scholarly journals Case Report: Key Role of the Impella Device to Achieve Complete Revascularization in a Patient With Complex Multivessel Disease and Severely Depressed Left Ventricular Function

2021 ◽  
Vol 8 ◽  
Author(s):  
Giovanni Monizzi ◽  
Luca Grancini ◽  
Paolo Olivares ◽  
Antonio L. Bartorelli
Keyword(s):  
Coronary Artery ◽  
High Risk ◽  
Left Ventricular ◽  
Multivessel Disease ◽  
Lv Function ◽  
Complete Revascularization ◽  
Coronary Perfusion ◽  
Heart Team ◽  
Hemodynamic Support

Background: Left ventricle (LV) assist devices may be required to stabilize hemodynamic status during complex, high-risk, and indicated procedures (CHIP). We present a case in which elective hemodynamic support with the Impella CP device was essential to achieve complete revascularization with PCI in a patient with complex multivessel disease and severely depressed LV function.Case Summary: A 45-year-old male with no previous history of cardiovascular disease presented to the emergency department for new onset exertional dyspnoea. Echocardiography showed severely depressed LV function (EF 27%) that was confirmed with cardiac magnetic resonance. Two chronic total occlusions (CTOs) of the proximal right coronary artery (RCA) and left circumflex coronary artery (LCx) were found at coronary angiography. After Heart Team evaluation, PCI with Impella hemodynamic support was planned. After crossing and predilating the CTO of the LCx, ventricular fibrillation (VF) occurred. No direct current (DC) shock was performed because the patient was conscious thanks to the support provided by the Impella pump. About 1 min later, spontaneous termination of VF occurred. Afterwards, the two CTOs were successfully treated with good result and no complications. Recovery of LV function was observed at discharge. At 9 months, the patient had no symptoms and echocardiography showed an EF of 60%.Discussion: In this complex high-risk patient, hemodynamic support was essential to allow successful PCI. It is remarkable that the patient remained conscious and hemodynamically stable during VF that spontaneously terminated after 1 min, likely because the Impella pump provided preserved coronary perfusion and LV unloading. This case confirms the pivotal role of Impella in supporting CHIP, particularly in patients with multivessel disease and depressed LV function.

Minimally Invasive Direct Coronary Artery Bypass in High-Risk Patients with Multivessel Disease

2021 ◽  
Author(s):  
Grischa Hoffmann ◽  
Christine Friedrich ◽  
Katharina Huenges ◽  
Rainer Petzina ◽  
Astrid-Mareike Vogt ◽  
...  
Keyword(s):  
Coronary Artery ◽  
High Risk ◽  
Minimally Invasive ◽  
Coronary Artery Bypass ◽  
Artery Bypass ◽  
Multivessel Disease ◽  
Complete Revascularization ◽  
High Risk Patients ◽  
Risk Patients

Abstract Background High-risk patients with multivessel disease (MVD) including a complex stenosis of the left anterior descending coronary may not be ideal candidates for guideline compliant therapy by coronary artery bypass grafting (CABG) regarding invasiveness and perioperative complications. However, they may benefit from minimally invasive direct coronary artery bypass (MIDCAB) grafting and hybrid revascularization (HCR). Methods A logistic European system for cardiac operative risk evaluation score (logES) >10% defined high risk. In high-risk patients with MVD undergoing MIDCAB or HCR, the incidence of major adverse cardiac and cerebrovascular events (MACCEs) after 30 days and during midterm follow-up was evaluated. Results Out of 1,250 patients undergoing MIDCAB at our institution between 1998 and 2015, 78 patients (logES: 18.5%; age, 76.7 ± 8.6 years) met the inclusion criteria. During the first 30 days, mortality and rate of MACCE were 9.0%; early mortality was two-fold overestimated by logES. Complete revascularization as scheduled was finally achieved in 64 patients (82.1%). Median follow-up time reached 3.4 (1.2–6.5) years with a median survival time of 4.7 years. Survival after 1, 3, and 5 years was 77, 62, and 48%. Conclusion In high-risk patients with MVD, MIDCAB is associated with acceptable early outcome which is better than predicted by logES. Taking the high-risk profile into consideration, midterm follow-up showed satisfying results, although scheduled HCR was not realized in a relevant proportion. In selected cases of MVD, MIDCAB presents an acceptable alternative for high-risk patients.

