Hemodynamics of patient-specific aorta-pulmonary shunt configurations

Optimal hemodynamics in aorta-pulmonary shunt reconstruction is essential for improved post-operative recovery of the newborn congenital heart disease patient. However, prior to in vivo execution, the prediction of post-operative hemodynamics is extremely challenging due to the interplay of multiple confounding physiological factors. It is hypothesized that the post-operative performance of the surgical shunt can be predicted through computational blood flow simulations that consider patient size, shunt configuration, cardiac output and the complex three-dimensional disease anatomy. Utilizing only the routine patient-specific pre-surgery clinical data sets, we demonstrated an intelligent decision-making process for a real patient having pulmonary artery atresia and ventricular septal defect. For this patient, a total of 12 customized candidate shunt configurations are contemplated and reconstructed virtually using a sketch-based computer-aided anatomical editing tool. Candidate shunt configurations are evaluated based on the parameters that are computed from the flow simulations, which include 3D flow complexity, outlet flow splits, shunt patency, coronary perfusion and energy loss. Our results showed that the modified Blalock-Taussig (mBT) shunt has 12% higher right pulmonary artery (RPA) and 40% lower left pulmonary artery (LPA) flow compared to the central shunt configuration. Also, the RPA flow regime is distinct from the LPA, creating an uneven flow split at the pulmonary arteries. For all three shunt sizes, right mBT innominate and central configurations cause higher pulmonary artery (PA) flow and lower coronary artery pressure than right and left mBT subclavian configurations. While there is a trade-off between energy loss, flow split and coronary artery pressure, overall, the mBT shunts provide sufficient PA perfusion with higher coronary artery pressures and could be preferred for similar patients having PA overflow risk. Central shunts would be preferred otherwise particularly for cases with very low PA overflow risk.     

Risks of discontinuing anticoagulant therapy in a selected group of patients with atherosclerotic heart disease: a prospective study

In 134 patients with coronary artery disease, long-term oral anticoagulant therapy (mean duration, 56 months) for acute myocardial infarction (98 patients), acute coronary insufficiency (25 patients) or severe chronic angina (11 patients) was terminated abruptly in 50 patients (group 1) and gradually in 84 (group 2). The 134 patients represented a homogeneous population of patients with coronary artery disease since most patients older than 75 years and those with conditions known to increase the risks of thromboembolic complications were excluded. The two groups were comparable in terms of sex, age, presence of risk factors, duration of anticoagulant therapy, and presence of angina and abnormal resting electrocardiograms during therapy. Patients were evaluated 6 months after cessation of anticoagulant therapy and, since abrupt withdrawal of therapy did not carry a higher risk than gradual discontinuation, data for groups 1 and 2 were tabulated together.Of the 84 patients with angina at the end of therapy 15 experienced an increase in its severity and this symptom appeared in another patient (relapse rate, 18%). Angina progressed to fatal acute myocardial infarction in four (mortality, 3%) and nonfatal infarction in two; however, all six had extensive coronary artery disease and poor left ventricular function. The results of this study suggest that neither abrupt nor gradual cessation of anticoagulant therapy is associated with an inordinate exacerbation of heart disease.     

Dobutamine stress magnetic resonance imaging suffices for the demonstration of myocardial ischaemia and viability

