Quantitative flow ratio and intravascular ultrasound guided percutaneous coronary intervention of left anterior descending lesion concomitant with severe coronary myocardial bridge

Severe coronary stenosis concomitant with congenital coronary myocardial bridge(MB)is a tough scenario for cardiologist to perform revascularization,for which the complication rates including in-stent restenosis,stent fracture,stent thrombosis and even coronary perforation are still high.[1,2]Meanwhile,the necessity of revascularization in such patients is worth prudent evaluation.Cardiac imaging modalities are crucial and helpful in making revascularized decisions and strategies.Herein,we report a case using quantitative flow ratio(QFR)and intravascular ultrasound(IVUS)to facilitate accurate revascularization in a patient with both severe coronary stenosis and deep coronary MB.

Evaluation of intracoronary function after reduction of ventricular rate by esmolol in severe stenotic myocardial bridge: A case report

BACKGROUND Severe stenotic myocardial bridges(MBs)have been reported to lead to intracoronary ischaemia,but the physiological evaluation of MBs using intracoronary function evaluation indicators after intraoperative drug treatment has not been fully established.CASE SUMMARY We performed through snuff fossa for coronary angiography in a patient with chest tightness after repeated exercise,and the results showed that the middle part of the anterior descending branch was a MB with 100%systolic compression.The intracoronary function evaluation(defined as the ratio of distal coronary pressure to aortic pressure with zero microcirculation resistance)was instantaneous wave-free ratio(IFR)without drug and fractional flow reserve(FFR)with adenosine.The IFR was 0.73,and the FFR was 0.66.Then esmolol 0.02μg/kg/min was intravenously injected.The IFR and FFR were measured again when the heart rate dropped to 60 beats/min.The IFR was 0.83,and the FFR 0.65.CONCLUSION This case report is a case of isolated MB with severe stenosis.After intraoperative drug treatment decreased the ventricular rate,an increase in the coronary function evaluation index was immediately observed to confirm the effective improvement of coronary blood flow.

Coronary artery aneurysm combined with myocardial bridge:A case report

BACKGROUND Coronary artery aneurysm combined with myocardial bridge is a very rare clinical situation.The prognosis of this clinical situation is not yet clear.CASE SUMMARY A coronary artery aneurysm and myocardial bridge in the same segment of the coronary artery were found in a 54-year-old female patient who underwent coronary angiography and intravascular ultrasound examination.Through conservative treatment,the patient was discharged from the hospital smoothly,and she was in good condition during 5 mo of follow-up.CONCLUSION Coronary artery aneurysm combined with myocardial bridge seems to have a good prognosis,but due to the rarity of this clinical situation,further research and follow-up are needed.

Myocardial bridge-related coronary heart disease:Independent influencing factors and their predicting value

BACKGROUND Myocardial bridge(MB)will compress the mural coronary artery(MCA)during the systole and cause myocardial ischemia.In the diagnosis of coronary heart disease(CHD),because the structure of MB is difficult to be observed by coronary angiography(CAG),the clinical study of the influence of MB on CHD is lacking.With the advancement of computed tomography coronary angiography technology,detailed observations of the MB anatomy have realized.AIM To explore the main influencing factors of MB-related CHD and to find potential indicators for predicting MB-related CHD.METHODS A total of 1718 patients with suspected CHD due to the symptoms of myocardial ischemia were enrolled as subjects.Patients diagnosed with CHD were included in a CHD group,and patients with no significant abnormalities were included in a control group.In the CHD group,patients were divided into an MB-CHD subgroup if MB-related CHD was found.In the control group,patients were divided into a simple MB subgroup if MB was found.The patient's clinical data and MB-related indicators,including the branch of MB,MB type(superficial/deep type),MB length,MB thickness,systolic and diastolic compression of the MCA,and MCA systolic stenosis rate were recorded and compared.Logistic regression analysis was used to explore the independent influencing factors of MD-related CHD.ROC curve was used to analyze the diagnostic efficacy of potential indicators for MB-related CHD.RESULTS There were 1060 cases in the CHD group and 658 cases in the control group,and there were 236 cases in the MB-CHD subgroup and 52 cases in the simple MB subgroup.Multivariate logistic regression analysis showed that the combined MB had a significant effect on the occurrence of CHD(P<0.05).MB thickness,systolic compression,diastolic compression,and MCA systolic stenosis rate had significant effects on the occurrence of MB-related CHD(P<0.05).The area under the curve(AUC)of the combination of these influencing factors for the diagnosis of MB-related CHD was 0.959,which was significantly higher than the AUCs of the four indicators separately(P<0.05).The sensitivity was 97.06%and the specificity was 87.63%.CONCLUSION MB thickness,systolic compression,diastolic compression,and MCA systolic stenosis are independent influencing factors for MB-related CHD.The combination of these factors has potential diagnostic value for MB-related CHD.

