Beta-Blockade in Intraseptal Anomalous Coronary Artery With Reversible Myocardial Ischemia

2021 ◽  
Vol 12 (1) ◽  
pp. 145-148
Author(s):  
Tam T. Doan ◽  
Athar M. Qureshi ◽  
Shagun Sachdeva ◽  
Cory V. Noel ◽  
Dana Reaves-O’Neal ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Myocardial Ischemia ◽  
Dobutamine Stress ◽  
Medical Intervention ◽  
Beta Blockade ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Reversible Ischemia ◽  
Improve Patient

Anomalous aortic origin of a left coronary artery (L-AAOCA) with an intraseptal course is a rare anomaly and can be associated with myocardial ischemia and sudden cardiac death. No surgical or medical intervention is known to improve patient outcomes. A 7-year-old boy with intraseptal L-AAOCA presented with nonexertional chest pain, syncope, and had reversible myocardial ischemia on provocative testing. The patient was started on β-blockade, following which his symptoms improved and resolved over a period of six years. A follow-up dobutamine stress magnetic resonance imaging no longer showed reversible ischemia, and cardiac catheterization with fractional flow reserve did not show coronary flow compromise.

Abstract 13116: Ventilatory Gas Exchange in Stable Coronary Artery Disease

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sashiananthan Ganesananthan ◽  
Christopher Rajkumar ◽  
Matthew Shun-Shin ◽  
Alexandra Nowbar ◽  
Michael Foley ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Gas Exchange ◽  
Myocardial Ischemia ◽  
Dobutamine Stress ◽  
Fractional Flow ◽  
Single Vessel ◽  
Flow Reserve ◽  
Patient Reported ◽  
Artery Disease

Introduction: Cardiopulmonary exercise testing (CPET) provides a non-invasive evaluation of exercise physiology via ventilatory gas exchange (VGE). We do not know how these assessments correlate with myocardial ischemia or angina symptoms in patients with stable single-vessel coronary artery disease (CAD). In this analysis, we use randomised, blinded data from the ORBITA trial to investigate the association between VGE, ischemia and symptoms in patients with severe single-vessel CAD. Methods: Patients underwent treadmill CPET using the smoothed-modified Bruce protocol, after a 6-week medical optimisation phase during which antianginals were uptitrated. Symptoms were assessed using the Seattle Angina Questionnaire (SAQ), EuroQOL 5 and Canadian Cardiovascular Society (CCS) angina class. Ischemia was quantified using fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) and dobutamine stress echocardiography (DSE). Results: We assessed 195 patients [mean age 66.1±9.1, 143 (73.3%) male]. We found a significant association between peak oxygen uptake (VO 2 ) and minute ventilation to carbon dioxide (VE/VCO 2 ) slope, and physician assessed CCS class [P correlation(cor) <0.0001(Figure 1), P cor <0.0001, respectively], patient-reported SAQ angina frequency score [P cor <0.011(Figure 1), P cor <0.0001], physical limitation (P cor <0.0001, P cor =0.0001) and EuroQOL 5 visual analogue score (P cor = 0.0011, P cor =0.0019). There was no detectable relationship between peak VO 2 or VE/VCO 2 slope, and FFR, iFR or DSE (p>0.05, for all). Patients with an oxygen pulse plateau however, had higher dobutamine stress echo score compared to those without (+0.71; 95%CI 0.22-1.21, p=0.0049). Conclusions: The association between VGE and angina symptoms is stronger than its ability to detect severity of myocardial ischemia. This analysis highlights the complexity of the relationship between symptoms, functional capacity and myocardial ischemia.

scholarly journals Myocardial Ischemia in Children With Anomalous Aortic Origin of a Coronary Artery With Intraseptal Course

