RESUMEN
BACKGROUND: Inflammation and immunity play important roles in the formation of coronary collateral circulation (CCC). The pan-immune-inflammation value (PIV) is a novel marker for evaluating systemic inflammation and immunity. The study aimed to investigate the association between the PIV and CCC formation in patients with chronic total occlusion (CTO). METHODS: This retrospective study enrolled 1150 patients who were diagnosed with CTO through coronary angiographic (CAG) examinations from January 2013 to December 2021 in China. The Cohen-Rentrop criteria were used to catagorize CCC formation: good CCC formation (Rentrop grade 2-3) and poor CCC formation group (Rentrop grade 0-1). Based on the tertiles of the PIV, all patients were classified into three groups as follows: P1 group, PIV ≤ 237.56; P2 group, 237.56< PIV ≤ 575.18; and P3 group, PIV > 575.18. RESULTS: A significant relationship between the PIV and the formation of CCC was observed in our study. Utilizing multivariate logistic regression and adjusting for confounding factors, the PIV emerged as an independent risk factor for poor CCC formation. Notably, the restricted cubic splines revealed a dose-response relationship between the PIV and risk of poor CCC formation. In terms of predictive accuracy, the area under the ROC curve (AUC) for PIV in anticipating poor CCC formation was 0.618 (95% CI: 0.584-0.651, P < 0.001). Furthermore, the net reclassification index (NRI) and integrated discrimination index (IDI) for PIV, concerning the prediction of poor CCC formation, were found to be 0.272 (95% CI: 0.142-0.352, P < 0.001) and 0.051 (95% CI: 0.037-0.065, P < 0.001), respectively. It's noteworthy that both the NRI and IDI values were higher for PIV compared to other inflammatory biomarkers, suggesting its superiority in predictive capacity. CONCLUSIONS: PIV was associated with the formation of CCC. Notably, PIV exhibited potential as a predictor for poor CCC formation and showcased superior predictive performance compared to other complete blood count-based inflammatory biomarkers.
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Circulación Colateral , Angiografía Coronaria , Circulación Coronaria , Oclusión Coronaria , Mediadores de Inflamación , Inflamación , Valor Predictivo de las Pruebas , Humanos , Masculino , Persona de Mediana Edad , Oclusión Coronaria/fisiopatología , Oclusión Coronaria/diagnóstico por imagen , Femenino , Estudios Retrospectivos , Enfermedad Crónica , Anciano , Inflamación/diagnóstico , Inflamación/sangre , Inflamación/inmunología , Inflamación/fisiopatología , Mediadores de Inflamación/sangre , Medición de Riesgo , China , Biomarcadores/sangre , Factores de Riesgo , PronósticoRESUMEN
A 32-year-old man, who was treated for T-cell lymphoma, presented in cardiac arrest. He had been treated for heart failure with reduced ejection fraction. Veno-arterial extracorporeal membrane oxygenation was initiated immediately. We diagnosed him as non-ST elevated myocardial infarction. Coronary angiography demonstrated the occlusion of the trifurcation in the proximal left anterior descending artery (LAD). We failed to advance the first guidewire into the distal LAD by angio-based conventional wiring. Intravascular ultrasonography (IVUS) of the proximal diagonal branch revealed two diaphragms separating the distal lumen without connection, which looks like lotus root-like appearance. We quickly penetrated the plaque using IVUS-based real-time 3D wiring using the tip detection method. The contrast injection via the microcatheter showed the distal diagonal branch (D2). After the balloon dilation in D2, IVUS image revealed a torn plaque between D2 and the distal LAD. Subsequently we advanced the guidewire to the distal LAD using IVUS-based real-time 3D wiring using the tip detection method through the tear of the plaque. Finally, we successfully performed the revascularization of LAD in a preferable procedure time. The patient recovered well and was discharged 39 days after cardiac arrest. This case highlights the efficacy of IVUS-based real-time 3D wiring using the tip detection method even in the emergent and challenging situation.