Comparison of myocardial perfusion scintigraphy and computed tomography (CT) angiography based on conventional coronary angiography

Coronary artery disease is one of the most common and important health problems in the world. Early diagnosis of this disease is very important to treat before severe myocardial damage occurred. Myocardial perfusion scintigraphy (MPS) and computed tomography coronary angiography (CTCA) which evaluates regional myocardial perfusion and coronary arteries, respectively, are reliable and non-invasive methods in terms of coronary artery disease. In this study we aimed to compare MPS and CTCA based on conventional coronary angiography (CCA). Totally 60 patients were included in the study. CCA and MPS were performed to 30 patients;CCA and CTCA were performed to the rest of the patients (30 patients). Lesions were classified as mild, moderate and severe in these imaging methods. MPS and CTCA were compared with CCA by using chi-square and Fisher’s exact test. MPS and CTCA’s p values were found for left anterior descending artery (LAD) p: 0, p: 0.271;for circumflex artery (Cx) p: 0.256, p: 0.08 and for right coronary artery (RCA) p: 0.033, p: 0.271, respectively. Furthermore MPS and CTCA’s sensitivity, specificity, accuracy, positive predictive value and negative predictive value were calculated 81% to 87%;70% to 49%;73% to 72%;54% to 72%;90% to 71%, respectively. CCA results were found more concordant with MPS for LAD and RCA lesions and more concordant with CTCA for Cx lesions. It was also found that positive predictive value of MPS and negative predictive value of CTCA were significantly higher than the others. As a result, MPS and CTCA were suggested as complementary techniques for the diagnosis of coronary artery disease, not as alternatives to each other.

A Research Based on Hemodynamic Model for Heart-Mural Coronary Artery-Myocardial Bridge

An experimental model for heart-mural coronary artery-myocardial bridge was established based on the theory of hemodynamics. The application of the model demonstrated that it can repeat to great extent the phenomenon of myocardial bridge compressing mural coronary artery that results in abnormal hemodynamic characteristic. The in vitro simulation experiment indicates that the anomaly of normal stress, circumferential stress and wall shear stress mainly occurs in the proximal end. As the oppression level increases, the mean proximal stress and the oscillatory value (maximum-minimum) increase obviously. The experimental model for heart-mural coronary artery-myocardial bridge provides a method to study relationship between myocardial bridge and atherosclerosis.

Polymorphisms in the genes for coagulation factor Ⅱ,Ⅴ,Ⅶ in patients undergoing coronary angiography

Objective: To determine whether polymorphisms in the genes for coagulation factor Ⅱ,Ⅴ,Ⅶ could predispose an individual to increase risk for coronary artery disease (CAD) and/or myocardial infarction (MI) in Chinese. Methods: We screened coagulation factor Ⅱ( G20210A),Ⅴ( G1691A),Ⅶ( R353Q and HVR4) genotype in 374 patients undergoing coronary angiography by polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP) assay. Results: The R353Q and HVR4 genotype of the factor Ⅶ distribution was in accordance with Hardy-Weinberg equilibrium. The frequencies of FVⅡ genotype or allele did not show statistically significant differences between CAD group and controls or between male and female.The frequencies of the Q allele and ( RQ + QQ) genotype were significantly higher among the CAD patients without myocardial infarction (MI) history than among those with MI history (P < 0.05). However, HVR4 polymorphism was not significantly different within groups. We only find one normal control of factorⅡ(G20210A) mutation. No coagulation factor Ⅴ(G1691A) mutation was found in the CAD patients and con-trois. Conclusion: The factor Ⅱ(G20210A),Ⅴ(G1691A) mutation is absent and may not be a major genetic factor for CAD and/or MI; the Q allele of the R353Q polymorphism of the factor Ⅶ gene may be a protective genetic factor against myocardial infarction in Chinese.