2020 ◽  
Vol 13 (3) ◽  
Author(s):  
Tam T. Doan ◽  
Rodrigo Zea-Vera ◽  
Hitesh Agrawal ◽  
Carlos M. Mery ◽  
Prakash Masand ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Myocardial Perfusion ◽  
Myocardial Ischemia ◽  
Fractional Flow Reserve ◽  
Fractional Flow ◽  
Benign Condition ◽  
Flow Reserve ◽  
Exercise Restriction ◽  
Myocardial Hypoperfusion

Background: Intraseptal anomalous aortic origin of a coronary artery is considered a benign condition. However, there have been case reports of patients with myocardial ischemia, arrhythmia, and sudden cardiac death. The purpose of this study was to determine the clinical presentation, myocardial perfusion on provocative stress testing, and management of children with anomalous aortic origin of a coronary artery with an intraseptal course in a prospective cohort. Methods: Patients with anomalous aortic origin of a coronary artery and intraseptal course were prospectively enrolled from December 2012 to May 2019, evaluated, and managed following a standardized algorithm. Myocardial perfusion was assessed using stress imaging. Fractional flow reserve was performed in patients with myocardial hypoperfusion on noninvasive testing. Exercise restriction, β-blockers, and surgical intervention were discussed with the families. Results: Eighteen patients (female 6, 33.3%), who presented with no symptoms (10, 55.6%), nonexertional (4, 22.2%), and exertional symptoms (4, 22.2%), were enrolled at a median age of 12.4 years (0.3–15.9). Perfusion imaging was performed in 14/18 (77.8%) and was abnormal in 7/14 (50%); fractional flow reserve was positive in 5/8 (62.5%). All 4 patients with exertional symptoms and 3/10 (30%) with no or nonexertional symptoms had myocardial hypoperfusion. Coronary artery bypass grafting was performed in a 4-year-old patient; β-blocker and exercise restriction were recommended in 4 patients not suitable for surgery. One patient had nonexertional chest pain and 17 were symptom-free at median follow-up of 2.5 years (0.2–7.1). Conclusions: Up to 50% of patients with intraseptal anomalous aortic origin of a coronary artery had inducible myocardial hypoperfusion during noninvasive provocative testing. Long-term follow-up is necessary to understand the natural history of this rare anomaly.

scholarly journals Physiological Evaluation of Anomalous Aortic Origin of a Coronary Artery Using Computed Tomography–Derived Fractional Flow Reserve

2021 ◽  
Author(s):  
Julien Adjedj ◽  
Fabien Hyafil ◽  
Xavier Halna du Fretay ◽  
Patrick Dupouy ◽  
Jean‐Michel Juliard ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Coronary Artery ◽  
Ct Angiography ◽  
Fractional Flow Reserve ◽  
Coronary Ct Angiography ◽  
Functional Evaluation ◽  
Fractional Flow ◽  
Coronary Ct ◽  
Flow Reserve

Background With the emergence of coronary computed tomography (CT) angiography, anomalous aortic origin of a coronary artery (ANOCOR) is more frequently diagnosed. Fractional flow reserve derived from CT (FFRCT) is a noninvasive functional test providing anatomical and functional evaluation of the overall coronary tree. These unique features of anatomical and functional evaluation derived from CT could help for the management of patients with ANOCOR. We aimed to retrospectively evaluate the physiological and clinical impact of FFRCT analysis in the ANOCOR registry population. Methods and Results The ANOCOR registry included patients with ANOCOR detected during invasive coronary angiography or coronary CT angiography between January 2010 and January 2013, with a planned 5‐year follow‐up. We retrospectively performed FFRCT analysis in patients with coronary CT angiography of adequate quality. Follow‐up was performed with a clinical composite end point (cardiac death, myocardial infarction, and unplanned revascularization). We obtained successful FFRCT analyses and 5‐year clinical follow‐up in 54 patients (average age, 60±13 years). Thirty‐eight (70%) patients had conservative treatment, and 16 (30%) patients had coronary revascularization after coronary CT angiography. The presence of an ANOCOR course was associated with a moderate reduction of FFRCT value from 1.0 at the ostium to 0.90±0.10 downstream the ectopic course and 0.82±0.11 distally. No significant difference in FFRCT values was identified between at‐risk and not at‐risk ANOCOR. After a 5‐year follow‐up, only one unplanned percutaneous revascularization was reported. Conclusions The presence of ANOCOR was associated with a moderate hemodynamic decrease of FFRCT values and associated with a low risk of cardiovascular events after a 5‐year follow‐up in this middle‐aged population.

