Transcript Coronary Anomalies & Staged Revascularization

Coronary Anomalies
&
Staged Revascularization
Jason S. Finkelstein, M.D.
Tulane University HSC
Cardiology Division
2/5/04
Definitions
• A coronary artery or arterial branch is any
vessel that carries blood to the cardiac
parenchyma
• The name and nature of a coronary artery
or branch is defined by that vessel’s distal
vascular territory, not by its origin
Definitions
• Normal: Coronary anatomy observed in
>1% of any unselected population
• Normal variant: relatively unusual but
found in >1% of that population
• Anomaly: morphologic feature seen in
<1% of that population
Variable Features
• Ostium
– Location, size, angle of origination
• Size
• Proximal course
• Mid-course
• Termination
Incidence
• Yamanka and Hobbs reviewed the Cleveland Clinic Foundation angiographic
database from 1960-1988.
• Total 126,595 coronary angiograms done, and 1686 (1.3%) identified as
showing isolated coronary anomaly.
• 87% had anomaly of origin and distribution.
• Reports vary that 4-15% of young adults who die of SCD have some type of
coronary anomaly
– Cath and Cardiovascular Diag. 1990 21:28-40
Incidence
• A newer study reviewed 1950 consecutive angiograms at
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Texas Heart Institute
Incidence of coronary variants were 5.6% in patients
with & w/o CAD
• 3.8% had congenital AV disease
– 27% of these patients had coronary anomalies
• Coronary anomalies do not predispose patients to CAD
• Angelini; Coronary artery anomalies; 1999
Left circumflex
• Runs along the left AV groove, descends
beneath the left atrial appendage, and
courses downward toward the crux of the
heart for a variable distance
• If the circumflex artery reaches the crux of
the heart and produces a PDA , it is
generally called “dominant”
Left Circumflex Anomalies
• Absent Circumflex
• Circumflex arising from the Right Coronary
Cusp
• Co-dominant patterns (RCA & Circumflex)
– Circumflex is dominant in 9% of the
population
Absent Circumflex
• Large superdominant RCA crosses the crux of
the heart and ascends in AV groove and
perfuses the posterolateral and lateral walls.
• Suspect when contrast in LCA reveals unusually
long proximal segment and non perfusing lateral
wall
• In absence of occlusive disease not
hemodynamically significant.
LCx arising from RCA or right sinus
• A very common anomaly (0.67% of population)
• Courses posterior to the aorta and enters the left AV
groove and supplies lateral wall
• Suspect when contrast in LCA reveals unusually long
proximal segment and non perfusing lateral wall
Angelini. P, Coronary artery anomalies; 1999
LCx arising from right aortic sinus
• Clinical significance:
– Prolong catheterization
– CT surgeons should be informed to avoid accidental
compression during valve replacement
– Regarded as a benign anomaly
Staged Revascularization
Multiple Complex Plaques in AMI
• Retrospective study analyzing 253 angiograms
• Single complex plaques were identified in 153
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pts (60.5%)
Multiple complex plaques were identified in 100
patients (39.5%)
Clinical outcomes were recorded over 1 year
such as in-hospital outcomes, recurrent AMI, UA,
repeat revasc, death
Results:
• Multiple complex plaques were less likely to
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undergo angioplasty (86% vs. 95%)
Required more urgent bypass (27 v. 5%)
Increased incidence of ACS (19% v. 2.6%)
Repeat angioplasty (32 % v. 12.4%)
CABG (35% vs. 11%)
Higher mortality after 1 year (17% v. 12%)
– Not statistically significant
– Goldstein, et al; NEJM: 343 (13) 915-923
Proposed conclusions
• Multiple complex lesions identifies patients
at increased risk for CV events
• Aggressive medical management with
statins & anti-inflammatory agents
• Multi-vessel staged PCI or surgical
intervention
Single or Staged Multivessel PCI
• 264 consecutive patients
• PCI conducted in 129 pts in a single
session
• 135 pts had staged PCI
• Mean interval between staged sessions
was 45.6 +/- 22.3 days
• Lesion suggested by stress testing was
treated first
Single or Staged Multivessel PCI
• End Points:
– Cardiac death
– Q-wave MI
– CABG
– Repeated PCI
– Hemodynamic instability requiring IABP
– Vascular complications
Single or Staged Multivessel PCI
• Results:
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MACE (30 day follow up) 2.9% v. 7.0%
1 yr follow up 26.1 v. 36%
Lower rate of reinterventions 23.1% v. 33.6%
Lower rate of MI’s 0.7% v. 3.9%
Restenosis 15.5% v. 17%
Nikolsky et al, Amer Heart Journal; 143:1017-26
Limitations
• Non-randomized trial
• None of the results were statistically
significant
• A staged approach is safe and allows and
has high success rates
• Single staged procedure was more costeffective
Primary PCI for AMI with Multivessel CAD
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285 patients with an evolving MI
163 pts had 2 vessel disease
122 pts had 3 vessel disease
Angioplasty performed on IRA and other vessels
1 yr and 3 yr survivals were 92% and 87%
respectively (p<0.001)
Global EF increased from 50 to 57%
predischarge
– Kahn et al, JACC 1990;16:1089-96
Staged MIDCAB and PCI
• 11 patients selected for procedure with class 3
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and class 4 angina
All pts received LIMA to LAD
9 pts went for PTCA 4 days after MIDCAB
10/11 patients require no anti-anginal meds and
are symptom free at 1 yr
Advantage of “hybrid” approach is less invasive
and enhanced recovery
– Izzat et al. IJC 1997 S105-109
Hybrid Revasc. In Pts with AMI &
MVD
• 11 patients with ACS and multivessel disease
• Occlusion of target artery was treated by PCI and then
followed by MIDCAB
• Coronary angiography was conducted at 2 weeks, 6
months 1 & 3 yrs to evaluate anastamosis and restenosis
Matsumoto y, et al; Jpn J CV Surg 2001; Dec 700-5
Results
• Coronary anigography at post-op, 6 months, 1 &
3 yrs showed patent grafts with no stenosis
• PCI was reconducted on restenotic lesions for 3
patients
• Hybrid revasc. is safe and effective over the
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short term
Overall acceptance depends on the functional
success of the 2 procedures
History
• Mrs. Z is a 70 yr old AA female with past medical
history of htn, elevated cholesterol, tobacco use
(quit 15 yrs ago) who arrived at Charity ER in
the AM complaining of substernal chest pain
associated with nausea & vomiting.
• Pt denied any SOB, diaphoresis, but her pain is
classified as 9/10
History
• Pt is given IV Tridil, morphine, ASA, and Oxygen
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in the ER
EKG reveals STEMI in V1-V3 and T wave
inversions in leads I and aVL. Trop level was 1.9
• Patient was then given IV lopressor, Lovenox
and Integrelin and taken to the cath lab