Asunto(s)
Angiografía Coronaria , Oclusión Coronaria , Paro Cardíaco , Placa Aterosclerótica , Ultrasonografía Intervencional , Humanos , Masculino , Adulto , Paro Cardíaco/terapia , Paro Cardíaco/etiología , Paro Cardíaco/fisiopatología , Resultado del Tratamiento , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Imagenología Tridimensional , Angioplastia Coronaria con Balón/instrumentación , Valor Predictivo de las PruebasRESUMEN
BACKGROUND: Although occlusion of the right coronary artery (RCA) is common in the remote stages of Kawasaki disease, revascularization of the RCA is challenging in children and is usually managed by observation without intervention. METHODS: Using adenosine-stress 13N-ammonia myocardial perfusion positron emission tomography, we evaluated coronary circulation in 14 patients (12 males) with RCA occlusion to identify ischemia (myocardial flow ratio < 2.0) in the RCA region and examined hemodynamics, cardiac function, and coronary aneurysm diameter. These variables were also compared in patients with/without RCA segmental stenosis (SS). RESULTS: There were five cases of ischemia in the RCA region. RCA myocardial blood flow (MBF) at rest was higher in patients with ischemia than in those without ischemia, but the difference was not significant (1.27 ± 0.21 vs. 0.82 ± 0.16 mL/min/g, p = 0.2053). Nine patients presented with RCA SS, and age at onset of Kawasaki disease tended to be lower in those with SS. The maximum aneurysm diameter of RCA was significantly smaller in patients with SS (10.0 ± 2.8 vs. 14.7 ± 1.6, p = 0.0239). No significant differences in other variables were observed between patients with/without ischemia and SS. CONCLUSIONS: At rest, MBF in the RCA region was relatively well preserved, even in patients with RCA occlusion, and there was no progressive deterioration in cardiac function. Adenosine stress showed microcirculatory disturbances in only half of the patients, indicating that it is reversible in children with Kawasaki disease.
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Amoníaco , Circulación Coronaria , Síndrome Mucocutáneo Linfonodular , Imagen de Perfusión Miocárdica , Radioisótopos de Nitrógeno , Tomografía de Emisión de Positrones , Humanos , Síndrome Mucocutáneo Linfonodular/complicaciones , Síndrome Mucocutáneo Linfonodular/fisiopatología , Síndrome Mucocutáneo Linfonodular/diagnóstico por imagen , Masculino , Femenino , Amoníaco/sangre , Tomografía de Emisión de Positrones/métodos , Niño , Preescolar , Imagen de Perfusión Miocárdica/métodos , Oclusión Coronaria/etiología , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/fisiopatología , Aneurisma Coronario/etiología , Aneurisma Coronario/diagnóstico por imagen , Aneurisma Coronario/fisiopatología , Adolescente , Lactante , HemodinámicaRESUMEN
The conus artery (CA) supplies the right ventricular outflow tract (RVOT). ST-segment elevation in leads V1-3, which can resemble Brugada electrocardiogram (EKG) patterns, has been reported due to occlusion of the CA. A 68-year-old male was admitted to the hospital with a diagnosis of non-ST-elevation myocardial infarction. A coronary angiogram revealed a dissection in the conus artery, most likely caused by the catheter. Due to the small caliber of the CA, medical therapy was chosen as the course of action. However, after the procedure, an EKG showed changes consistent with features of both type-1 and type-2 Brugada patterns, with ST-segment elevations in leads V1-4. Subsequent coronary imaging revealed that the CA had progressed to total occlusion. Despite multiple attempts to gain reentry into the true lumen, they were unsuccessful. Based on the risk-benefit ratio, the decision was made to continue with medical therapy. This is the first reported case of CA occlusion induced by catheter dissection, which manifested as anteroseptal ST-segment elevation. The patient did not report any anginal symptoms or arrhythmic events, which contrasts with conventional knowledge. Not all CA obstructions or RVOT infarcts cause Brugada-like patterns. When they do, ST elevations tend to be less than those in true Brugada syndrome.