scholarly journals Do athletes play by different rules? Obstructive coronary artery disease in asymptomatic competitive Masters athletes: a case series

2020 ◽  
Vol 4 (3) ◽  
pp. 1-5
Author(s):  
James McKinney ◽  
Nathaniel Moulson ◽  
Barbara N Morrison ◽  
Jobanjit S Phulka ◽  
Phillip Yeung ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Exercise Stress ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Masters Athletes ◽  
The Mean ◽  
Artery Disease

Abstract Background Both the age and number of endurance Masters athletes is increasing; this coincides with increasing cardiovascular risk. The vast majority of sports-related sudden cardiac deaths (SCDs) occur among athletes &gt;35 years of age. Coronary artery disease (CAD) is the most common cause of SCD amongst Masters athletes. Case summary In our prospective screening trial, six asymptomatic Masters athletes with ischaemia on electrocardiogram exercise stress testing had their coronary anatomy defined either by cardiac computed tomography or coronary angiography. Three patients underwent coronary angiography, with fractional flow reserve (FFR) testing performed when indicated. Subsequent percutaneous revascularization was performed in one patient after a shared-decision making process involving the patient and the referring cardiologist. All six athletes identified with obstructive CAD were male. The mean age and Framingham risk score was 61.8 years (±9.5) and 22.7% (±6.1), respectively. The mean metabolic equivalent of task achieved was 14.4 (±3.8). All athletes were treated with optimal medical therapy as clinically indicated. No cardiac events occured in 4.3 years of follow-up. Discussion Guidelines recommend revascularization of Masters athletes to alleviate the ischaemic substrate despite a paucity of evidence that revascularization will translate into a reduction in myocardial infarct or sudden cardiac arrest/death. Herein, although a limited study population, we demonstrate a lack of clinical events after 4.3 years of follow-up whether or not revascularization was performed. A prospective multicentre registry for asymptomatic Masters athletes with documented obstructive CAD is needed to help establish the role of revascularization in this population.

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

2020 ◽  
Vol 29 (1) ◽  
pp. 22-29 ◽  
Author(s):  
D. C. J. Keulards ◽  
P. J. Vlaar ◽  
I. Wijnbergen ◽  
N. H. J. Pijls ◽  
K. Teeuwen
Keyword(s):  
Coronary Artery ◽  
Chronic Total Occlusion ◽  
Coronary Intervention ◽  
Fractional Flow ◽  
Total Occlusion ◽  
Flow Reserve ◽  
Donor Artery ◽  
Before And After ◽  
Over Time

AbstractStudies 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.

scholarly journals Computed tomography-derived characterisation of pericoronary,epicardial and paracardial adipose tissue and its association with myocardial ischemia as assessed by computed and invasive fractional flow

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M Goeller ◽  
H Duncker ◽  
M Moshage ◽  
D Dey ◽  
D Bittner ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Adipose Tissue ◽  
Coronary Artery ◽  
Myocardial Ischemia ◽  
Multivariable Analysis ◽  
Fractional Flow ◽  
Circumflex Artery ◽  
Flow Reserve ◽  
Ct Attenuation ◽  
Significant Difference