scholarly journals Non-invasive Global and Regional Myocardial Work Predicts High-Risk Stable Coronary Artery Disease Patients With Normal Segmental Wall Motion and Left Ventricular Function

2021 ◽  
Vol 8 ◽  
Author(s):  
Jun Zhang ◽  
Yani Liu ◽  
Youbin Deng ◽  
Ying Zhu ◽  
Ruiying Sun ◽  
...  
Keyword(s):  
Coronary Artery ◽  
High Risk ◽  
Wall Motion ◽  
Stable Coronary Artery Disease ◽  
Left Ventricular ◽  
Lv Function ◽  
Work Index ◽  
Normal Wall ◽  
Artery Disease ◽  
Global Work

Background: Previous studies suggested that myocardial work (MW) may identify abnormalities in the left ventricular (LV) function and establish a more sensitive index for LV dysfunction at the early stage. This study aimed to explore the value of global and regional MW parameters in predicting high-risk stable coronary artery disease (SCAD) patients with normal wall motion and preserved LV function.Patients and Methods: A total of 131 patients, who were clinically diagnosed as SCAD with normal wall motion and LV function, were finally included in this study. Global MW parameters, including global work index (GWI), global constructive work (GCW), global waste work (GWW), and global work efficiency (GWE) were measured with non-invasive LV pressure-strain loops constructed from speckle-tracking echocardiography. Regional myocardial work index (RWI) and work efficiency (RWE) were also calculated according to the perfusion territory of each major coronary artery. All patients underwent coronary angiography and were divided into the high-risk SCAD group, the non-high-risk SCAD group, and the No SCAD group according to the range and degrees of coronary arteries stenosis.Results: The global longitudinal strain (GLS), GWI and GCW were statistically different (P < 0.001) among the three groups. In the high-risk SCAD group, GLS, GWI, and GCW were significantly lower than the other two groups (P < 0.05). Receiver operating characteristic analysis demonstrated GWI and GCW could predict high-risk SCAD at a cutoff value of 1,808 mm Hg% (sensitivity, 52.6%; specificity, 87.8%; predictive positive value, 76.3%; predictive negative value, 69.9%) and 2,308 mm Hg% (sensitivity, 80.7%; specificity, 64.9%; predictive positive value, 63.3%; predictive negative value, 80.0%), respectively. Multivariate analyses showed that carotid plaque, decreased GWI, and GCW was independently related to high-risk SCAD. The cutoff values of RWILAD, RWILCX, and RWIRCA were 2,156, 1,929, and 1,983 mm Hg% in predicting high-risk SCAD, respectively (P < 0.001). When we combined RWI in two or three perfusion regions, the diagnostic performance of SCAD was improved (P < 0.001).Conclusions: Both global and regional MW parameters have great potential in non-invasively predicting high-risk SCAD patients with normal wall motion and preserved LV function, contributing to the early identification of high-risk patients who may benefit from revascularization therapy.

scholarly journals 1635 Catch me if you can: a rare case of two-staged MitraClip detachment

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
M G Bucci ◽  
M Previtali ◽  
M C Araujo Dos Anjos ◽  
G Binda ◽  
A Mazzola ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Mitral Valve ◽  
Artery Bypass ◽  
Clinical Status ◽  
Left Ventricular ◽  
Lv Function ◽  
Chronic Obstructive ◽  
Heart Team ◽  
Posterior Leaflet ◽  
Stable Conditions

