Surgical Correction of Coronary Artery Ectasia Combining Congenital Coronary Artery Fistula

Background:Coronary artery ectasia(CAE)complicated with concomitant congenital coronary artery fistula(CCAF)is rare.This study characterizes the clinical characteristics of CAE combining CCAF,and reports a single-institution experience with surgical correction of CAE combining CCAF.Methods:A total of 24 symptomatic patients(8 males,median 52.5 years old)who underwent surgical correction of CAE combining CCAF in this center were reviewed.Based on the size of ectatic segment,the CAE were classified as a giant CAE(>20 mm,n=14)and a non-giant CAE(≤20 mm,n=10).Individualized surgical approaches were chosen.The patients were followed up for a median of 3.8 years.Results:The overwhelming majority of CAEs were solitary,and only 4.2%of CAEs were associated with multiple lesions.CAEs were predominantly located in the right coronary artery with predilection to women more than to men(2:1).95.8%of patients with the CCAF had single fistula defect.The right atrium was the most frequent drainage site(33.3%)followed by the left ventricle(25.0%).Surgical mortality was 4.2%.All 22 follow-up patients survived with recovery from symptoms and New York Heart Association(NYHA)functional class I-II.In 10 patients with non-giant CAEs undergoing closure of fistula alone,favorable in-hospital outcomes were recorded,but residual fistula(one patient)and acute inferior wall myocardial infarction related to intracoronary thrombosis(one patient)were observed at follow-up.In 11 patients with giant CAEs undergoing aneurysm resection plus distal bypass grafting at the time of closure of fistula,favorable in-hospital outcomes and encouraging midterm results were recorded.Additionally,in 3 patients with giant CAEs undergoing closure of fistula plus aneurysmal plication,adverse events occurred,including surgical death related to rupture of the ectatic segment(one patient),perioperative myocardial infarction caused by acute thromboembolism(one patient),nonfatal inferior wall myocardial infarction related to intracoronary thrombosis(one patient)at follow-up.Conclusion:Individualized surgical approaches based on the size and the location of ectatic coronary artery as well as fistula should be offered to symptomatic patients with CAE combining CCAF.

Antithrombotic treatment strategy for patients with coronary artery ectasia and acute myocardial infarction: A case report

BACKGROUND There is no consensus on the antithrombotic treatment strategy for patients with coronary artery ectasia(CAE).CASE SUMMARY This case reports the dynamic observation of a patient for 48 mo after a diagnosis of CAE with acute myocardial infarction(AMI).The first antithrombotic agents used were aspirin(100 mg/d)and clopidogrel(75 mg/d).During the sixth month of observation,a second AMI occurred involving the same culprit vessel;therefore,antithrombotic agents were changed to aspirin(100 mg/d)and ticagrelor(90 mg twice per day).Twelve months after the second AMI,an attempt to reduce the dosage ticagrelor failed;therefore the original dose was continued.The CAE was relatively stable during the following 4 years.CONCLUSION This case indicates that a combination of aspirin and ticagrelor may be more effective for CAE patients with AMI than aspirin and clopidogrel.

Clinical features of coronary artery ectasia in the elderly

Objective To investigate the incidence, imaging and clinical characteristics in elderly patients with coronary artery ectasia （CAE）. Methods A retrospective analysis was conducted on patients with CAE who underwent coronary angiography between January 2006 and December 2012. According to age, the enrolled patients were divided into two groups （elderly group, age≥ 65 years; non-elderly group, age 〈 65 years）. The clinical feature, imaging characteristics and the 5-year survival rate of the two groups were compared.Results The preva-lence of CAE in elderly patients was 0.33%. Patients in elderly group were found to have significantly higher proportion of female （30.1%vs. 10.1%,P〈 0.001）, three-vessel disease （60.5%vs. 45.2%,P = 0.003） and localized ectasia （55.0%vs. 40.2%,P = 0.003）. In addition, body mass index （20.90 ± 2.71 kg/m2vs. 22.31 ± 2.98 kg/m2,P 〈 0.001） and percentage of current smokers （45.0%vs. 64.6%,P 〈 0.001） were significantly lower in elderly group. Cumulative survival curves demonstrated reduced 5-year cumulative survival at the follow-up in the elderly group compared with the non-elderly group （88.0%vs. 96.0%,P = 0.002）. But the 5-year event free survival rate failed to show a significant difference between the two groups （31.0%vs. 35.0%,P= 0.311）.ConclusionThe prevalence of CAE in elderly patients was 0.33%, which was about 1/3 of the entire numbers of CAE patients. There were significant differences between the elderly and the non-elderly patients with CAE in terms of coronary artery disease risk factors and coronary artery ectatic characteristics. CAE might be asso-ciated with increased mortality risk in the elderly.

Independent Prognostic Value of High-sensitivity C-reactive Protein in Patients with Coronary Artery Ectasia

Background：Despite its severity,coronary artery ectasia （CAE） is still poorly understood.High-sensitivity C-reactive protein （hs-CRP） has been recognized as a prognostic factor in some cardiovascular diseases but not assessed in CAE.The aim of this observational study was to investigate the prognostic value of hs-CRP in CAE.Methods：Our analysis evaluated the effect of the baseline hs-CRP on cardiovascular events （CVs） （cardiac death and nonfetal myocardial infarction） in consecutively enrolled stable CAE patients.We used the Cox proportional hazards regression models to examine the association between baseline hs-CRP level and follow-up CVs in CAE.The net reclassification improvement and integrated discrimination improvement （IDI） of hs-CRP were also assessed.Results：We obtained the follow-up results of 540 patients over a median follow-up period of 36 （37.41 ± 15.88） months.The multivariable Cox analysis showed that the hs-CRP was a significant predictor of adverse outcomes in CAE （hazard ratio [HR]：2.99,95% confidence interval [CI]：1.31-6.81,P =0.0091）.In Kaplan-Meier analysis,the group with hs-CRP 〉3 mg/L had a lower cumulative 66-month event-free survival rate （log-rank test for trend,P =0.0235） and a higher risk ofCVs （HR =2.66,95% CI：1.22-5.77,P =0.0140） than the group with hs-CRP ≤3 mg/L.Hs-CRP added predictive information beyond that given by the baseline model comprising the classical risk factors （P value for IDI =0.0330）.Conclusions：A higher level of hs-CRP was independently associated with cardiac death and nonfatal myocardial infarction in CAE patients.The hs-CRP level may therefore provide prognostic information for the risk stratification of CAE patients.

Coronary artery aneurysm:A review

Coronary artery aneurysm(CAA)is a clinical entity defined by a focal enlargement of the coronary artery exceeding the 1.5-fold diameter of the adjacent normal segment.Atherosclerosis is the main cause in adults and Kawasaki disease in children.CAA is a silent progressive disorder incidentally detected by coronary angiography,but it may end with fatal complications such as rupture,compression of adjacent cardiopulmonary structures,thrombus formation and distal embolization.The pathophysiological mechanisms are not well understood.Atherosclerosis,proteolytic imbalance and inflammatory reaction are involved in aneurysmal formation.Data from previously published studies are scarce and controversial,thereby the management of CAA is individualized depending on clinical presentation,CAA characteristics,patient profile and physician experience.Multiple therapeutic approaches including medical treatment,covered stent angioplasty,coil insertion and surgery were described.Herein,we provide an up-to-date systematic review on the pathophysiology,complications and management of CAA.