The importance of three dimensional coronary artery reconstruction accuracy when computing virtual fractional flow reserve from invasive angiography

Three dimensional (3D) coronary anatomy, reconstructed from coronary angiography (CA), is now being used as the basis to compute ‘virtual’ fractional flow reserve (vFFR), and thereby guide treatment decisions in patients with coronary artery disease (CAD). Reconstruction accuracy is therefore important. Yet the methods required remain poorly validated. Furthermore, the magnitude of vFFR error arising from reconstruction is unkown. We aimed to validate a method for 3D CA reconstruction and determine the effect this had upon the accuracy of vFFR. Clinically realistic coronary phantom models were created comprosing seven standard stenoses in aluminium and 15 patient-based 3D-printed, imaged with CA, three times, according to standard clinical protocols, yielding 66 datasets. Each was reconstructed using epipolar line projection and intersection. All reconstructions were compared against the real phantom models in terms of minimal lumen diameter, centreline and surface similarity. 3D-printed reconstructions (n = 45) and the reference files from which they were printed underwent vFFR computation, and the results were compared. The average error in reconstructing minimum lumen diameter (MLD) was 0.05 (± 0.03 mm) which was < 1% (95% CI 0.13–1.61%) compared with caliper measurement. Overall surface similarity was excellent (Hausdorff distance 0.65 mm). Errors in 3D CA reconstruction accounted for an error in vFFR of ± 0.06 (Bland Altman 95% limits of agreement). Errors arising from the epipolar line projection method used to reconstruct 3D coronary anatomy from CA are small but contribute to clinically relevant errors when used to compute vFFR.

Adverse in-hospital prognosis in patients with non-ST-segment elevation myocardial infarction with right bundle branch block – red flag ECG and sicker patients

Introduction Recent recommendations regarding myocardial infarction (MI) underline the adverse prognosis associated with right bundle branch block (RBBB), suggesting that, in some cases of non-ST-segment elevation MI (NSTEMI) with RBBB a primary percutaneous coronary intervention (PCI) strategy should be considered. However, it is unclear if this is due to a more difficult and late diagnosis or to the clinical severity inherent to these patients (pts). Purposes To characterize the NSTEMI with RBBB population and find predictors of worse prognosis. Methods Retrospective analysis of pts included in the Portuguese Registry of Acute Coronary Syndromes with NSTEMI, comparing pts with RBBB (group A) vs without RBBB (group B), regarding clinical and demographic variables, diagnostic and therapeutic approaches. Primary endpoint was heart failure, electrical and mechanical complications and death in the in-hospital period. Results We included 9375 pts, 686 in group A and 8689 in group B. Pts in group A were more likely to be male (p&lt;0.001) and over 75 years old (p&lt;0.001). Also, they were more prone to have cardiovascular risk factors (hypertension - p&lt;0.001, diabetes – p&lt;0.001) and history of coronary artery disease (stable angina p=0.007, previous MI p=0.002 and revascularization, either PCI – p=0.016 or surgery – p&lt;0.001), stroke (p&lt;0.001), chronic kidney disease (p&lt;0.001) and cancer (p=0.025), comparing to pts in group B. There were no differences between time from onset of symptoms and first medical contact or hospital admission between groups. Upon admission, these pts presented more frequently with hypotension (p=0.026), Killip class&gt;II (p&lt;0.001) and atrial fibrillation (p&lt;0.001) than pts in group B. There were statiscally significant differences between groups, regarding the use of inotropes (p&lt;0.001), non-invasive (p=0.008) and invasive ventilation (p=0.018) and temporary pacing (p=0.001), all of them higher in group A. Pts with RBBB were less likely to undergo coronary angiography (CA) (p&lt;0.001). However, among those who did, there were no differences in CA timing (p=0.091), but pts from group A had more frequently multivessel disease (p=0.044) and no revascularization was undertaken (p=0.012). About 16.64% of all pts reached the endpoint, but unfavourable in-hospital outcome was significantly more common in group A (p&lt;0.001). RBBB remained an independent predictor of the endpoint (p=0.032) in a multivariate regression analysis, controlled for other variables (namely gender, age, cardiovascular risk factors, previous evidence of cardiovascular disease, and clinical and coronary anatomy data) – AUC of 0.833. Conclusion Although pts with NSTEMI and RBBB have a poorer in-hospital prognosis, partly due to their bigger clinical complexity (older age, multiple comorbidities and complex coronary anatomy), RBBB itself still remains an independent predictor of worse outcome. FUNDunding Acknowledgement Type of funding sources: None.

