is the rarest form, with a prevalence of 1 out of 1 million people. It is characterised by severe hypercholesterolemia leading to premature cardiovascular disease, and it often does not respond to traditional therapy due to the lack of receptors for functional LDL-c. LDL-c levels can exceed between six and ten times the normal values, in which case liver transplantation has become the treatment of choice for patients who do not respond to routine pharmacological therapies. This study presents two cases of homozygous familial hypercholesterolemia in young patients aged 14 and 15, with prior liver transplantation and severe coronary disease in major vessels (anterior descending artery and right coronary artery) who underwent successful implant of a drug-eluting stent.