Polymorphisms in the coagulation factor Ⅶ gene and the risk of myocardial infarction in patients undergoing coronary angiography

Objective To investigate whether coagulation factor Ⅶ (FⅦ) polymorphisms play a role in the pathogenesis of coronary artery disease (CAD) and/or myocardial infarction (MI) in a series of Hans.Methods The Arg 353 Gln and HVR4 polymorphisms of FⅦ gene were determined in 374 patients undergoing selective coronary angiography by PCR and restriction fragment length polymorphism assay.Results The FⅦ genotype distribution was in accordance with Hardy-Weinberg equilibrium. The frequencies of FⅦ genotypes or alleles did not show significant differences between the CAD group and the controls or between the males and the females. The frequencies of carriers of the Gln 353 allele and (Arg/Gln+Gln/Gln) genotypes were significantly higher in the CAD patients without MI than in those with MI ( P =0.031,odds ratio 0.37,95% CI: 0.15-0.94). However,HVR4 polymorphisms were not significantly different between the two groups ( P >0.05).Conclusion Carrying the F Ⅶ Gln 353 gene may be a protective factor against MI in the Chinese Hans.

Angiographic differentiation of systolic narrowing of the left anterior descending coronary artery in hypertrophic cardiomyopathy from myocardial bridges

To the Editor： I read with great interest the case report of multiple myocardial bridges affecting both coronary arteries in a patient with hypertrophic cardiomyopathy. However, I differ with the authors in their interpretation of the coronary arteriograms.

Variant angina associated with isolated myocardial bridging:evaluation using intravascular ultrasound and quantitative coronary angiography

Variant angina, first described by Prinzmetal et a in 1959. is hypothesized to be caused by transient coronary＇ vasospasm at the site of an atherosclerotic plaque and leading to repetitive episodes of transmural myocardial ischemia. Myocardial bridging, a congenital coronary abnormality, is defined as a segment of a major epicardial coronary after, running intramurally through the myocardium.2 The association of variant angina and isolated myocardial bridging is very uncommon. A review of the literature reveals only one case report）ndicating a causal relationship between the two diseases.We present an additional case who experienced Prinzmetal variant angina related to isolated myocardial bridging of the left anterior descending coronary artery （LAD）, which was evaluated with intravascular ultrasound and quantitative coronary angiography.

Myocardial bridging analysis by coronary computed tomographic angiography in a Saudi population

AIM: To assess the incidence, location, morphology and clinical association of myocardial bridging in a Saudi population using coronary computed tomographic angiography(CCTA). METHODS: A total of 350 CCTA of Saudi patients were included in this study(236 men, 114 women) with a mean age of 56.3 years. All patients were examined for appropriateness criteria of CCTA indications(typical chest pain, recent onset cardiomyopathy, left bundle branch block, etc.). The scans were retrospectively reviewed for the presence of myocardial bridging and any other pathological association. RESULTS: Myocardial bridging was found in 89 of 350(22.5%) patients. Most of the intramuscular segments were of the superficial type and found in the mid left anterior descending(LAD)(24.6%), followed by distal LAD(3.7%), diagonal branches(2%), ramus intermedius artery(1.4%) and obtuse marginal artery(0.8%). No myocardial bridging was detected in the right coronary or circumflex arteries. No significant differences were found between males and females(P = 0.14). Coronary artery atherosclerosis was found in 51 of 89(57.3%) patients with MB. Atherosclerotic plaques were not detected in the intramuscular or distal segment of bridging arteries. Dynamic compression was observed in 35(94.5%) patients with full encasement. No evidence of myocardial hypoperfusion was found in the territories supplied by the bridging arteries. CONCLUSION: CCTA is excellent in analyzing myocardial bridging in a Saudi population and the results are comparable to other populations. However, finding the real incidence may need a large multicenter study.

A single JL 3.5 guiding catheter for transradial coronary angiography and intervention reduces one-year death risk in acute ST-segment elevation myocardial infarction

Background Reperfusion therapy as early as possible in patients with acute ST-segment elevation myocardial infarction（STEMI） can reduce myocardial necrosis, and thus decrease mortality and improve prognosis. Therefore, shortening door-to-ballon（D2B） time is critically important. However, whether using a single guiding catheter（JL3.5） for transradial coronary angiography and intervention can reduce D2 B time and improve prognosis is unknown yet. Methods From December 2012 to December 2015, 185 patients with STEMI receiving emergent coronary angiography（CAG） and primary percutaneous coronary intervention（PCI） were retrospectively enrolled and divided into two groups： treatment group（use a single JL 3.5 guiding catheter, n = 87） and control group（routine catheter, n = 98）. Clinical data, complications rates, procedure time and outcomes in 1 year between the 2 groups were analyzed.Results There were significant reduction in D2 B time, surgery time and contrast consumption in treatment group. Incidence of in-hospital death（2.3% vs. 10.2%, P = 0.029） and MACEs（12.6% vs. 27.6%, P = 0.029） were also lower in treatment group. All patients had completed the one-year follow up and 21 patients died. The difference in one-year mortality were statistically significant between two groups（4.6% vs. 17.3%, P = 0.006）. Multiple logistic analysis showed that the using of single JL3.5 was independently associated with decreased risk of one-year mortality（OR = 0.11, 95%CI： 0.02-0.47, P = 0.003）. Conclusions A single guiding catheter（JL 3.5） in patients with STEMI is feasible and safe. It can reduce D2 B time, procedure time, contrast consumption and risk of one-year mortality.