A artéria do cone (AC) irriga a via de saída do ventrículo direito (VSVD). A elevação do segmento ST nas derivações V1-3, que pode assemelhar-se aos padrões de eletrocardiograma (ECG) de Brugada, foi relatada devido à oclusão da AC. Um paciente do sexo masculino, 68 anos de idade, foi internado no hospital com diagnóstico de infarto do miocárdio sem supradesnivelamento do segmento ST. Uma angiografia coronária revelou uma dissecção na AC, provavelmente causada pelo cateter. Devido ao pequeno calibre da AC, a terapia medicamentosa foi escolhida como curso de ação. No entanto, após o procedimento, um ECG mostrou alterações consistentes com características dos padrões de Brugada tipo 1 e tipo 2, com elevações do segmento ST nas derivações V1-4. A imagem coronariana subsequente revelou que a AC havia progredido para oclusão total. Apesar das diversas tentativas de obter a reentrada no lúmen verdadeiro, não houve êxito. Com base na relação risco-benefício, foi tomada a decisão de continuar com a terapia medicamentosa. Este é o primeiro caso relatado de oclusão da AC induzida por dissecção por cateter, que se manifesta como elevação ântero-septal do segmento ST. O paciente não relatou sintomas anginosos ou eventos arrítmicos, o que contrasta com o conhecimento convencional. Nem todas as obstruções da AC ou infartos da VSVD causam padrões semelhantes aos de Brugada. Quando isso ocorre, as elevações de ST tendem a ser menores do que as da verdadeira síndrome de Brugada.
Asunto(s)
Síndrome de Brugada , Angiografía Coronaria , Electrocardiografía , Humanos , Masculino , Anciano , Síndrome de Brugada/fisiopatología , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/fisiopatología , Oclusión Coronaria/etiología , Infarto del Miocardio con Elevación del ST/etiología , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/diagnóstico por imagenAsunto(s)
Oclusión Coronaria , Humanos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Enfermedad Crónica , Resultado del Tratamiento , Intervención Coronaria Percutánea/instrumentación , Masculino , Angiografía Coronaria , Tomografía de Coherencia ÓpticaRESUMEN
BACKGROUND: There is limited data on predicting successful chronic total occlusion crossing using primary antegrade wiring (AW). OBJECTIVES: The aim of this study was to develop and validate a machine learning (ML) prognostic model for successful chronic total occlusion crossing using primary AW. METHODS: We used data from 12,136 primary AW cases performed between 2012 and 2023 at 48 centers in the PROGRESS CTO registry (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention; NCT02061436) to develop 5 ML models. Hyperparameter tuning was performed for the model with the best performance, and the SHAP (SHapley Additive exPlanations) explainer was implemented to estimate feature importance. RESULTS: Primary AW was successful in 6,965 cases (57.4%). Extreme gradient boosting was the best performing ML model with an average area under the receiver-operating characteristic curve of 0.775 (± 0.010). After hyperparameter tuning, the average area under the receiver-operating characteristic curve of the extreme gradient boosting model was 0.782 in the training set and 0.780 in the testing set. Among the factors examined, occlusion length had the most significant impact on predicting successful primary AW crossing followed by blunt/no stump, presence of interventional collaterals, vessel diameter, and proximal cap ambiguity. In contrast, aorto-ostial lesion location had the least impact on the outcome. A web-based application for predicting successful primary AW wiring crossing is available online (PROGRESS-CTO website) (https://www.progresscto.org/predict-aw-success). CONCLUSIONS: We developed an ML model with 14 features and high predictive capacity for successful primary AW in chronic total occlusion percutaneous coronary intervention.
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Oclusión Coronaria , Aprendizaje Automático , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Sistema de Registros , Humanos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Masculino , Femenino , Resultado del Tratamiento , Enfermedad Crónica , Anciano , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Reproducibilidad de los Resultados , Factores de Riesgo , Técnicas de Apoyo para la Decisión , Factores de TiempoRESUMEN
BACKGROUND: The atherogenic index of plasma (AIP) is considered an independent risk factor for coronary artery disease (CAD). The present study investigated whether AIP correlates with the formation of coronary collateral circulation (CCC) in CAD patients with chronic total occlusion (CTO). METHODS: This retrospective study included 1093 CAD patients with CTO confirmed by coronary angiography from January 2020 to December 2020 at Beijing Anzhen Hospital. Based on the Rentrop scoring system, the patients were divided into the good CCC group and the poor CCC group. AIP was calculated by log (triglyceride/high-density lipoprotein cholesterol). Meanwhile, the study population was further divided into four groups according to the quartiles of AIP. RESULTS: Patients in the poor CCC group exhibited significantly higher AIP compared to those in the good CCC group (0.31 ± 0.27 vs. 0.14 ± 0.24, p < 0.001). Multivariate logistic regression analysis revealed an independent association between AIP and poor CCC, regardless of whether AIP was treated as a continuous or categorical variable (p < 0.001), after adjusting for confounding factors. Besides, this association remained consistent across most subgroups. The incorporation of AIP into the baseline model significantly enhanced the accuracy of identifying poor CCC [area under the curve (AUC): baseline model, 0.661 vs. baseline model + AIP, 0.721, p for comparison < 0.001]. CONCLUSIONS: Elevated AIP is independently associated with an increased risk of poor CCC in CAD patients with CTO, and AIP may improve the ability to identify poor CCC in clinical practice.