Abstract Introduction Increased pericoronary adipose tissue (PCAT) computed tomography (CT) attenuation derived from coronary CT angiography (CTA) around the right coronary artery (RCA) reflects coronary inflammation and relates to cardiac mortality. Purpose We aimed to investigate the yet unclear association between CT-derived characterisation of different cardiac adipose tissue compartments and the presence of myocardial ischemia as assessed by fractional flow reserve (FFR). Methods 133 stable individuals (64 years, 74% male) with coronary artery disease (CAD) underwent CTA including computed FFR (FFR-CT) measurement followed by invasive angiography with FFR (invasive FFR) assessment. The CT attenuation (HU) and volume (mm3) of PCAT were quantified around the RCA (10 to 50 mm from RCA ostium), the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) with the help of semi-automated software. The per patient PCAT CT attenuation was calculated as followed: (PCAT CT attenuation of RCA+LAD+LCX)/3. Quantification of epicardial adipose tissue (EAT) and paracardial adipose tissue (PAT; all intrathoracic adipose tissue outside the pericardium) were performed in non-contrast cardiac CT data sets using a fully automated deep-learning based algorithm. Results Median FFR-CT was 0.86 [0.79, 0.91] and median invasive FFR was 0.87 [0.81, 0.93]. Patients with presence of myocardial ischemia (n=26) defined by a FFR-CT threshold of ≤0.75 showed a significant higher PCAT CT attenuation of RCA (−75.1 HU vs. −81.1 HU, p=0.011) and per patient (−74.5 HU vs. −77.7 HU, p=0.045) than individuals without myocardial ischemia (n=107). In multivariable analysis adjusted for age, BMI, gender and traditional risk factors, both RCA and per patient PCAT CT attenuation were significant predictors of myocardial ischemia as assessed by FFRCT ≤0.75. Between individuals with myocardial ischemia compared to individuals without myocardial ischemia there was no significant difference neither in the volume and CT attenuation of EAT and PAT nor in the PCAT volume of RCA, LAD, LCX and per patient PCAT volume. Conclusions Our observations suggest that PCAT CT attenuation instead of PCAT volume, EAT and PAT measures might be associated with the presence of myocardial ischemia as assessed by FFR. FUNDunding Acknowledgement Type of funding sources: Foundation. Main funding source(s): German Heart Foundation e.V.

Abstract 4470: Long Term Follow Up After Fractional Flow Reserve-guided Treatment Of ‘Moderate’ Left Main Coronary Artery Stenosis

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Michalis Hamilos ◽  
Thomas Cuisset ◽  
Jaydeep Sarma ◽  
Emanuele Barbato ◽  
Jozef Bartunek ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Fractional Flow Reserve ◽  
Left Main Coronary Artery ◽  
Medical Group ◽  
Left Main ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Surgical Group

Introduction: We assesed the value, in terms of long-term clinical outcome, of a fractional flow reserve (FFR)-guided treatment strategy in patients with angiographically ‘intermediate’ left main coronary artery (LMCA) stenoses. Methods: In 215 consecutive patients with an angiographically ‘intermediate’ unprotected LMCA stenosis (between 30–70%, by visual estimate), FFR measurements and off line quantitative coronary angiography (QCA) were obtained. When FFR was ≥0.80, patients were treated medically (medical group); When FFR was <0.80 coronary artery bypass grafting (CABG) was advocated (surgical group). Incidence of death, myocardial infarction and any coronary revascularisation procedure were recorded. Results: 140 patients had an FFR≥0.80 and 75 patients had an FFR<0.80. Percent diameter stenosis at QCA correlated significantly with FFR (r = −0.38, p<0.001), but a very large scatter was observed (Figure 1B ). Mean follow up duration was 35 ± 25 months. The incidence of death was 7.9 % in the medical group and 9.3 % in the surgical group. (Figure 1A , p=0.73). Conclusions : Angiography alone does not allow appropriate decision making in patients with angiographically ‘intermediate’ stenosis of the LMCA. Given the favorable outcome of an FFR-guided strategy such patients deserve FFR assessment before blindly proceeding to revascularisation. Figure 1: A Kaplan-Meier mortality curves for the 2 study groups. B Scatterplots showing the distribution of % diameter stenosis and the corresponding FFR values (filled dots indicate FFR≥0.80 and circles indicate FFR<0.80).

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