Improved Outcomes of Combined Main Branch Stenting and Side Branch Drug-Coated Balloon versus Two-Stent Strategy in Patients with Left Main Bifurcation Lesions

Background. Drug-eluting stent (DES) plus drug-coated balloon (DCB) is a safe and effective treatment strategy for coronary artery bifurcation lesions, but there is no report about this strategy being used for left main (LM) bifurcation lesions. We aim to explore the efficacy and safety of DES plus DCB in the treatment of LM bifurcation lesions. Methods. A total of 100 patients diagnosed with LM bifurcation lesions by coronary angiography were retrospectively enrolled at our center from January 2018 to December 2019. They received either a two-stent strategy or a main branch (MB) stenting plus side branch (SB) DCB strategy and were accordingly divided into the 2-DES group and the DES + DCB group. Patients treated with DES + DCB were compared with a cohort of matched patients treated with a 2-DES strategy. Clinical data was collected and quantitative coronary analysis was performed. Results. For immediate postoperative angiography, though the two groups had no differences in the minimal luminal diameter (MLD) and luminal stenosis of MB, the DES + DCB group had significantly lower SB ostial MLD and a higher degree of residual lumen stenosis than the 2-DES group ( P < 0.05 ). At the time of follow-up, the SB ostial MLD of the DES + DCB group was higher than that of the 2-DES group, but lumen stenosis, late lumen loss (LLL), and LLL at the distal end of the left MB were all smaller than those of the 2-DES group ( P s < 0.05 ). Furthermore, the incidence of lumen restenosis and MACE between the two groups had no significance. Conclusion. The combination of DES and DCB is relatively safe and effective for the treatment of LM bifurcation lesions, and this strategy seems to have advantages in reducing LLL at the SB ostium.

Redo aortic valve replacement with a non-conventional intraoperative decision to avoid left main stem obstruction.

Redo aortic valve surgery for failure of a previously implanted valve is always challenging. In case of small-sized implanted valves, the use of a balloon-expanding Sapien-3 valve can enhance the final effective orifice area, avoid complex annulus enlargement techniques, and can reduce operative time and morbidities. We describe a case where after explanting a failed 19mm St. Jude mechanical aortic valve and further deployment of a 23mm Sapien-3 valve, the left coronary ostia was obstructed by the skirt of the transcatheter prosthesis. After careful removal of a little part of the skirt, we were able to restore the coronary flow and the patient had a favorable outcome.

ASSOCIATION OF ST ELEVATION IN LEAD AVR WITH LEFT MAIN STEM AND TRIPLE VESSEL DISEASES IN PATIENTS WITH NON-ST ELEVATION MYOCARDIAL INFARCTION

Objectives: To determine frequency of left main stem (LMS) and triple vessel coronary artery disease (3VCAD) in patients of Non-ST-elevation myocardial infarction (NSTEMI) and to compare the frequency of LMS and 3VCAD in patients with NSTEMI with or without ST elevation in lead aVR. Methodology: Total 346 patients with NSTEMI having age 30-70 years were included in this descriptive cross-sectional study. The data on demographic details was collected. All patients underwent electrocardiography (ECG) and cardiac specific troponin-I assessment. Patients were categorized as NSTEMI with or without ST-elevation in lead aVR. Coronary angiography was performed in all patients and angiographic findings were noted. Results: Mean age of patients was 51.87±10.03 years. There were 218 (63.01%) males and 128 (36.99%) female patients. 182 (52.60%) patients of NSTEMI had ST elevation in aVR. LMS disease was found in 53 (29.10%) patients with ST elevation in aVR. Sensitivity, specificity, positive predive value and negative predictive value of ST elevation in aVR for LMS disease was 62.35%, 50.57%, 29.12% and 80.49% respectively. 3 VCAD was found in 54 (29.70%) with ST elevation in aVR. Sensitivity, specificity, positive predive value and negative predictive value of ST elevation in aVR for 3VCAD was 77.14%, 53.52%, 29.67% and 90.24% respectively. Conclusion: NSTEMI patients with ST elevation in aVR may have higher chances of having LMS disease or 3VCAD. There is high negative predictive value for ST elevation in aVR to predict LMS disease or 3VCAD.