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Biomarcadores , Circulación Colateral , Angiografía Coronaria , Circulación Coronaria , Oclusión Coronaria , Humanos , Masculino , Oclusión Coronaria/fisiopatología , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/sangre , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Enfermedad Crónica , Biomarcadores/sangre , Medición de Riesgo , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/diagnóstico , Valor Predictivo de las Pruebas , Triglicéridos/sangre , HDL-Colesterol/sangre , Factores de Riesgo , PronósticoRESUMEN
The precise features of lesions in non-ST-segment elevation myocardial infarction (NSTEMI) patients with total occlusion (TO) of the infarct-related artery (IRA) are still unclear. This study employs optical coherence tomography (OCT) to investigate pathological features in NSTEMI patients with or without IRA TO and explores the relationship between thrombus types and IRA occlusive status. This was a single-center retrospective study. A total of 202 patients diagnosed with NSTEMI were divided into two groups: those with Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 before percutaneous coronary intervention (PCI) (referred to as the TO group, n = 100) and those TIMI flow grade 1-3 (referred to as the Non-TO group, n = 102). Baseline characteristics, coronary angiography findings, and OCT results were collected. Multivariate logistic analysis identified factors influencing TO in NSTEMI. The category of NSTEMI was further subdivided based on the type of electrocardiogram (ECG) into two subgroups: ST segment unoffset myocardial infarction (STUMI) and ST segment depression myocardial infarction (STDMI). This division allows for a more specific classification of NSTEMI cases. The TO group had a younger age, higher male representation, more smokers, lower hypertension and cerebrovascular disease incidence, lower left ventricular ejection fraction (LVEF), and higher creatine kinase myocardial band (CKMB) and creatine kinase (CK) peak levels. In the TO group, LCX served as the main IRA (52.0%), whereas in the Non-TO group, LAD was the predominant IRA (45.1%). Compared to the Non-TO group, OCT findings demonstrated that red thrombus/mixed thrombus was more common in the TO group, along with a lower occurrence of white thrombus (p < 0.001). The TO group exhibited a higher prevalence of STUMI (p = 0.001), whereas STDMI was more commonly observed in the Non-TO group (p = 0.001). NSTEMI presents as STUMI and STDMI distinct entities. Red thrombus/mixed thrombus in IRA often indicates occlusive lesions with STUMI on ECG. White thrombus suggests non-occlusive lesions with STDMI on ECG.
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Angiografía Coronaria , Trombosis Coronaria , Vasos Coronarios , Electrocardiografía , Infarto del Miocardio sin Elevación del ST , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Tomografía de Coherencia Óptica , Humanos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Infarto del Miocardio sin Elevación del ST/diagnóstico por imagen , Infarto del Miocardio sin Elevación del ST/terapia , Anciano , Trombosis Coronaria/diagnóstico por imagen , Trombosis Coronaria/patología , Factores de Riesgo , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/fisiopatología , Análisis Multivariante , Modelos Logísticos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/fisiopatología , Circulación Coronaria , Distribución de Chi-Cuadrado , Oportunidad RelativaRESUMEN
Chronic total occlusions (CTOs) are frequent in patients with previous coronary artery bypass graft (CABG) surgery. Percutaneous coronary intervention (PCI) is the usual revascularization strategy. Whether or not the presence of a graft on a CTO vessel and post-PCI graft patency impacts outcomes after CTO-PCI is unknown. We sought to evaluate the impact of post-PCI graft patency on the durability of CTO-PCI. In total, 259 patients with previous CABG who underwent CTO-PCI in 12 international centers in 2019 to 2023 were categorized into "grafted" and "ungrafted" groups based on the presence of graft on a CTO vessel. The grafted group was subdivided into "graft-occluded" and "graft-patent" groups, depending on graft patency. The primary end points were (1) technical success rate, (2) target vessel failure, and (3) CTO failure rates at 1 year. CTO failure was defined as target vessel revascularization and/or significant in-stent restenosis. A total of 199 patients (77%) were in the grafted group. Grafted CTOs showed higher complexity and lower technical success rates (70% vs 80%, p = 0.004) than nongrafted CTOs. Of the grafted CTOs, 140 (70%) were in the grafted-occluded group and 59 (30%) were in the grafted-patent group. The technical success was lower in the former group (65% vs 81%, p = 0.022). An occluded graft was an independent predictor of technical failure (odds ratio 2.04, 95% confidence interval 1.03 to 4.76, p = 0.049) and persistent post-PCI graft patency was a strong independent predictor of CTO failure at 1 year (hazard ratio 5.6, 95% confidence interval 1.2 to 27.5, log-rank p = 0.033). In conclusion, in patients with previous CABG who underwent CTO-PCI, post-PCI graft patency was a significant predictor of CTO failure.
