Evaluation of major coronary artery Bifurcation angles with digital angiography: A detailed study of prevalence in the Upper Euphrates Basin

Objectives: To investigate the diversity and average values of bifurcation angles in a large population to help develop new methods. Methods: One thousand five individuals (504 females, 501 male) who visited the Cardiology Polyclinic of Fırat University Hospital with the complaint of chest pain between 2010 and 2015 were evaluated retrospectively. Bifurcation angle measurements between LMCA-CX, CX-LAD, LMCA-LAD, CX-OM1, CX-OM2, LAD-D1, LAD-D2, RCA-RMD, RCA-RVD and PDA-PL were evaluated in all cases. Results: Bifurcation angles between LMCA-LAD, LMCA-Cx and LAD-Cx branches with “> 90 wide angle bifurcations”, and Cx-OM1, Cx-OM2, LAD-D1, LAD-D2, RCA-RMD and PDA-PL with “<70 Y type bifurcation angle” were found to be high in male and female individuals. The RCA-RVD in female individuals was “<70 Y-type bifurcation” in 14 (2.8%) people, “> 70-90 T-type bifurcation” in 209 (41.5%) people, and “> 90 wide angle bifurcation” in 281 (55.8%) people. Results for male subjects were compatible with this. The correlations of all angles were examined. Robust positive correlations (p≤0.001) were found for the angular measurements between the main branches and the side branches (Cx-OM1, Cx-OM2, LAD-D1, LAD-D2 and RCA-RMD, PDA-PL). Conclusion: With the help of developing technology, we believe that all this coronary angiography data will guide bifurcation stent techniques, which are essential alternatives to bypass. doi: https://doi.org/10.12669/pjms.38.3.4782 How to cite this:Deniz G, Kavakli A, Kucukukur M, Kose E, Karaca I. Evaluation of major coronary artery Bifurcation angles with digital angiography: A detailed study of prevalence in the Upper Euphrates Basin. Pak J Med Sci. 2022;38(3):---------. doi: https://doi.org/10.12669/pjms.38.3.4782 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Molecular evaluation of exon 8 cystathionine rs5742905T T>C gene polymorphism and determination of its frequency, distribution pattern, and association with susceptibility to Coronary Artery Disease. In North Indian Population

Background: The protein coded by cystathionine β synthase (CBS) gene act as a catalyzer, converts homocysteine to cystathionine. Impairment of CBS gene leads to homocystinuria by cystathionine β synthase deficiency which is linked to Coronary Artery Disease. A number of polymorphisms study have been performed in cystathione β synthase gene. In the current study we planned to analyze the influence of CBS T833C gene polymorphism and its association with Coronary Artery Disease development and its progression in the north Indian population. Materials and method: The present study comprises 100 angiographically confirmed CAD patients and 100 age and sex-matched healthy controls. A ≥ 50% luminal stenosis at one major coronary artery was considered for the inclusion criteria of the cases. The investigation of T833C polymorphism in the CBS gene was performed by PCR- RFLP technique. Result: In result, we found that homozygous mutant (CC ) and heterozygous (TC) genotypes of CBS T833C gene polymorphism, were significantly higher in CAD patients as compared to healthy subjects. We also observed a substantial increased CAD risk exists in dominant, codominant inheritance and allele specific models for the CBS T833C gene polymorphism. We, analyzed the differential distribution with respect to disease severity, but there was no significant association (p=0.96). Conclusion: In conclusion, this study demonstrates that CBS T833C gene polymorphism plays a key role in developing coronary artery disease and its progression.

Three-dimensional alignment of microvasculature and cardiomyocytes in the developing ventricle

While major coronary artery development and pathologies affecting them have been extensively studied, understanding the development and organization of the coronary microvasculature beyond the earliest developmental stages requires new tools. Without techniques to image the coronary microvasculature over the whole heart, it is likely we are underestimating the microvasculature’s impact on normal development and diseases. We present a new imaging and analysis toolset to visualize the coronary microvasculature in intact embryonic hearts and quantify vessel organization. The fluorescent dyes DiI and DAPI were used to stain the coronary vasculature and cardiomyocyte nuclei in quail embryo hearts during rapid growth and morphogenesis of the left ventricular wall. Vessel and cardiomyocytes orientation were automatically extracted and quantified, and vessel density was calculated. The coronary microvasculature was found to follow the known helical organization of cardiomyocytes in the ventricular wall. Vessel density in the left ventricle did not change during and after compaction. This quantitative and automated approach will enable future cohort studies to understand the microvasculature’s role in diseases such as hypertrophic cardiomyopathy where misalignment of cardiomyocytes has been observed in utero.