Acute myocardial infarction due to myocardial bridge

Myocardial bridge （MB） is regarded as a common .anatomic variant rather than a congenital conditionanomaly, defined as the intrainyocardial course of a portion of the coronary artery. It was first mentioned by Rayman in 1737 and first described by Grainicianu in the early 1920s. The current gold standard tor diagnosing MB is coronary angiography with the typical systolic compression of the epicardial coronary vessel （milking effect）.

Early and Late Coronary Angiographic Changes After Thrombolysis in Acute Myocardial Infarciton

Objective The coronaryanatomic feature and development after thrombolysis in acute myocardial infarction (AMI) were studied. Mehtods 100 patients with AMI received urokinase and strepokinase. Coronary angiography (CAG) was performed at 90 minuts and again at 3 to 4 weeks. Results Successful thrombolysis occurred in 60 cases, but failed in 40. The ratio of reperfusion was 60%. CAG showed there were residual thrombi in 84 patients (84% ) and complete coronary occlusion in 40(40% ). Angiography at 3 to 4 weeks after thrombolysis showed the stenosis worsened in 8 patients and improved in 10. Conclusion AMI is caused by sudden coronary thrombotic occlusion and can be reperfused by using thrombolytic agent or mechanical methods. Throm-bolytic agents usually can not resolve thrombi completely. So percutaneous transluminal coronary angiography (PTCA) is recommended as an important method to improve serious residual stenosis.

Case of angina pectoris at rest and during effort due to coronary spasm and myocardial bridging

We present a case of a 71-year-old male who hadchest symptoms at rest and during effort. He had felt chest oppression during effort for 1 year,and his chest symptoms had recently worsened. One month before admission he felt chest squeezing at rest in the early morning. He presented at our institution to evaluate his chest symptoms. Electrocardiography and echocardiography failed to show any specific changes. Because of the possibility that his chest symptoms were due to myocardial ischemia,he was admitted to our institution for coronary angiography(CAG). An initial CAG showed mild atherosclerotic changes in the proximal segment of the left anterior descending coronary artery(LAD) and mid-segment of the left circumflex coronary artery. Subsequent spasm provocation testing using acetylcholine revealed a bilateral coronary vasospasm,which was relieved after the intracoronary infusion of nitroglycerin. Finally,a CAG showed myocardial bridging(MB) of the mid-distal segments of the LAD. Fractional flow reserve using the intravenous administration of adenosine triphosphate was positive at 0.77,which jumped up to 0.90 through the myocardial bridging segments when the pressure wire was pulled back. Thus,coronary vasospasm and MB might have contributed to his chest symptoms at rest and during effort. Interventional cardiologists should consider the presence of MB as a potential cause of myocardial ischemia.

Spontaneous coronary artery dissection as a cause of myocardial infarction

Spontaneous coronary artery dissection(SCAD) is a rare disease that is usually seen in young women in left descending coronary artery and result in events like sudden cardiac death and acute myocardial infarction. A 70-year-old man was admitted to the emergency department with chest pain which started 1 h ago during a relative's funeral. The initial electrocardiography demonstrated 2 mm ST-segment depression in leads V1-V3 and the patient underwent emergent coronary angiography. SCAD simultaneously in two different coronary arteries [left anterior descending(LAD) artery and left circumflex(LCx)] artery was detected and SCAD in LCx artery was causing total occlusion which resulted in acute myocardial infarction. Successful stenting was performed thereafter for both lesions. In addition to the existence of SCAD simultaneously in two different coronary arteries, the presence of muscular bridge and SCAD together at the same site of the LAD artery was another interesting point which made us report this case.

Novel Approaches for the Use of Cardiac/Coronary Computed Tomography Angiography

Recent developments in the novel imaging technology of cardiac computed tomography(CT)not only permit detailed assessment of cardiac anatomy but also provide insight into cardiovascular physiology.Foremost,coronary CT angiography(CCTA)enables direct noninvasive examination of both coronary artery stenoses and atherosclerotic plaque characteristics.Calculation of computational fl uid dynamics by cardiac CT allows the noninvasive estimation of fractional fl ow reserve,which increases the diagnostic accuracy for detection of hemodynamically signifi cant coronary artery disease.In addition,a combination of myocardial CT perfusion and CCTA can provide simultaneous anatomical and functional assessment of coronary artery disease.Finally,detailed anatomical evaluation of atrial,ventricular,and valvular anatomy provides diagnostic information and guidance for procedural planning,such as for transcatheter aortic valve replacement.The clinical applications of cardiac CT will be extended with the development of these novel modalities.