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Angiografía Coronaria , Puente de Arteria Coronaria , Oclusión Coronaria , Oclusión de Injerto Vascular , Intervención Coronaria Percutánea , Grado de Desobstrucción Vascular , Humanos , Masculino , Femenino , Puente de Arteria Coronaria/métodos , Oclusión Coronaria/cirugía , Oclusión Coronaria/fisiopatología , Anciano , Persona de Mediana Edad , Intervención Coronaria Percutánea/métodos , Enfermedad Crónica , Oclusión de Injerto Vascular/diagnóstico por imagen , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Despite the effectiveness of the retrograde approach for chronic total occlusion (CTO) lesions, there are no standardized tools to predict the success of retrograde percutaneous coronary intervention (PCI). OBJECTIVES: The aim of this study was to develop a prediction tool to identify CTO lesions that will achieve successful retrograde PCI. METHODS: This study evaluated data from 2,374 patients who underwent primary retrograde CTO-PCI and were enrolled in the Japanese CTO-PCI Expert Registry between January 2016 and December 2022 (NCT01889459). All observations were randomly assigned to the derivation and validation cohorts at a 2:1 ratio. The prediction score for guidewire failure in retrograde CTO-PCI was determined by assigning 1 point for each factor and summing all accrued points. RESULTS: The JR-CTO score (moderate-severe calcification, tortuosity, Werner collateral connection grade ≤1, and nonseptal collateral channel) demonstrated a C-statistic for guidewire failure of 0.72 (95% CI: 0.67-0.76) and 0.71 (95% CI: 0.64-0.77) in the derivation and validation cohorts, respectively. Patients with lower scores had higher guidewire and technical success rates and decreased guidewire crossing time and procedural time (P < 0.01). CONCLUSIONS: The JR-CTO (Japanese Retrograde Chronic Total Occlusion) score, a simple 4-item score that predicts successful guidewire crossing in patients undergoing retrograde CTO-PCI, has the potential to support clinical decision-making for the retrograde approach.
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Oclusión Coronaria , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Sistema de Registros , Humanos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Masculino , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Japón , Femenino , Anciano , Enfermedad Crónica , Persona de Mediana Edad , Resultado del Tratamiento , Factores de Riesgo , Reproducibilidad de los Resultados , Técnicas de Apoyo para la Decisión , Medición de Riesgo , Circulación Coronaria , Circulación Colateral , Toma de Decisiones Clínicas , Factores de Tiempo , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/terapia , Pueblos del Este de AsiaAsunto(s)
Oclusión Coronaria , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Insuficiencia del Tratamiento , Humanos , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Enfermedad Crónica , Factores de Riesgo , Medición de Riesgo , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Técnicas de Apoyo para la Decisión , Toma de Decisiones Clínicas , Resultado del TratamientoRESUMEN
Left main occlusion presenting as ST-segment elevation myocardial infarction is an exceedingly morbid condition. This article reports a case of cardiac arrest in a patient after a treadmill stress test. Coronary angiography revealed 100% occlusion of the left main coronary artery. Left ventricular unloading with the Impella CP heart pump (ABIOMED/Johnson & Johnson MedTech) was used, after which epicardial blood flow was restored without angioplasty. The patient underwent surgical revascularization. Despite a prolonged revascularization time, there was no evidence of severe myocardial injury postoperatively.
