Spontaneous Coronary Artery Disease (SCAD) in a Patient With Systemic Lupus Erythematosus (SLE).

Spontaneous coronary artery dissection (SCAD) is a rare phenomenon that emerges as an acute coronary syndrome (ACS) and sudden cardiac death, especially in young women. We report a case of a woman with systemic lupus erythematosus (SLE) who presented with syncope and was found to have SCAD.

Short- and Mid-Term Outcomes of Complex and High-Risk Versus Standard Percutaneous Coronary Interventions in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: The prevalence of coronary artery disease (CAD) in patients undergoing TAVR varies and is associated with increased morbidity and mortality. We evaluated the outcomes of complex and high-risk percutaneous coronary interventions (CHIP-PCIs) and TAVR compared with standard PCI and TAVR. Between January 2014 and March 2021, a total of 276 consecutive patients with severe aortic stenosis (AS) who underwent TAVR and PCI at 3 centers within Northwell Health were retrospectively reviewed. CHIP-PCI was defined as PCI with one of the following: left ventricular ejection fraction (LVEF) <30%; left main coronary artery (LMCA)/chronic total occlusion (CTO) intervention; atherectomy; or need for left ventricular (LV) support. One hundred twenty- seven patients (46%) had CHIP-PCI prior to TAVR and 149 patients (54%) had standard PCI. Thirteen percent of CHIP-PCI and 22% of standard PCI cases were done concomitantly with TAVR. CHIP-PCI criteria were met for low EF (19%), LMCA (25%), CTO (3%), LV support (20%), and atherectomy (50%). The types of valves used were similarly divided (49% balloon expandable vs 51% self expanding. Major adverse cardiac or cerebrovascular event (MACCE) rate for CHIP-PCI/TAVR was 4.9% at 30 days vs 1.3% for standard PCI/TAVR (P=.09), driven by in-hospital stroke. At 1 year, the rates of MACCE for CHIP-PCI/TAVR remained higher than for standard PCI/TAVR, but was not statistically significant (8.7% vs 4%; P=.06), driven by revascularization. We found no differences between major and/or minor vascular complications. New York Heart Association classification at 1 month was similar (I/II 93% vs 95%; P=.87). Our study suggests that CHIP-PCI can be safely performed in patients with complex CAD and concomitant severe AS.

Comparison of clinical outcomes between use of overexpanding an undersized versus nominal-sized SAPIEN 3 ultra transcatheter heart valve in patients with borderline annulus area.

BACKGROUND: For patients with borderline annulus areas that fall between two valve sizes, overinflating a smaller balloon-expandable transcatheter heart valve (THV) may be preferable to nominal sizing of a larger THV. OBJECTIVES: To evaluate the outcomes of nominal preparation versus over-expanding an under-sized SAPIEN 3 Ultra (S3U) transcatheter heart valve (OE-THV) in cases with borderline annuli. METHODS: 958 patients that underwent TAVR with the S3U at four high-volume TAVR centers between January 2017 and December 2020 were retrospectively reviewed. 336 patients were identified as borderline annuli size, of which 146 (44%) received OE-THVs and 190 (56%) received nominal-sized THVs. The primary composite endpoint included: in-hospital mortality, aortic injury, moderate/severe paravalvular leak (PVL), permanent pacemaker implant (PPM), stroke, or conversion to surgery. RESULTS: Baseline characteristics were similar except for a larger percentage of females in the OE-THV (53.42% vs. 42.11%, p = 0.04). TAVR with OE-THV resulted a reduction in the primary composite endpoint (13.69% vs. 22.63%, p = 0.04). On subgroup analysis, there was no difference between 20 mm OE-THV versus 23 mm nominal or 23 mm OE-THV versus 26 mm nominal, but there was a reduction in the primary composite endpoint in patients with larger annuli that received a 26 mm OE-THV compared to the 29 mm nominally sized THV (9.7% vs. 27.4%, p = 0.02). At 1 month and 1 year follow-up, there was no significant difference in mortality, PVL rates, NYHA class, and/or KCCQ score. CONCLUSION: Overinflating a smaller-sized S3U THV may be a safer option in comparison to nominal sizing in patients with borderline annular area.

Intra-Atrial Right Coronary Artery and Anomalous Origin of Left Circumflex Artery Found Concurrently.

Coronary artery anomalies (CAAs) are known to be anatomical aberrations in the origin and structure. Due to the diverse anatomical variants, surgeons and angiographers have struggled when faced with patients who have CAA. To frame the complicated issues surrounding CAA, we present a case of a young patient found to have two CAAs, concurrently on coronary computed tomography angiography (CCTA), while in the emergency room being evaluated for chest pain. Patient was medically observed without any invasive procedure since he was deemed to have low cardiovascular risk. Subsequently, literature on prevalence, as well as high risk findings are reviewed. Further studies to evaluate pharmacological, angiographic, and surgical interventions may have additional benefit for both patients and practitioners. Our aim is to help shed the light on difficulties cardiologists are facing during angiography. Additionally, our paper offers some guidance for how to evaluate and follow patients with similar findings into the future.

A Curious Case of an Anomalous Right Coronary Artery.

Single coronary artery (SCA) is an unusual congenital anomaly, seen by diagnostic coronary angiography. Absence of the right coronary artery (RCA) is one of the rarest coronary artery anomalies occurring when the artery fails to develop in the right atrioventricular (AV) groove. Herein, we describe the case of a 58-year-old man presenting with new onset decompensated congestive heart failure found to have a congenitally absent right coronary ostium. The AV groove extended such that the left circumflex artery supplied the domain of the RCA. Such coronary artery anomalies are rare, and we aim to shed further insight into these congenital processes so that operators may remain vigilant of them in their practice.

Repeat Revascularization Post Coronary Artery Bypass Grafting: Comparing Minimally Invasive and Traditional Sternotomy Techniques in 1468 Cases.

BACKGROUND: Traditional open sternotomy coronary artery bypass grafting (CABG) utilizes highly invasive techniques that lead to several serious complications. In response, minimally invasive cardiac surgery CABG (MICS-CABG) was developed. MICS-CABG is safe, reproducible, and with fewer complications, while allowing for better postoperative recovery periods. There is a paucity of data exploring rates of repeat revascularization in patients post MICS-CABG compared to post traditional sternotomy CABG. METHODS: This was a retrospective billing database review examining 1468 CABG patients at a large university medical center from January 2005 to December 2017. The primary objective was to compare the rate of repeat revascularization events between MICS-CABG and traditional open sternotomy CABG over an eight-year follow-up period. RESULTS: Our study population consisted of 1468 patients, of whom 513 had MICS-CABG and 955 had traditional CABG. The number of patients undergoing repeat revascularization within the eight-year surveillance was 99 for MICS-CABG and 75 for traditional CABG. The Kaplan-Meier survival probability estimates for eight years were 0.86 for MICS-CABG and 0.91 for traditional CABG. The mean time until a repeat revascularization event was 84.1 months for MICS-CABG and 88.5 months for traditional CABG. CONCLUSIONS:  Traditional CABG was found to have a statistically significantly longer time to repeat revascularization than MICS-CABG. Despite the technical challenges associated with MICS-CABG, the time to repeat revascularization was different by only about four months, which may not hold large clinical significance. This suggests that MICS-CABG may have a role to play due to previous findings showing a reduction in complications while allowing for better postoperative recovery periods.