Abstract Case report A 74-year-old man presented with acute heart failure and chronic obstructive pulmonary disease exacerbation. His medical history revealed: anterior myocardial infarction in 2005, treated with primary PCI of left anterior descending coronary artery followed by triple coronary artery bypass, atrial fibrillation, hypertension, diabetes mellitus and obesity. Transthoracic and transesophageal echocardiography (TEE) showed severe functional ischemic mitral regurgitation (MR) with multiple jets, the main one involving the A2-P2 scallops due to asymmetric tethering of the posterior leaflet. The vena contracta diameter (VC) was 8 mm, the effective regurgitant orifice area (EROA) 0.53 cm². Global left ventricular (LV) function was preserved with inferior-posterior wall akinesis. After "Heart Team" discussion, due to high surgical risk, the patient was referred for percutaneous mitral valve repair (PMVR) using MitraClip (MC) system (Abbott Vascular, Illinois). One clip (MC-XTR) was placed at the A3-P3 segments; subsequently, prior to releasing a second clip (MC-XTR), the first one partially detached from the posterior leaflet (Fig A). A third clip (MC-NTR) was implanted medially. The grasp was challenging but at the end of the procedure, the first clip appeared stable and marked reduction of MR was achieved (Fig B). 7 days later, the patient became symptomatic for resting dyspnea and worsened his clinical status. A control 2D-3D TEE revealed a complete detachment of the first implanted clip, visible distally into the LV, trapped in the mitral valve subchordal apparatus (Fig C). This resulted in massive MR (VC: 12 mm, EROA: 0.91 cm²) with an eccentric posteriorly directed regurgitant jet (Fig D). The patient underwent emergency surgical retrieval of the migrated clip, and removal of the torn mitral valve anterior leaflet. The other two clips were also removed (Fig E), and a bioprosthetic mitral valve was implanted. The procedure was completed uneventfully and the patient is in stable conditions at 2-months follow-up. Discussion The constant stretching and whip effect of the mitral leaflets captured between the clips arms, used in PMVR, can lead to complications. Partial clip detachment is a rare adverse event described in ∼0.7-4.9% of patients within 30 days after MC intervention*. We experienced a two-staged MC detachment that is an even rarer complication and requires emergency surgery. In addition, we highlights the usefulness of 3D TEE for early diagnosis and better imaging characterization in patients who develop complications after MC procedure. No conflict of interest. *Puls M, Lubos E, Boekstegers P, von Bardeleben RS, Ouarrak T, Butter C, Zuern CS, Bekeredjian R, Sievert H, Nickenig G, Eggebrecht H, Senges J, Schillinger W. One-year outcomes and predictors of mortality after MitraClip therapy in contemporary clinical practice: results from German transcatheter mitral valve interventions registry. Eur Heart J 2016;37:703-12. Abstract 1635 Figure.

Abstract 3351: The Coronary Suction Wave in Humans Is Not Diminished by Ischemia Induced Left Ventricular Diastolic Dysfunction.

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Stephen P Hoole ◽  
Paul A White ◽  
Patrick M Heck ◽  
Sadia N Khan ◽  
Michael O’Sullivan ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Diastolic Dysfunction ◽  
Coronary Arteries ◽  
Cardiac Cycle ◽  
Left Ventricular ◽  
Balloon Occlusion ◽  
Lv Function ◽  
List Type ◽  
Ventricular Relaxation ◽  
Diastolic Left Ventricular Dysfunction

Background: A dominant suction wave due to ventricular relaxation has been postulated to contribute to normal coronary artery flow. We hypothesised that this wave would: be present in diseased coronary arteries, occur at the appropriate time in the cardiac cycle and be diminished following coronary artery balloon occlusion due to ischemia induced diastolic LV dysfunction. Methods: Simultaneous coronary pressure - velocity and LV pressure - volume were invasively recorded at baseline and after 1 minute coronary balloon occlusion, in 10 patients with single vessel coronary disease and normal LV function. Net coronary wave intensity (WI) = (dP/dt).(dU/dt) was calculated using MatLab software. Results: A dominant forward pushing wave and a backward suction wave (figure - shaded wave) were demonstrated in diseased coronary arteries. The suction wave occurred early in diastole, during active ventricular relaxation. Ischemia induced LV diastolic dysfunction was demonstrated after coronary artery occlusion (mean % Δ from baseline (SD): LV dP/dt min = −14.8 (13.8), p=0.008, LV Tau = +19.1(14.9), p = 0.011) but there was no significant change in suction WI (mean (SD): baseline = −1.35 (0.20) m −2 s −2 x10 5 , post-balloon occlusion −1.49(0.59) m −2 s −2 x10 5 , p =0.67). Conclusion: The coronary suction wave occurs in diseased coronary arteries at the appropriate time in the cardiac cycle but is not diminished by ischemia induced diastolic left ventricular dysfunction.