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Angiografía Coronaria , Circulación Coronaria , Corazón Auxiliar , Infarto del Miocardio con Elevación del ST , Función Ventricular Izquierda , Humanos , Persona de Mediana Edad , Circulación Coronaria/fisiología , Oclusión Coronaria/fisiopatología , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/cirugía , Oclusión Coronaria/complicaciones , Electrocardiografía , Revascularización Miocárdica/métodos , Pericardio/fisiopatología , Diseño de Prótesis , Recuperación de la Función , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/cirugía , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/terapia , Resultado del Tratamiento , Función Ventricular Izquierda/fisiología , FemeninoRESUMEN
Transcatheter aortic valve implantation (TAVI) with commissural alignment aims to limit the risk of coronary occlusion and maintain good coronary access. However, due to coronary origin eccentricity within the coronary cusp, coronary-commissural overlap (CCO) may still occur. TAVI using coronary alignment, rather than commissural alignment, may further improve coronary access. To compare rates of CCO after TAVI using commissural versus coronary alignment methodology. Cardiac CT scans from 102 patients with severe (tricuspid) aortic stenosis referred for TAVI were analysed. Native cusp asymmetry and coronary eccentricity were defined and used to simulate TAVI using commissural versus coronary alignment. Rates of optimal coronary alignment (< 10° from cusp centre) and severe misalignment (< 15° from coronary-commissural overlap) were compared. Additionally, the impact of valve misalignment during implantation was assessed. The native right coronary artery (RCA) origin was 15.8° (9.5 to 24°) closer to the right coronary cusp/non-coronary cusp (RCC-NCC) commissure than the centre of the right coronary cusp. The native left coronary artery (LCA) origin was 4.5° (0 to 11.5°) closer to the left coronary cusp/non-coronary cusp (LCC-NCC) commissure than the centre of the left coronary cusp (p < 0.01). Compared to commissural alignment, coronary alignment doubled the proportion of optimally-aligned RCAs (62/102 [60.8%] vs. 31/102 [30.4%]; p < 0.001), without a significant change in optimal LCA alignment (62/102 [60.8% vs. 74/102 [72.6%]; p = 0.07). There were no cases of severe misalignment with either strategy. Simulating 15° of valve misalignment resulted in severe RCA compromise risk in 7/102 (6.9%) of commissural alignment cases, compared to none using coronary alignment. Fluoroscopic projection was similar with both approaches. Coronary alignment resulted in a 2-fold increase of optimal TAVI positioning relative to the RCA ostium when compared to commissural alignment without impacting the LCA. Use of coronary alignment rather than commissural alignment may improve coronary access after TAVI and is less sensitive to valve rotational error, particularly for the right coronary artery.
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Estenosis de la Válvula Aórtica , Válvula Aórtica , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Oclusión Coronaria , Índice de Severidad de la Enfermedad , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/fisiopatología , Masculino , Factores de Riesgo , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Válvula Aórtica/fisiopatología , Femenino , Anciano , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/etiología , Oclusión Coronaria/fisiopatología , Oclusión Coronaria/terapia , Anciano de 80 o más Años , Resultado del Tratamiento , Estudios Retrospectivos , Medición de Riesgo , Valor Predictivo de las Pruebas , Vasos Coronarios/diagnóstico por imagen , Prótesis Valvulares Cardíacas , Tomografía Computarizada MultidetectorRESUMEN
OBJECTIVE: To explore the impact of diabetes on collateral circulation (CC) development in patients with chronic total coronary occlusion (CTO) and the underlying regulatory mechanism. METHODS: This study was conducted among 87 patients with coronary heart disease (CHD), who had CTO in at least one vessel as confirmed by coronary angiography. Among them 42 patients were found to have a low CC level (Cohen-Rentrop grades 0-1) and 45 had a high CC level (grades 2-3). In the 39 patients with comorbid diabetes mellitus and 48 non-diabetic patients, insulin resistance (IR) levels were compared between the subgroups with different CC levels. The steady-state mode evaluation method was employed for calculating the homeostatic model assessment for insulin resistance index (HOMA-IR) using a mathematical model. During the interventional procedures, collateral and peripheral blood samples were collected from 22 patients for comparison of the metabolites using non-targeted metabolomics analysis. RESULTS: NT-proBNP levels and LVEF differed significantly between the patients with different CC levels (P<0.05). In non-diabetic patients, HOMA-IR was higher in low CC level group than in high CC level groups. Compared with the non-diabetic patients, the diabetic patients showed 63 upregulated and 48 downregulated metabolites in the collateral blood and 23 upregulated and 14 downregulated metabolites in the peripheral blood. The differential metabolites in the collateral blood were involved in aromatic compound degradation, fatty acid biosynthesis, and steroid degradation pathways; those in the peripheral blood were related with pentose phosphate metabolism, bacterial chemotaxis, hexanoyl-CoA degradation, glycerophospholipid metabolism, and lysine degradation pathways. CONCLUSION: The non-diabetic patients with a low level of CC had significant insulin resistance. The degradation pathways of aromatic compounds, fatty acid biosynthesis, and steroid degradation are closely correlated with the development of CC.