Coronary Angiography in Patients with and without STEMI Following Out-of-Hospital Cardiac Arrest

Introduction: Little is known about discrepancies between patients who present with or without STEMI following out-of-hospital cardiac arrest (OHCA). Material and Methods: All patients with OHCA who were admitted to our hospital between January 1st 2008 and December 31st 2013 were classified according to their initial laboratory and electrocardiographic findings into STEMI, NSTEMI or no ACS. Results: Overall, 147 patients [32 STEMI (21.8%), 28 NSTEMI (19.0%) and 87 no ACS (59.2%)] were included with a mean age of 63.7 ± 13.3 years;there were 84 men (57.1%) and 63 (42.9%) women. Of these, 63 patients (51.7%) received coronary angiography [29 STEMI (90.6%), 9 NSTEMI (32.1%) and 38 no ACS (43.7%)] showing a high prevalence of coronary artery disease (CAD) [28 STEMI (96.6%), 9 NSTEMI (100.0%) and 26 no ACS (68.4%)] requiring percutaneous coronary intervention (PCI) in 52 cases [28 STEMI (96.6%), 8 NSTEMI (88.9%) and 16 no ACS (42.1%)]. Discussion: Coronary angiography immediately after hospital admission is feasible if all are prepared for potential further resuscitation efforts during cardiac catheterization. Primary focus on haemodynamic stabilisation may reduce the rates of coronary angiographies in patients following OHCA. Altogether, our data support the call for immediate coronary angiography in all patients following OHCA irrespective of their initial laboratory or electrocardiographic findings.

Risk Factors and Relation Between Clinical,Biochemical Marker and Stenosis Extent of Coronary Artery in Young Adults With Acute Myocardial Infarction

Objectives To analyze risk factors and the relation between clinical, biochemical marker and the stenosis extent of coronary artery in patients below the age of 45 years with acute myocardial infarction （AMI）. Methods A retrospective investigation was performed on 92 patients below the age of 45 with AMI at the First Affiliated Hospital of Medical School of Xi′an Jiaotong University in 2003-2007. The etiology, morbidity, risk factors, clinical features and results of coronary angiography were studied. Various clinical and biochemical markers were assessed to find out what were associated with the stenosis extent of coronary artery. Meanwhile, the differences between one-vessel disease （group A） and two-vessel or multi-vessel disease （group B） patients with AMI were comparatively analyzed. Results Risk factors analysis revealed that a history of cigarette smoking, metabolic disorders and abusive drinking were mainly found in young AMI patients below the age of 45 years, and metabolic disorder mainly consists of decreased high-density lipoprotein cholesterol （HDL-C） and hypertriglyceridemia. AMI in patients below the age of 45 years account for 10.3% of all AMI. Angiographically, the incidence of one-vessel affected was most frequent in the young adults （73.75 %）. The most committed vessel was LAD （80.00 %）. A higher incidence with history of hypertension and diabetes or impaired glucose tolerance was found in group B, but a history of preceding angina 1 month earlier was more frequently found in group A. Improved Genisi scores of coronary angiography was lower in group A than in group B（7.49±3.63 vs 15.08±6.08）. Correlation analysis showed that log（LDL-C/HDL-C）（r= 0.238, P= 0.037）, TC/HDL-C （r= 0.232, P= 0.046） were directly correlated with angiographic scores, and HDL-C（r= -0.202, P= 0.042）was inversely correlated. Multielement gradual linear regression analysis showed log（LDL-C/HDL-C）, TC/HDL-C were associated with the extent of stenosis of coronary artery. Furthermore, the correlation was linear dependence. Conclusions A history of cigarette smoking, metabolic disorders and abusive drinking are mainly found in young patients with AMI under the age of 45 years. Bad life style is the main motivator. The main cause is atherosclerosis（95%）. A higher incidence of history of hypertension and diabetes or impaired glucose tolerance is associated with multi-vessel affected,log（LDL-C/HDL-C）, TC/HDL-C are linear dependent on the extent of stenosis of coronary artery. Thus changing of bad life style （stop smoking et al）, improving of lipoprotein profile are more important for the prevention and treatment of AMI in young adults.