Abstract 13917: Post-systolic Shortening in the Ischemic Myocardium is Attenuated in Multivessel Disease

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Daisuke Sakurai ◽  
Toshihiko Asanuma ◽  
Kasumi Masuda ◽  
Masamichi Oka ◽  
Koichiro Kotani ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Disease Model ◽  
Left Ventricular ◽  
Ischemic Myocardium ◽  
Multivessel Disease ◽  
Vessel Disease ◽  
Single Vessel ◽  
The Difference ◽  
The Relationship ◽  
Single Vessel Disease

Background: Post-systolic shortening (PSS) is myocardial shortening that occurs after end-systole and is considered as a sensitive marker of myocardial ischemia. Empirically, PSS in patients with multivessel disease is smaller than that in those with single vessel disease. Although this seems to be due to a decrease of difference in contraction between the ischemic and the surrounding myocardium, no study has elucidated it. We investigated the relationship between PSS and the difference of contraction between the ischemic and surrounding myocardium in an animal model which underwent left anterior descending coronary artery (LAD) occlusion (single vessel disease model) followed by left circumflex coronary artery (LCx) occlusion (multivessel disease model). Methods: In 7 open-chest dogs, left ventricular short-axis images (GE Vivid E9) and hemodynamic data were acquired at 3 conditions: (1) at baseline, (2) during LAD occlusion, and (3) during both LAD and LCx occlusion. Circumferential strains were analyzed in 6 segments by speckle tracking software. The amplitude of PSS (ε PSS ) and end-systolic strain (ε ES ) were measured and the difference of ε ES between a segment perfused by the LAD and the average of the other 5 segments was calculated (Δε ES ). Results: In the LAD segment, dyskinetic motion and PSS occurred during LAD occlusion but they were paradoxically attenuated during both LAD and LCx occlusion. ε PSS significantly correlated with Δε ES (r=0.95, p<0.05). Although ε PSS significantly decreased during both occlusion compared to LAD occlusion, ε PSS corrected by Δε ES (ε PSS /Δε ES ) did not decrease (figure). Conclusions: PSS in the ischemic myocardium was attenuated when the surrounding myocardium also became ischemic. The difference of contraction between the ischemic and the surrounding myocardium at end-systole seems to be a determinant of the amplitude of PSS. A parameter ε PSS /Δε ES may be useful for assessing ischemia in patients with multivessel disease.

Abstract 5817.5: Assessment of Global Left Ventricular Function and Volumes with 320-Slice MSCT: A Comparison with 2D Echocardiography

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Fleur R de Graaf ◽  
Joanne D Schuijf ◽  
Jacob M van Werkhoven ◽  
J Wouter Jukema ◽  
Gaetano Nucifora ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Function Analysis ◽  
Imaging Modality ◽  
Linear Regression Analysis ◽  
Left Ventricular ◽  
Lv Function ◽  
Intravenous Contrast ◽  
2D Echocardiography ◽  
Artery Disease

Background. Multi-slice computed tomography (MSCT) has been demonstrated as a feasible imaging modality for non-invasive assessment of coronary artery disease and left ventricular (LV) function analysis. Recently, 320-slice systems have become available with 16 cm anatomical coverage allowing prospective image acquisition of the entire heart within a single rotation or heart beat. However, limited data are currently available with these systems. The purpose of the present study therefore was to evaluate the accuracy of 320-slice MSCT in the assessment of global LV function as compared to 2-dimensional (2D) echocardiography. Methods. A head-to-head comparison between 320-slice MSCT and 2D echocardiography was performed in 40 patients (24 male; mean age 61 ± 9 years) with known or suspected coronary artery disease (CAD). During intravenous contrast agent administration, the entire heart was imaged in a single heartbeat, using prospective dose modulation (full dose during 65–85% of R-R interval). The following parameters were used: gantry rotation time 350 ms, tube voltage 120 kV, tube current 300–500mA. LV end-diastolic volumes (LVEDV) and LV end-systolic volumes (LVESV) were determined and the LV ejection fraction (LVEF) was derived. Two-dimensional echocardiography served as the gold standard. Results. Average LVEF was 59% ± 8% (range 31%–77%) as determined on 2D-echocardiography, compared with 61% ± 8% (range 33%–78%) on MSCT. Evaluation of LVEF by linear regression analysis showed a good correlation between MSCT and 2D-echocardiography (r = 0.84; p < 0.001). A close correlation between MSCT and 2D-echocardiography was also demonstrated for the assessment of LVEDV (r = 0.81; p < 0.001) and LVESV (r = 0.89; p < 0.001). At Bland-Altman analysis, mean differences (± SD) of 20.88 ml ± 23.07 ml (p < 0.01) and 6.83 ml ± 13.01 ml (p < 0.01) were observed between MSCT and 2D-echocardiography for LVEDV and LVESV respectively. As a result, LVEF was slightly overestimated with MSCT (1.98% ± 4.54%; p < 0.01). Conclusion. Accurate assessment of LV function and volumes is feasible with 320-slice MSCT in patients with known or suspected CAD.