The relationship between coronary anatomy and primary percutaneous coronary intervention features and prognostically unfavorable CMR-based characteristics of acute ST-elevation myocardial infarction

Purpose To investigate the impact of coronary anatomy and pPCI parameters on the most prognostically significant MRI measures of acute MI with ST segment elevation (MVO, infarct size). Methods The study included 52 patients with STEMI and primary percutaneous coronary intervention (pPCI) of infarct-related arteries (IRA). On Days 3–7 contrast-enhanced cardiac MRI was done. Tissue analysis of scans was performed evaluating infarct size, presence and size of MVO. Results The study included 52 patients with first STEMI within &lt;48 hours of onset. All patients urgently underwent pPCI for reperfusion. Patients were divided into 2 groups separated by the median time to reperfusion treatment (3 hours). There were no significant differences between groups in MRI-measured EF (In the group with later pPCI (&gt;3 hours of symptom onset EF was 49.0±11.0%, and in the comparator group – 45.7±10.5%, p=0,2). MRI-measured infarct size was significantly higher in the group where pPCI was done &gt;3 hours of symptom onset: 18.1±1.7% of the LV mass, compared to the early reperfusion group – 10.9±1.9% (p=0.009). MVO magnitude was also higher in the later pPCI group (2.6±0.64% vs 0.03±0.3% in the comparator group), (p&lt;0,027). Correlation analysis also revealed a reliable relationship between IS and time to reperfusion (R 0.381, p=0.006). LAD lesions were associated with higher infarct size values (p=0.02) and higher risk of MVO (odds ratio 2.9, CI 0.83–10.0, p=0.03). Complete occlusion of IRA was associated with higher IS (16,97±3.3 vs 12.05±1.4, p=0.02). There was no reliable correlations between IRA patientcy and MVO magnitude (p=0.7). Conclusions In this study pPCI timing, in groups of below and more than 3 hours after symptom onset, had no significant impact on EF, as determined by MRI. However, pPCI timing exceeding 3 hours significantly influenced infarct size, the occurrence and magnitude of microvascular obstruction. LAD being the IRA was associated with larger IS, higher risks of MVO development. Patient IRA was associated with smaller IS as determined by MRI. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Healthcare Russian Federation

EFFECT OF EECP (ENHANCED EXTERNAL COUNTER PULSATION) ON LEFT VENTRICULAR FUNCTION AS MEASURED BY ECHOCARDIOGRAPHY USING STRAIN.

India stands as one of the fastest developing countries in the world. It has entered quickly into an epidemiological transition leading to a 1 phenomenal increase in non-communicable diseases . Of them leading the way is coronary artery disease. 0 It has been estimated that 4 lakh 2 deaths a year are attributable to cardiovascular disease. The most common symptom in CAD is angina pectoris. The treatment for angina includes medical therapy and coronary revascularization by PTCA or CABG. However, a large number of these patients are not suitable to the usual procedures due to unfavorable coronary anatomy, repeated revascularization attempts, elderly age group, associated comorbidities and patient's preference.

Clinical course and surgical outcomes in middle-age adults with anomalous aortic origin of a coronary artery