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Circulación Colateral , Oclusión Coronaria , Resistencia a la Insulina , Femenino , Humanos , Masculino , Enfermedad Crónica , Circulación Colateral/fisiología , Angiografía Coronaria , Circulación Coronaria/fisiología , Oclusión Coronaria/fisiopatología , Diabetes Mellitus/metabolismo , Diabetes Mellitus/fisiopatologíaRESUMEN
An 86-year-old female with history of surgical aortic valve replacement presented with clinical signs of heart failure. Echocardiography revealed a reduction in left ventricular systolic function and severe bioprosthetic aortic valve dysfunction. This is the first reported case of valve-in-valve transcatheter aortic valve replacement with concomitant undermining iatrogenic coronary obstruction with radiofrequency needle procedure in a surgical bioprosthetic valve.
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Estenosis de la Válvula Aórtica , Válvula Aórtica , Bioprótesis , Prótesis Valvulares Cardíacas , Enfermedad Iatrogénica , Diseño de Prótesis , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Anciano de 80 o más Años , Femenino , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Resultado del Tratamiento , Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Ablación por Catéter/efectos adversos , Falla de Prótesis , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Lesiones Cardíacas/etiología , Lesiones Cardíacas/diagnóstico por imagen , Lesiones Cardíacas/terapia , Agujas , Función Ventricular Izquierda , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/etiología , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Angiografía CoronariaRESUMEN
BACKGROUND: Shockwave intravascular lithotripsy (S-IVL) is widely used during percutaneous coronary intervention (PCI) of calcified coronary arteries. Ventricular capture beats during S-IVL are common but arrhythmias are rare. CASE PRESENTATION: A 75-year-old woman was scheduled for PCI to a short, heavily calcified chronic total occlusion of the right coronary artery. After wiring of the occlusion, S-IVL was used to predilated the calcified stenosis. During S-IVL, the patient developed ventricular fibrillation twice. CONCLUSION: To our knowledge, this is only the second reported case of VF during S-IVL. Although very rare, it is important to be aware of this potential and serious complication.
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Litotricia , Intervención Coronaria Percutánea , Calcificación Vascular , Fibrilación Ventricular , Humanos , Anciano , Femenino , Fibrilación Ventricular/etiología , Fibrilación Ventricular/diagnóstico , Fibrilación Ventricular/terapia , Fibrilación Ventricular/fisiopatología , Litotricia/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Resultado del Tratamiento , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/terapia , Calcificación Vascular/etiología , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/etiología , Oclusión Coronaria/terapia , Oclusión Coronaria/fisiopatología , Angiografía CoronariaRESUMEN
Background and Objectives: In this present study, we investigated the impact of mechanosensitive microRNAs (mechano-miRs) on the collateral development in 126 chronic total occlusion (CTO) patients, selected from 810 undergoing angiography. Materials and Methods: We quantified the collateral blood supply using the collateral flow index (CFI) and assessed the transcoronary mechano-miR gradients. Results: The patients with favorable collaterals had higher CFI values (0.45 ± 0.02) than those with poor collaterals (0.38 ± 0.03, p < 0.001). Significant differences in transcoronary gradients were found for miR-10a, miR-19a, miR-21, miR-23b, miR-26a, miR-92a, miR-126, miR-130a, miR-663, and let7d (p < 0.05). miR-26a and miR-21 showed strong positive correlations with the CFI (r = 0.715 and r = 0.663, respectively), while let7d and miR-663 were negatively correlated (r = -0.684 and r = -0.604, respectively). The correlations between cytokine gradients and mechano-miR gradients were also significant, including Transforming Growth Factor Beta with miR-126 (r = 0.673, p < 0.001) and Vascular Endothelial Growth Factor with miR-10a (r = 0.602, p = 0.002). A regression analysis highlighted the hemoglobin level, smoking, beta-blocker use, miR-26a, and miR-663 as significant CFI determinants, indicating their roles in modulating the collateral vessel development. Conclusions: These findings suggest mechanosensitive microRNAs as predictive biomarkers for collateral circulation, offering new therapeutic perspectives for CTO patients.