We report three patients in whom dobutamine stress magnetic imaging (DS-MRI) was essential in assessing myocardial ischaemia. Two patients were referred to the cardiologist because of chest pain. Patient A had typical exertional angina and a normal resting electrocardiogram (ECG). Patient B had typical exercise-induced angina and had recently experienced an attack of severe chest pain at rest for 15 minutes. The ECG showed a complete left bundle branch block (LBBB). Patient C was referred for heart failure of unknown origin. There were no symptoms of chest pain during rest or exercise. Echocardiography in this patient demonstrated global left ventricular (LV) dilatation, systolic dysfunction and a small dyskinetic segment in the inferior wall. In all these patients exercise stress testing had failed to demonstrate myocardial ischaemia. Patients A and C produced normal findings whereas in patient B the abnormal repolarisation due to pre-existent LBBB precluded a diagnosis of ischaemia.Breath-hold DS-MRI was performed to study LV wall motion and wall thickening at rest through increasing doses of dobutamine. A test was considered positive for myocardial ischaemia if wall motion abnormalities developed at high-dose levels of the drug (20 μg/kg/min or more with a maximum of 40 μg/kg/min) in previously normal vascular territories or worsened in a segment that was normal at baseline. Recovery of wall thickening in a previously hypokinetic or akinetic segment at a low dose of dobutamine (5-10 μg/kg/min) was taken as proof of viability.Patients A and B developed hypokinesia progressing into akinesia at high-dose dobutamine in the anteroseptal area of the LV indicative of ischaemia. These findings were corroborated by coronary angiography demonstrating severe coronary artery disease which led to coronary artery bypass grafting (CABG) in patient A and balloon angioplasty in patient B. In patient C global recovery of LV contractions during low-dose dobutamine was followed by hypokinesia in the inferoseptal area during high-dose dobutamine. This biphasic response indicates myocardial viability as well as ischaemia. CABG was carried out because of multiple stenoses in the left coronary artery. Post-operatively LV function normalised.DS-MRI is a valuable method for detecting myocardial ischaemia and viability in patients with suspected coronary artery, and can be applied in every hospital with MRI equipment at its disposal.     

Incidence of anomalous origin of coronary artery in 1879 Chinese adults on dual-source CT angiography

Background and Objective. Dual-source CT (DSCT) has been used to detect coronary artery anomalies. The purpose of this study was to assess the incidence of anomalous origin of the coronary artery in Chinese adults. Methods. We summarised all patients who underwent DSCT coronary angiography (CTCA) from December 2006 to February 2008, and data of anomalous origin of the coronary artery in Chinese adults were recorded. Results. 1879 patients underwent CTCA during that period; 24 patients with an anomalous origin of the coronary artery were detected, giving an incidence of 1.3%. Fifteen patients had an anomalous origin of the right coronary artery (12 from left coronary sinus, 3 high takeoff), eight patients had an anomalous origin of the left coronary artery (LCA from posterior sinus of Valsalva in three cases, LCX from the right coronary sinus, LCX from RCA, high takeoff, LCA from right coronary sinus, and single coronary artery in one case, respectively), and one patient had an anomalous origin of both coronary arteries (high takeoff). Conclusion. The incidence of anomalous origin of the coronary artery in Chinese adults in this study is 1.3%. DSCT can clearly visualise the anomalous origin and course of the coronary artery and is a useful screening modality. (Neth Heart J 2010;18:466-70.)     

Acute two-vessel coronary closure in a patient with Down's syndrome

Myocardial infarctions are rare in patients with Down's syndrome. This paper reports an unusually aggressive presentation of two-vessel simultaneous coronary occlusion during an intended percutaneous intervention. Since survival in patients with Down's syndrome is improving, encounters with late (and perhaps unusual) sequelae of coronary artery disease are expected to increase.     

Selection and care of cardiac patients for plastic surgery

A major operation after successful coronary artery bypass surgery has been proved as safe as an operation for a patient free from coronary artery disease. Most patients with angina who demonstrate an operable coronary lesion should usually be scheduled for coronary artery bypass before undergoing nonemergency surgery. It is advisable to postpone elective plastic surgery for 6 weeks to 3 months after coronary bypass and 6 months after myocardial infarction. The life expectancy of cardiac patients must be carefully considered before elective plastic surgery, because performing an operation on a patient who cannot live to enjoy the benefits is unwise. Working together, cardiac surgeons, cardiologists, and plastic surgeons can now prolong the quantity of life and enrich its quality in properly selected and carefully managed patients.     