Association of Diabetes with Coronary Collateral Formation in Patients with Ischaemic Heart Disease

Background: Although myocardial ischemia is known to be significantly related to the development of coronary collateral vessels (CCVs), there is considerable variation between patients with ischemic heart disease in the presence of collateral development. The nature of this variability is not well known. Likewise, it remains unclear whether diabetes mellitus (DM) has any effect on CCVs. The aim of this study was to evaluate the effect of DM on CCVs. Methods: A total of 100 patients who had a stenosis of >95% in any major coronary artery in angiograms were included in the study. Of these patients, 30 patients constitute the diabetic group. Remaining 70 patients were non-diabetic. For case-control matching, 30 non-diabetic patients (mean age, 52.03± 8.69 years) were selected randomly and were included in the control group. The CCVs were graded according to the Rentrop scoring system, and the collateral score was calculated by summing the Rentrop numbers of every patient. Results: There was no statistical difference between patients with and without DM in clinical baseline characteristics. The mean number of diseased vessels in the DM group (2.10±0.76) was higher than that in the nondiabetic group (1.63± 0.72 P.017). The mean collateral score was (1.13± 0.86) in the DM group and (1.97± 1.61) in the control group. After confounding variables were controlled for, the collateral score in the diabetic group was significantly different from that in the nondiabetic group (p=0.015). Conclusions: Our findings suggest that CCV development is poorer in patients with DM than in patients without DM. Thus, we can speculate that DM is an important factor affecting CCV development. Cardiovasc. j. 2020; 12(2): 89-95

Coronary dissection with ST elevation myocardial infarction responding to thrombolytic and conservative therapy alone

In this report, we describe a case of spontaneous coronary dissection involving left anterior descending artery presenting with acute anterior myocardial infarction successfully treated with thrombolytic and conservative therapy with a suggestion that spontaneous resolution of thrombus occurred before coronary intervention could be performed. As we did not have initial angiogram due to patient’s refusal, this assumption is speculative. However, this case suggests that dissections may heal spontaneously and could be treated with conservative approach in selected cases based on best clinical judgment. It is important to realize that the clinical course of a major coronary artery dissection remains unpredictable. Therefore, cardiologists should always treat each case individually and consider coronary interventions if conservative treatment is not leading to resolution of ST elevation or in patients with hemodynamic compromise. This case is followed by discussion about conservative versus invasive management of spontaneous coronary dissections.

Ischemic mitral regurgitation: modern evidence based echocardiography diagnosis, quantification and risks stratification review

Ischemic mitral regurgitation (IMR) is a frequent complication in the patients after acute myocardial infarction (AMI) or in ischemic cardiomyopathy (ICM), associated with significant prognosis worsening. Mitral valve (MV) involvement may be primary (organic MR) or secondary (functional MR). Primary MR develops because of mitral subvalvular apparatus rupture as an AMI complication. Secondary IMR develops in the conditions of normal MV cusps and chords structure because of balance impairment between MV closure and tension forces secondary to left ventricle (LV) geometry alterations. According to evidence data both scenarios of IMR are associated with at least one major coronary artery critical stenosis (>70%). Secondary IMR is the most frequent consequence of ischemic cardiomyopathy. IMR diagnosis is associated with elevated patients mortality compared to those without it. It has been shown, that survival within patients with IMR after AMI down to 40% in case of moderate-to-severe IMR, compared to 62% in the patients with mild IMR or 84% in the patients without IMR at all. Pathophysiological mechanisms of IMR are not fully understood, but it is well known, that IMR is a complex entity, having left chambers, especially left ventricle (LV) remodeling as a key cause. Echocardiography (EchoCG) significantly contributes to understanding the underlying mechanisms of IMR. The aim of this review is to summarize modern evidence based data about IMR mechanisms and analysis of contemporary EchoCG indices for diagnosis, evaluation and risks stratification in the patients with IMR. IMR develops in approximately 20% of patients after AMI with increasing occurrence over past years, significantly influencing patients’ prognosis. IMR is a complex and dynamic entity, where LV remodeling is the main factor of MV dysfunction. EchoCG plays the clue role in IMR diagnosis giving the detailed information about its mechanisms and severity grading. Comprehensive EchoCG in the patients with coronary arteries disease (CAD) allows a better and comprehensive approach in risks stratification and optimal surgical IMR treatment planning.