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Circulación Colateral , Oclusión Coronaria , MicroARNs , Humanos , MicroARNs/sangre , Masculino , Femenino , Persona de Mediana Edad , Circulación Colateral/fisiología , Oclusión Coronaria/fisiopatología , Oclusión Coronaria/diagnóstico , Anciano , Angiografía Coronaria/métodos , Enfermedad Crónica , Circulación Coronaria/fisiologíaRESUMEN
BACKGROUND: The role of circulating progenitor cells (CPC) in collateral formation that occurs in the presence of chronic total occlusions (CTO) of a coronary artery is not well established. In stable patients with a CTO, we investigated whether CPC levels are associated with (a) collateral development and (b) ischemic burden, as measured by circulating high sensitivity troponin-I (hsTn-I) levels. METHODS: CPCs were enumerated by flow cytometry as CD45med+ blood mononuclear cells expressing CD34 and both CD34 and CD133 epitopes. The association between CPC counts and both Rentrop collateral grade (0, 1, 2, or 3) and hsTn-I levels were evaluated using multivariate regression analysis, after adjusting for demographic and clinical characteristics. RESULTS: In 89 patients (age 65.5, 72% male, 27% Black), a higher CPC count was positively associated with a higher Rentrop collateral grade; [CD34+ adjusted odds ratio (OR) 1.49 95% confidence interval (CI) (0.95, 2.34) P = 0.082] and [CD34+/CD133+ OR 1.57 95% CI (1.05, 2.36) P = 0.028]. Every doubling of CPC counts was also associated with lower hsTn-I levels [CD34+ ß -0.35 95% CI (-0.49, -0.15) P = 0.002] and [CD34+/CD133+ ß -0.27 95% CI (-0.43, -0.08) P = 0.009] after adjustment. CONCLUSION: Individuals with higher CPC counts have greater collateral development and lower ischemic burden in the presence of a CTO.
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Circulación Colateral , Oclusión Coronaria , Humanos , Masculino , Circulación Colateral/fisiología , Femenino , Oclusión Coronaria/sangre , Oclusión Coronaria/diagnóstico , Oclusión Coronaria/fisiopatología , Anciano , Persona de Mediana Edad , Enfermedad Crónica , Células Madre , Circulación Coronaria/fisiología , Biomarcadores/sangre , Citometría de Flujo/métodosRESUMEN
Coronary obstruction during transcatheter aortic valve replacement (TAVR) poses a significant threat, prompting a closer examination of prevention and bailout strategies. Following TAVR deployment with a coronary artery obstruction complication and recognizing the complexities involved in engaging the left main coronary artery through TAVR cells. This case introduces the "Ping-pong" technique using a second guide catheter. When faced with difficulty in engaging the catheter through TAVR cells, an innovative solution is proposed. Inserting a wire into the valsalva and utilizing a rapid inflate-deflate balloon maneuver successfully facilitates catheter access into the left main, offering a promising intervention for challenging scenarios. In conclusion, this study emphasizes the severe implications of coronary obstruction during TAVR. The innovative "Ping-pong" technique and rapid inflate-deflate balloons emerge as valuable interventions, showcasing their potential in challenging catheter engagement scenarios. These insights offer a promising avenue for enhancing patient outcomes in TAVR procedures.