血清同型半胱氨酸、高敏C反应蛋白及肱踝脉搏波传导速度与冠心病患者冠脉病变程度的相关性研究

目的:探讨血清同型半胱氨酸(Hcy)、高敏C反应蛋白(hs-CRP)及肱踝脉搏波传导速度(baPWV)与冠心病患者冠脉病变程度的相关性。方法:选取2015年6月-2017年10月期间承德医学院附属医院收治的疑似冠心病的患者324例为研究对象,根据冠状动脉造影结果分为冠心病组213例与非冠心病组111例,根据不同冠脉病变程度将冠心病组分为单支病变组87例,双支病变组74例,多支病变组52例,检测并对比所有患者血清Hcy、hs-CRP水平及baPWV值,分析Hcy、hs-CRP水平及baPWV值与冠心病患者冠脉病变程度相关性。结果:冠心病组患者血清Hcy、hs-CRP水平及baPWV值较非冠心病组升高(P0.05)。冠心病组不同冠脉病变程度患者血清Hcy、hs-CRP水平及baPWV值整体比较差异有统计学意义(P0.05),多支病变组与双支病变组患者血清Hcy、hs-CRP水平及baPWV值高于单支病变组,且多支病变组高于双支病变组,差异有统计学意义(P0.05)。经Pearson相关性分析显示,Hcy、hs-CRP及baPWV均与冠心病患者冠脉病变程度呈正相关(P0.05)。结论:冠心病患者血清Hcy、hs-CRP水平及baPWV值高于非冠心病者,且血清Hcy、hs-CRP水平及baPWV值随着冠心病患者冠脉病变程度的加重而升高,与冠脉病变程度呈正相关。     

Global revascularization: the role of the cardiologist

There are compelling reasons for cardiologists to undertake a more global approach to patients with peripheral vascular diseases: atherosclerosis is a 'systemic' disease frequently causing both coronary and peripheral vascular problems in the same patient; coronary artery disease is the most common cause of morbidity and mortality in patients with peripheral vascular disease; and peripheral vascular disease negatively impacts the management of angina pectoris and congestive heart failure. There are four major areas of special interest to the cardiologist: (1) iliac arteries (vascular access), (2) renal arteries (hypertension and volume overload), (3) subclavian arteries (coronary steal with a left internal mammary artery [LIMA] graft), and (4) carotid arteries (stroke). Technical skills necessary to perform coronary angioplasty are transferable to the peripheral vasculature. However, an understanding of the natural history of peripheral disease, patient and lesion selection criteria, and knowledge of other treatment alternatives are essential to performing these procedures safely and effectively. Appropriate preparation and training, and a team approach, including an experienced vascular surgeon, are both desirable and necessary before interventional cardiologists who are inexperienced in the treatment of peripheral vascular disease attempt percutaneous peripheral angioplasty. There are inherent advantages for patients when the cardiologist performing the procedure is also a clinician. Judgments regarding the indications, timing, and risk/benefit ratio of procedures are enhanced by a long-term relationship between physician and patient. Finally, in view of the increased incidence of coronary artery disease in patients with atherosclerotic peripheral vascular disease, the participation of a cardiologist in their care seems appropriate.     

Adverse effects on macrophage lipid transport and survival by high density lipoprotein from patients with coronary heart disease

High density lipoprotein (HDL)–macrophage interactions have the potential to modulate macrophage function in a beneficial way to prevent the development of lipid‐loaded foam cell formation in atherosclerosis. Although HDL is atheroprotective, it can become dysfunctional in chronic inflammatory conditions and increase cardiovascular risk. Here, we examined the effect of dysfunctional‐HDL from patients with coronary artery disease, on macrophage function in comparison to functional‐HDL from controls. Exposure of macrophages to dysfunctional‐HDL for 24 h resulted significant increase in cellular oxidative stress, cholesterol, and cytotoxicity. It also stimulated mitochondrial membrane depolarization, DNA damage, apoptosis, and cleavage of poly (ADP‐ribose) polymerase, which are characteristics of proapoptotic pathways. In contrast, functional‐HDL treatment maintained cholesterol homeostasis, essential membrane potential, DNA integrity, and cell survival. These results demonstrate that HDL from coronary artery disease (CAD) patient promotes proatherogenic effects that in turn trigger macrophage apoptosis, an important feature in atherogenesis and thereby providing new insight in our understanding of the atherogenic mechanisms.     

