Coronary Artery Anomalies

Coronary artery anomalies (CAAs) are a group of congenital conditions characterized by abnormal origin or course of any of the 3 main epicardial coronary arteries. Although CAAs have been identified as a common underlying condition in young athletes with sudden cardiac death, the widespread use of invasive and noninvasive coronary imaging has led to increased recognition of CAAs among adults. CAAS are often discovered as an incidental finding during the diagnostic workup for ischemic heart disease. The clinical correlates and prognostic implication of CAAs remain poorly understood in this context, and guideline-recommended therapeutic choices are supported by a low level of scientific evidence. Several studies have examined whether assessment of CAA-related myocardial ischemia can improve risk stratification in these patients, suggesting that multimodality imaging and functional tests may be key in the management of CAAs. The aim of this review is to outline definitions, classification, and epidemiology of the most relevant CAAs, highlighting recent advances and the potential impact of multimodality evaluation, and to discuss current therapeutic opportunities.

The Coronary Arteries in Adults after the Arterial Switch Operation: A Systematic Review

Coronary artery status in adults long after the arterial switch operation (ASO) is unclear. We conducted a systematic review to provide an overview of coronary complications during adulthood and to evaluate the value of routine coronary imaging in adults after ASO, in light of current guidelines. Articles were screened for the inclusion of adult ASO patients and data on coronary complications and findings of coronary imaging were collected. A total of 993 adults were followed with a median available follow-up of only 2.0 years after reaching adulthood. Myocardial ischemia was suspected in 17/192 patients (8.9%). The number of coronary interventions was four (0.4%), and coronary death was reported in four (0.4%) patients. A lack of ischemia-related symptoms cannot be excluded because innervation studies indicated deficient cardiac innervation after ASO, although data is limited. Anatomical high-risk features found by routine coronary computed tomography (cCT) included stenosis (4%), acute angle (40%), kinking (24%) and inter-arterial course (11%). No coronary complications were reported during pregnancy (n = 45), although, remarkably, four (9%) patients developed heart failure. The 2020 European Society of Cardiology (ESC) guidelines state that routine screening for coronary pathologies is questionable. Based on current findings and in line with the 2018 American ACC/AHA guidelines a baseline assessment of the coronary arteries in all ASO adults seems justifiable. Thereafter, an individualized coronary follow-up strategy is advisable at least until significant duration of follow-up is available.

Advances in Quantitative Analysis of 18F-Sodium Fluoride Coronary Imaging

18F-sodium fluoride (18F-NaF) positron emission tomography (PET) has emerged as a promising noninvasive imaging tool for the assessment of active calcification processes in coronary artery disease. 18F-NaF uptake colocalizes to high-risk and ruptured atherosclerotic plaques. Most recently, 18F-NaF coronary uptake was shown to be a robust and independent predictor of myocardial infarction in patients with advanced coronary artery disease. In this review, we provide an overview of the advances in coronary 18F-NaF imaging. In particular, we discuss the recently developed and validated motion correction techniques which address heart contractions, tidal breathing, and patient repositioning during the prolonged PET acquisitions. Additionally, we discuss a novel quantification approach—the coronary microcalcification activity (which has been inspired by the widely employed method in oncology total active tumor volume measurement). This new method provides a single number encompassing 18F-NaF activity within the entire coronary vasculature rather than just information regarding a single area of most intense tracer uptake.

Myocardial bridging: non-invasive diagnostics and management

The article discusses a case of episodes of asymptomatic ST-T depression during exercise in a 37-year-old patient with complaints of irregular heartbeat, tachycardia up to 100 bpm, not related to exercise. According to contrast-enhanced multislice computed tomography, in the middle third, a muscle bridge with stenosis of up to 30% was found. The diagnosis was made: Congenital coronary artery anomaly: transmyocardial muscular bridge of the middle third of left anterior descending artery with stenosis up to 30%. Class 1 silent myocardial ischemia. Stage 0, class 0 chronic heart failure. Using non-invasive coronary imaging, it was possible to identify the cause of transient ST-T depression and to choose the appropriate therapy.

Intracoronary imaging reduces target vessel failure in primary percutaneous coronary intervention

Background Intracoronary imaging during percutaneous coronary intervention (PCI) allows better delineation of lesion characteristics and more accurate vessel sizing compared with angiogram alone. However, the benefit and safety of its use in primary percutaneous coronary intervention (PPCI) is uncertain. Purpose To determine whether the use of intracoronary imaging with intravascular ultrasound (IVUS) or optical coherence tomography (OCT)/ optical frequency domain imaging (OFDI) in PPCI is associated with better outcome. Method From Jan 2014 to Dec 2018, all patients with PPCI performed in our hospital were retrospectively studied. Baseline and procedural characteristics of angiographic-guided versus imaging-guided PCI were analyzed. Primary endpoint was target vessel failure, and procedural outcomes were contrast volume, number of stents implanted, mean stent length and diameter and use of post-dilatation. Safety outcomes were post-operative acute kidney injury (AKI), need for renal replacement therapy (RRT) and occurrence of no/slow reflow. Results A total of 408 patients were included, of which 223 (54.7%) used IVUS (n=176 80.3%) or OCT/OFDI (n=44 19.7%) during the procedure. Baseline and procedural characteristics were similar between both groups except more patients had history of PCI (12.6% vs 4.3% p=0.004) and left-main/ bifurcation lesions (12.6% vs 2.7% p<0.001). Intra-coronary imaging was associated with less target vessel failure during a median follow up of 22 months (Hazard ratio (HR): 0.59; 95% Confidence interval (CI): 0.36–0.97; p=0.036). Patients who had intra-coronary imaging during PPCI received more post-dilatation (77.1% vs 55.1% p<0.001), had longer (53mm vs 42mm p<0.001) and more stents (2 vs 1.67 p=0.003) implanted but had more contrast injected (151.2ml vs 130.6ml p=0.002). There was no statistically significant difference in mean stent diameter (3.07mm vs 3.02mm p=0.53), occurrence of slow/now reflow (15.3% vs 18.4% p=0.409), incidence of AKI (7.2% vs 10.8% p=0.197) or need for RRT (3.1% vs 5.4% p=0.254) between both groups. Conclusion Use of intra-vascular imaging during PPCI was associated with less target vessel failure, longer and more stents implanted and more frequent use of post-dilatation. Further prospective randomized controlled trial is suggested to confirm this benefit. Funding Acknowledgement Type of funding source: None