A multi-center, international, randomized, 2-year, parallel-group study to assess the superiority of IVUS-guided PCI versus qualitative angio-guided PCI in unprotected left main coronary artery (ULMCA) disease: Study protocol for OPTIMAL trial

Background Percutaneous coronary intervention (PCI) is used increasingly for revascularization of unprotected left main coronary artery (LMCA) disease. Observational studies and subgroup analyses from clinical trials, have suggested a possible benefit from the use of intravascular ultrasound (IVUS) guidance when performing unprotected LMCA PCI. However, the value of imaging with IVUS has never been proven in an appropriately powered randomized clinical trial. The OPtimizaTIon of Left MAin PCI With IntravascuLar Ultrasound (OPTIMAL) trial has been designed to establish whether IVUS-guided PCI optimization on LMCA is associated with superior clinical outcomes when compared with standard qualitative angiography-guided PCI. Methods The OPTIMAL trial is a randomized, multicenter, international study designed to enroll a total of 800 patients undergoing PCI for unprotected LMCA disease. Patients will be randomized in a 1:1 fashion to IVUS-guided PCI versus angiogram-guided PCI. In patients allocated to the angiogram-guided arm, use of IVUS is discouraged, unless there are safety concerns. In patients allocated to the IVUS guidance arm, pre-procedural IVUS assessment is highly recommended, whilst post-procedural IVUS assessment is mandatory to confirm appropriate stenting result and/or to guide stent result optimization, according to predefined criteria. Patients will be followed up to 2 years after the index procedure. The primary outcome measure is the Academic Research Consortium (ARC) patient-oriented composite endpoint (PoCE) which includes all-cause death, any stroke, any myocardial infarction and any repeat revascularization at 2 years follow-up. Discussion The OPTIMAL trial aims to provide definitive evidence about the clinical impact of IVUS-guidance during PCI to an unprotected LMCA. It is anticipated by the investigators, that an IVUS-guided strategy will be associated with less clinical events compared to a strategy guided by angiogram alone. Trial registration ClinicalTrials.gov: NCT04111770. Registered on October 1, 2019.

Multimodality Imaging Assessment of Anomalous Aortic Origin of the Left Main Coronary Artery Presenting With Syncope and Non-ST Elevation Myocardial Infarction

ABSTRACT Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital abnormality associated with myocardial ischemia and sudden cardiac death. We present a case of a 20 year old previously healthy male presenting with exertional syncope and non-ST elevation myocardial infarction. Coronary computed tomography angiography showed an anomalous left main coronary artery arising from the right coronary cusp with a slit-like appearance, acute angle origin, intramural course, and a subsequent inter-arterial course between the main pulmonary artery and the proximal aorta. Cardiac magnetic resonance imaging demonstrated myocardial infarction in the distribution of the left main coronary artery. The patient underwent successful surgical correction with unroofing of the left main coronary artery. He has had no syncopal episodes or recurrence of chest pain and returned to full duty status in the United States Marine Corps. This case report demonstrates the evaluation and management of a patient with AAOCA.

Unicorn: Anomalous Double Ostium Left Main Coronary Artery With Intra-Mural Connection - Diagnosed with Multi-Modality Imaging

Case report of a unicorn: anomalous double ostium left main coronary artery with common intra-mural connection. Three-dimensional virtual endo-luminal angioscopy and catheter-based imaging confirmed the diagnosis, subsequently avoiding cardiac surgical intervention.

Intratracheal Nodular Fasciitis: a Rare Lesion Case Report

Nodular fasciitis is a benign proliferation of myofibroblasts that usually arises in subcutaneous tissues of the trunk, neck, head, and upper extremities of young to middle-aged adults. It is not reported to arise in the intratracheal. We present a patient with chest tightness and asthma for three months. Chest computed tomography showed no displayed of left bronchus. The trachea of the left main bronchus was blocked by organisms under bronchoscope. The organisms were extracted and pathologically diagnosed as a rare, benign, intratracheal nodular fasciitis. One month later, the patient relapsed again and underwent resection.