Genetic variants on apolipoprotein gene cluster influence triglycerides with a risk of coronary artery disease among Indians

Apolipoprotein C3 and apolipoprotien A5 are proteins coded from the APOA1/C3/A4/A5 gene cluster. Sst I polymorphism on apolipoprotein C3 and −1131C polymorphism of apolipoprotien A5 are key variants involved in triglyceride metabolism and cause a significant cardio-metabolic risk. Here, we have evaluated these two variants for their roles in coronary artery disease in patients of the Indian population. The apolipoprotein gene cluster variants were analysed in 416 angiographically determined coronary artery disease patients and matched 416 controls using polymerase chain reaction—restriction fragment length polymorphism. The characteristics of the study subjects were analyzed statistically for their association with the polymorphisms. The alleles were combined as haplotypes and their combined risks were evaluated. The minor allele genotypes of both apolipoprotein C3 (S2) and apolipoprotien A5 (C) had a significant risk for coronary artery disease. The S2 allele genotyped patients had a significantly increased triglyceride level (P < 0.001) and increased triglycerides were observed among both patient and control CC genotype carriers. We identified the haplotype S2/C with a significant increased risk (P < 0.001) to coronary artery disease with increased levels of circulating triglycerides compared to other haplotypes in patients. We conclude that the variants on apolipoprotein C3 and apolipoprotien A5 modulate serum triglyceride levels and increase the risk of coronary artery disease.     

Association between coronary lesion severity and distal microvascular resistance in patients with coronary artery disease

Homogeneity of microvascular resistance in different perfusion areas of the same heart is generally assumed. We investigated the effect of the severity of an epicardial stenosis on microvascular resistance in 27 patients with coronary artery disease and stable angina. All patients had an angiographically normal coronary artery, an artery with an intermediate lesion, and an artery with a severe lesion; the latter was treated with angioplasty. In each patient, distal blood flow velocity and pressure were measured during baseline and maximal hyperemia (induced by intracoronary adenosine) using a Doppler and pressure guide wire, respectively. The ratio of mean distal pressure to average peak blood flow velocity was used as an index for the microvascular resistance (MRv). Within patients, the hyperemic MRv was higher in arteries with more severe stenosis (P = 0.021). After percutaneous transluminal coronary angioplasty (PTCA), the hyperemic MRv decreased (pre-PTCA, 2.6 vs. post-PTCA, 1.9 mmHg.cm(-1)s(-1), P < 0.01) toward the value of the reference artery (1.7 mmHg.cm(-1)s(-1); P = 0.67). We conclude that there is a positive association between coronary lesion severity and variability of distal microvascular resistance that normalizes after angioplasty. This study challenges the concept of uniform distribution of hyperemic MRv that is relevant for the interpretation of both noninvasive and invasive diagnostic tests.     

Duke Treadmill Score in prioritizing patients for coronary angiography: retrospective study of a Croatian regional hospital

Aim of the study was to determine the potential of Duke Treadmill Score (DTS) in prioritizing patients for coronary angiography in a transitional country clinical setting. We analyzed 114patients with suspected stable coronary artery disease who underwent exercise treadmill testing, and coronary angiography in Slavonski Brod General Hospital. DTS was calculated from treadmill test as: exercise time--(5 x ST deviation in mm)--(4 x exercise angina). Regarding the score, patients were grouped into three groups of risk for coronary artery disease: low risk, medium risk, and high risk patients. All patients underwent coronary angiography, and were grouped in accordance to the severity of the coronary artery disease into three groups: insignificant, significant, or severe coronary artery disease. All patients scored as high risk DTS had significant or severe coronary artery disease. Medium and low risk DTS patients had insignificant coronary artery disease in 50%, and 90% of cases, respectively. Medium risk patients with significant or severe coronary artery disease were significantly older, and had more frequent history of typical chest pain with higher number of episodes per week (P<0.05), whereas there were no differences regarding gender or presence of risk factors. There were no significant differences among medium risk patients regarding the severity of coronary artery disease in exercise time or ST deviation. However, the presence of limiting exercise angina in medium risk patients was significantly more related with significant and severe coronary artery disease (P<0.05). High risk DTS result showed great potential in stratifying patients for immediate coronary angiography. This scoring system may be used in prioritizing patients for coronary angiography in a transitional clinical setting.     