scholarly journals Clinical Characteristics and Outcomes From Percutaneous Coronary Intervention of Last Remaining Coronary Artery

2020 ◽  
Vol 13 (9) ◽  
Author(s):  
Ahmad Shoaib ◽  
Muhammad Rashid ◽  
Evangelos Kontopantelis ◽  
Andrew Sharp ◽  
Eoin F. Fahy ◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Artery ◽  
High Risk ◽  
Clinical Outcomes ◽  
Odds Ratio ◽  
Coronary Intervention ◽  
Left Ventricular ◽  
Sensitivity Analyses ◽  
Control Group ◽  
Percutaneous Coronary

Background: Patients with complex high-risk coronary anatomy, such as those with a last remaining patent vessel (LRPV), are increasingly revascularized with percutaneous coronary intervention (PCI) in contemporary practice. There are limited data on the outcomes of these high-risk procedures. Methods: We analyzed a large longitudinal PCI cohort (2007–2014, n=501 841) from the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing patients into 2 groups; LRPV group (n=2432) and all other PCI groups (n=506 691). Results: Patients in the LRPV PCI group were older, had more comorbidities, and higher prevalence of moderate-severe left ventricular systolic dysfunction. Mortality was higher in the LRPV PCI group during hospital admission (12 % versus 1.5 %, P <0.001), at 30 days (15% versus 2%, P <0.001), and at one-year (24% versus 5%, P <0.001). In a propensity score matching analysis the adjusted risk of mortality during index admission (odds ratio, 2.05 [95% CI, 1.65–2.44], P <0.001), at 30 days (odds ratio, 2.13 [95% CI, 1.78–2.5], P <0.001), at 1 year (odds ratio, 1.81 [95% CI, 1.59–2.03], P <0.001), and in-hospital major adverse cardiovascular events (odds ratio, 1.8 [95% CI, 1.42–2.19], P <0.001) were higher in LRPV PCI group as compared to control group. In sensitivity analyses, similar clinical outcomes were observed irrespective of which major epicardial coronary artery was treated. Conclusions: In this contemporary cohort, patients who had PCI to their LRPV had a higher-risk profile and more adverse clinical outcomes, irrespective of the vessel treated.

Downregulation of ventricular contractile function during early ischemia is flow but not pressure dependent

1998 ◽  
Vol 275 (5) ◽  
pp. H1520-H1523 ◽  
Author(s):  
Miao-Xiang He ◽  
H. Fred Downey
Keyword(s):  
Coronary Artery ◽  
Perfusion Pressure ◽  
Contractile Function ◽  
Coronary Perfusion Pressure ◽  
Coronary Perfusion ◽  
Rat Hearts ◽  
Myocardial Contractile Force ◽  
Myocardial Contractile ◽  
Artery Obstruction

The mechanism responsible for the abrupt fall in myocardial contractile function following coronary artery obstruction is unknown. The “vascular collapse theory” hypothesizes that the fall in coronary perfusion pressure after coronary artery obstruction is responsible for contractile failure during early ischemia. To test the role of vascular collapse in downregulating myocardial contractile force at the onset of ischemia, coronary flow of isolated rat hearts was abruptly decreased by 50, 70, 85, and 100% of baseline, and subsequent changes in coronary perfusion pressure and ventricular function were recorded at 0.5-s intervals. At 1.5 s after flow reductions ranging from 50 to 100%, decreases in contractile function did not differ, although perfusion pressure varied significantly from 45 ± 1 to 20 ± 2 mmHg. When function fell to 50% of baseline, perfusion pressures ranged from 35 ± 0.5 to 2.5 ± 1 mmHg for flow reductions ranging from 50 to 100%. Identical contractile function at widely differing coronary perfusion pressures is incompatible with the vascular collapse theory.

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