Funding Acknowledgements Type of funding sources: None. Background Patients with anomalous aortic origin of a coronary artery (AAOCA) present with a wide range of clinical manifestations, including ischemic symptoms (chest pain or dyspnea) and sudden cardiac death (SCD). Studies have identified coronary anatomic characteristics associated with a higher risk of SCD. However, most of the published literature consists of studies in adolescents and young adults. There is a paucity of data regarding outcomes in middle-aged patients. Current guidelines reveal gaps in evidence for identification of adults are at risk for SCD, and for whom surgery is beneficial. Purpose To study the clinical course and rate of major adverse cardiac events (MACE) in middle-aged adults with AAOCA based on presenting symptoms, coronary anatomy on coronary computed tomography angiography (CCTA), stress test results, and surgical management. Methods We included all patients from January 2013 to December 2019 age &gt; 18 at our institution who were found to have AAOCA. Patients with the following were excluded to minimize confounding factors which could cause MACE: coronary artery disease (CAD) with &gt;50% stenosis in any coronary vessel, CAD requiring revascularization, heart failure with ejection fraction &lt;40%, history of heart transplant, and non-AAOCA congenital heart disease. All patient charts were reviewed for demographics, coronary anatomy on CCTA, presenting symptoms, rationale for pursuing stress testing and CCTA, nature of surgical interventions, post-surgical course, and MACE (cardiovascular death, myocardial infarction, and need for coronary revascularization). All patients underwent PET as well as treadmill stress testing. Results Of 19,367 patients who underwent CCTA, 47 met inclusion criteria, with median age at diagnosis of 54 and median follow-up of 48 months. No patients suffered MACE. Twenty-five patients had AAORCA and 22 had AAOLCA (Table 1). Ten patients with AAORCA and 8 patients with AAOLCA presented with ischemic symptoms and had coronary anatomy characteristics associated with higher risk of SCD, as well as ischemia corresponding to the anomalous artery on stress testing and did not undergo surgery due to personal preference. Five symptomatic patients with stress-induced ischemia corresponding to the anomalous artery underwent surgery and all achieved symptom relief over a median follow up of 5 years. Conclusion As AAOCA is a significant cause of SCD in young adults, it is compelling to observe this adult cohort in which no patients experienced MACE, including 18 symptomatic patients with high-risk anatomy and stress-induced ischemia, as well as a Class I recommendations for surgery. The results suggest that although surgery may be beneficial for symptom relief, it does not necessarily improve mortality over an intermediate follow-up period. Future studies should examine surgical outcomes in middle-aged cohorts with larger sample sizes.

Live integration of comprehensive cardiac CT for myocardial fibrosis and coronary anatomy with electroanatomical mapping in patients with refractory ventricular tachycardia: a pilot study

Funding Acknowledgements Type of funding sources: None. Aim of the study was to verify the feasibility and accuracy of live integration of myocardial fibrosis evaluated at CCT with EAM. The present is the first report of live integration of cardiac computed tomography (CCT) data for myocardial fibrosis and coronary anatomy with electroanatomical mapping (EAM). We prospectively enrolled all patients admitted with a clinical indication to endocardial and epicardial EAM before radiofrequency catheter ablation (RFCA) of refractory ventricular tachycardia (VT) and an absolute contraindication to cardiac magnetic resonance. All patients underwent per protocol CCT for myocardial fibrosis and coronary anatomy evaluation, before RFCA procedures. Sensitivity, specificity, negative predictive value, positive predictive value and diagnostic accuracy were assessed for myocardial fibrosis evaluation with CCT vs EAM on a per segment-basis taking into consideration both any type of fibrosis and ischemic vs non ischemic subtypes. Live integration feasibility of CCT vs EAM was evaluated for every patients. Live integration feasibility and diagnostic performance of CCT vs EAM for myocardial fibrosis identification was evaluated for every patients. EAM adverse events were recorded as well. In all patients CCT data were successfully integrated with EAM during RFCA procedure. All patients had myocardial fibrosis correctly identified at CCT vs EAM on a per-patients basis. A diagnostic accuracy of 94.1% for detection of any type of myocardial fibrosis at CCT vs EAM was recorded. No pericardial tamponade and/or pericardial effusion were recorded. CCT identification of myocardial fibrosis is feasible and accurate vs EAM in a very selected high risk patients with clinical indication to RFCA of VT and contraindication to CMR. CCT images integration during EAM is feasible and enable to provide electrophysiologist useful information regarding myocardial fibrosis and coronary arteries location, possibly avoiding invasive coronary angiography.

Tetra ostial coronary anatomy- A rare pattern in transposition of great arteries.

Meticulous transfer of coronary arteries is of crucial importance in transposition of great arteries and determines the success of the switch procedure. This report describes a coronary anatomy consisting of four separate ostia from the two facing sinuses in a six-month-old infant presenting with d-transposition of great arteries and ventricular septal defect. Being a rare coronary arterial pattern not described in previous coding systems, the surgeon would do well to be aware of this possibility while performing the switch procedure.

Myocardial infarct late after Fontan-type surgery in pulmonary atresia and intact ventricular septum: a must-know complication! About a case report

Coronary abnormalities are frequent in pulmonary atresia and intact ventricular septum, mainly in patients with a very diminutive right ventricle. They severely impact on early and late prognosis. We describe an 8-year-old girl who presented with myocardial ischaemia, late after uneventful Fontan completion. The importance of precise delineation of the coronary anatomy upon initial assessment and during follow-up is emphasised.