Focus: Sex and Gender Health: Women and Chest Pain: Recognizing the Different Faces of Angina in the Emergency Department

Emergency departments (ED) in the United States see over eight million cases of chest pain annually. While a cardinal symptom of acute coronary syndrome (ACS), multiple emergent and non-emergent causes can attribute to chest pain. This case-based perspective describes the different sex-specific causes of angina seen in ED patients. Once coronary artery disease (CAD) is ruled out with standard protocols, microvascular dysfunction is perhaps the most prevalent but under-diagnosed cause of non-CAD related angina in ED patients. Additional causes include coronary artery spasm, coronary artery dissection, coronary artery endothelial dysfunction and myocardial bridging. Non-CAD related angina is associated with persistent chest pain causing poor function, quality of life, and recidivism. Clinicians should consider additional diagnostics to routinely screen for non-CAD related causes of angina in patients with recurrent chest pain. Future work is needed to better define the epidemiological, clinical, biological, and genetic correlates of microvascular dysfunction in these patients.     

女性冠心病患者的危险因素分析及与冠脉病变严重程度的关系

目的:了解女性冠心病患者的危险因素及与冠脉病变严重程度的关系。方法:随机选取本院2012年至2014年心血管科住院治疗的疑似冠心病女性患者150例,经冠脉造影确诊冠心病患者105例,非冠心病患者45例。对患者的临床资料和冠脉病变严重程度进行单因素和多因素分析。结果:冠心病患者高血压与糖尿病百分比、甘油三酯(TG)、总胆固醇(TC)、低密度脂蛋白(LDL-C)及纤维蛋白原水平均高于非冠心病患者,而高密度脂蛋白(HDL-C)和血红蛋白水平均低于非冠心病患者(P0.05);年龄、高血压与糖尿病百分比、血脂上升百分比(高TC、高TG、低HDL-C、高LDL-C)、高尿酸百分比和纤维蛋白原水平均随冠状动脉病变支数及Gensini积分的增加而增加(P0.05);多因素分析发现女性冠心病的影响因素分别为高LDL-C、糖尿病、低HDL-C、TG和高血压,其中高LDL-C的影响最为显著(P0.05)。结论:高血压、糖尿病史、血脂水平为女性冠心病的影响因素,其中高LDL-C的影响最显著,各影响因素均与冠脉病变程度紧密相关。     

Clinical outcomes of long coronary stents: a single-center experience

BACKGROUND: Coronary artery stenting is particularly useful during percutaneous coronary intervention for long lesions previously associated with a low procedural success rate and a high complication rate of dissection and occlusion. Current treatment options include implantation of a single long stent, multiple contiguous stents, or 'spot' stenting. However, multiple stent implantation may result in sections of overlapping stent or gaps of unstented segments and is an independent predictor of restenosis. The early and intermediate clinical outcome of single and multiple long stent (>/= 30 mm) implantation is not established. METHODS AND RESULTS: The authors retrospectively identified 123 consecutive patients who had undergone stenting using one or more long coronary stents. Baseline clinical data, procedural outcomes and completed clinical follow-up to 52 weeks were obtained by case-note review. The majority (69%) required intervention for stable coronary disease. Seventy-seven per cent of lesions were either type B2 or C and only 2% were in saphenous vein grafts. The procedural success rate was 94%. A total of 15 major events occurred in 13 patients (11%). Ten acute events occurred and five events were during the follow-up period from 30 days to 52 weeks. Two patients died, one from uncontrolled bleeding secondary to the use of antithrombotic agents and one at four weeks due to sudden death. One patient had a postprocedural infarct. Two patients required in-hospital repeat revascularization for acute vessel closure and eight required revascularization during follow-up (three cases of occlusion/thrombosis and five cases of restenosis). CONCLUSIONS: The use of long coronary stents (>/= 30 mm) for the treatment of long diffuse native vessel disease, saphenous vein graft disease and long coronary dissections is associated with a reasonable procedural success rate and acceptable early and intermediate-term clinical outcomes.     

Coronary physiology before and after chronic total occlusion treatment: what does it tell us?