Contrast-Induced Nephropathy Is Less Common in Patients with Good Coronary Collateral Circulation

Background/Aims: Contrast-induced nephropathy (CIN) is a typically reversible type of acute renal failure that develops after exposure to contrast agents; underlying endothelial dysfunction is thought to be an important risk factor for CIN. Although the mechanism of coronary collateral circulation (CCC) is not fully understood, a pivotal role of the endothelium has been reported in many studies. The aim of this study was to investigate whether there is a relationship between CCC and CIN. Methods: Patients with at least one occluded major coronary artery and blood creatinine analyses performed before and on the second day after angiography were included in the study. CIN was defined as a 25% or greater elevation of creatinine on the second day after exposure to the contrast agent. Collateral grading was performed according to the Rentrop classification. Patients were grouped according to whether they developed CIN or not, i.e., CIN(-) and CIN(+) group. Results: A total of 214 patients who met the inclusion criteria were included in the study. CIN was diagnosed in 43 patients (20.1%) in the study population. Good CCC was identified in 112 patients (65.5%) in the CIN(-) group, whereas it was identified in 13 patients (30.2%) in the CIN(+) group. In the CIN(-) group, good CCC was significantly more frequent (p < 0.001). Furthermore, collateral circulation was an independent predictor of CIN. Conclusion: Good collateral circulation was associated with a lower frequency of CIN, and poor collateral circulation was an independent predictor of CIN.

Abstract 16357: Identification of Circulating Proteins that Predict the Presence of Obstructive Coronary Artery Disease in Symptomatic, Non-Diabetic Patients Referred for Invasive Coronary Angiography

Background: The diagnosis of patients presenting for the first time with typical or atypical symptoms consistent with obstructive coronary artery disease (CAD) remains challenging; despite the existence of a number of non-invasive modalities for the assessment of CAD, the yield of obstructive CAD in patients who undergo invasive coronary angiography remains low. We sought to identify circulating protein biomarkers that might aid in the diagnosis of obstructive CAD in non-diabetic patients. Methods: 386 non-diabetic patients from the PREDICT study (NCT00500617) were divided into two independent case:control sets for initial marker discovery (Set 1, n=187) and preliminary model validation (Set 2, n=199). Cases were defined as patients with ≥50% stenosis in ≥1 major coronary artery; controls had < 50% stenosis in any major coronary artery as determined by quantitative coronary angiography (QCA). In 11% of the patients QCA was not available and 70% stenosis by clinical read was used as a case threshold. 135 protein markers were evaluated in plasma from Set 1 patients using an electrochemoluminescence-based platform (MesoScale); the top markers were analyzed in Set 2 and used to develop predictive models using penalized logistic regression (LASSO). Model performance was estimated via 2500 iteration of cross validation on random holdout sets of 14 patients. Results: In a sex and age adjusted analysis, nine protein markers obtained nominal significance (p < 0.05) in Set 1, with 9 additional markers trending towards significance (p 0.7); the average of these pairs was used for subsequent analysis. Top markers were evaluated in Set 2 and a five marker (Adiponectin, ApoA1, NT-proBNP, S100A8-MPO, PlGF) model was fitted via LASSO, resulting in a mean cross-validated AUC of 0.64. Conclusion: We have identified a set of plasma protein markers in subjects referred for invasive angiography, which in age and sex adjusted analysis are responsive to the presence of obstructive CAD. Use of such protein markers alone, or in combination with other genomic markers or clinical risk factors may aid in the identification of obstructive CAD in non-acute, symptomatic patients.

T-Cell Prolymphocytic Leukemia with Extensive Cardiovascular Infiltrate Leading to Multiple Myocardial Infarctions and Cardiac Death

Lymphocytic neoplasm involving the heart is not common and usually presents with pericardial effusion or focal myocardial infiltration. Myocardial infarctions due to leukemic infiltration of the coronary arteries are rarely reported. We present the case of a 52-year-old Guatemalan man with a one-year history of untreated T-cell prolymphocytic leukemia. He was admitted to our hospital for chemotherapy and evaluation of a pulmonary cavitary lesion by wedge resection. During sedation, the patient experienced acute respiratory failure and hypovolemic shock, from which he could not be resuscitated. Autopsy revealed that leukemic cells extensively infiltrated the aorta, myocardium, and coronary arteries. The lumina of the 3 major coronary artery branches showed 70% to 95% stenosis, with multifocal remote myocardial infarctions. Tumor cells were also detected in the lungs and other organs. The acute cardiorespiratory insufficiency secondary to leukemia—particularly the extensive infiltration of the coronary arteries and myocardium, and the multiple myocardial infarctions—eventually resulted in cardiac death.