Studies performed in the last two decades demonstrate that after successful percutaneous coronary intervention (PCI) of a chronically occluded coronary artery, the physiology of the chronic total occlusion (CTO) vessel and dependent microvasculature does not normalise immediately but improves significantly over time. Generally, there is an increase in fractional flow reserve (FFR) in the CTO artery, a decrease in collateral blood supply and an increase in FFR in the donor artery accompanied by an increase in blood flow and decrease in microvascular resistance in the myocardium supplied by the CTO vessel. Analogous to these physiological changes, positive remodelling of the distal CTO artery also occurs over time, and intravascular imaging can be helpful for analysing distal vessel parameters. Follow-up coronary angiography with physiological measurements after several weeks to months can be helpful and informative in a subset of patients in order to decide upon the necessity for treatment of residual coronary artery stenosis in the vessel distal to the CTO or in the contralateral donor artery, as well as in deciding whether stent optimisation is indicated. We suggest that such physiological guidance of CTO procedures avoids unnecessary overtreatment during the initial procedure, guides interventions at follow-up, and improves our understanding of what PCI in CTO means.

     

犬冠状动脉狭窄时血浆纤维连接蛋白的消耗

在实验犬上,观察了冠状动脉狭窄对冠状窦静脉血血浆纤维连接蛋白(Fn)含量的变化。结果表明:当冠脉狭窄程度大于75％时,冠状动脉狭窄可引起冠脉急性炎症反应和Fn的减少,此时伴有血小板聚集性和活性的增高。组织病理学检查证实有血管内皮细胞和毛细血管的损伤以及白细胞、血小板的沉积。 这一结果提示冠脉损伤后可引起冠脉循环中防御功能的减弱。     

The first multicentre study on coronary anomalies in the Netherlands: MuSCAT

BackgroundCurrent guidelines on coronary anomalies are primarily based on expert consensus and a limited number of trials. A gold standard for diagnosis and a consensus on the treatment strategy in this patient group are lacking, especially for patients with an anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) with an interarterial course.AimTo provide evidence-substantiated recommendations for diagnostic work-up, treatment and follow-up of patients with anomalous coronary arteries.MethodsA clinical care pathway for patients with ACAOS was established by six Dutch centres. Prospectively included patients undergo work-up according to protocol using computed tomography (CT) angiography, ischaemia detection, echocardiography and coronary angiography with intracoronary measurements to assess anatomical and physiological characteristics of the ACAOS. Surgical and functional follow-up results are evaluated by CT angiography, ischaemia detection and a quality-of-life questionnaire. Patient inclusion for the first multicentre study on coronary anomalies in the Netherlands started in 2020 and will continue for at least 3 years with a minimum of 2 years of follow-up. For patients with a right or left coronary artery originating from the pulmonary artery and coronary arteriovenous fistulas a registry is maintained.ResultsPrimary outcomes are: (cardiac) death, myocardial ischaemia attributable to the ACAOS, re-intervention after surgery and intervention after initially conservative treatment. The influence of work-up examinations on treatment choice is also evaluated.ConclusionsStructural evidence for the appropriate management of patients with coronary anomalies, especially (interarterial) ACAOS, is lacking. By means of a structured care pathway in a multicentre setting, we aim to provide an evidence-based strategy for the diagnostic evaluation and treatment of this patient group.Supplementary InformationThe online version of this article (10.1007/s12471-021-01556-9) contains supplementary material, which is available to authorized users.     

NONCARDIAC SURGERY COMBINED WITH CORONARY ARTERY BYPASS

The coexistence of coronary artery disease with noncardiac disease often leads to a dilemma in planning therapeutic procedures. This problem is especially difficult in the presence of accelerated angina or left coronary artery stenosis. A series of 17 patients is presented in which coronary artery bypass grafts were combined with noncardiac operations without mortality or significant morbidity. An illustrative case report shows the interrelated nature of the coexisting disorders. The conclusion of this study is that, at times, various surgical procedures should be combined with coronary artery bypass grafting for a smoother, less complicated recovery. However, there are no hard and fast rules dictating combined procedures; each operation must be planned according to the existing conditions and needs of the individual patient.     

Preoperative evaluation of the cardiac patient for noncardiac surgery.

Perioperative cardiac events continue to represent a significant cause of morbidity in patients undergoing noncardiac surgery. The evaluation of the high risk patient should begin with an assessment of the probability of coronary artery disease and exercise tolerance. Decisions to undergo further evaluation, including noninvasive testing, should be based upon the perioperative morbidity and mortality rate for the planned surgical procedure. In patients with significant coronary artery stenoses and a high probability of perioperative cardiac morbidity, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, and preoperative optimization of hemodynamics in an intensive care unit have all been advocated as means of reducing risk.