Angiographic findings and surgical treatments of coronary artery involvement in Takayasu arteritis

Tertiary syphilis and cardiovascular disease: the united triad: case report

Background

Syphilis, owing to its natural course, can lead to long-term damage to the aortic valve, such as insufficiency and rarely stenosis, ostial coronary stenosis, and syphilitic aortitis. Cardiovascular involvement alongside neurological involvement dominates the prognosis. This should no longer be seen, thanks to awareness and prevention programmes, medical treatment, and antibiotics.

Case summary

We report a case of a 54-year-old chronic smoker with no previous history, admitted for respiratory distress amid an impaired general condition. An electrocardiogram was performed, which showed sinus rhythm with lateral ST depression and T-wave inversion. Coronary angiography revealed an ostial stenosis of the left coronary artery. Echocardiography displayed a globular dilated left ventricle with a left ventricular ejection fraction of 40% and severe aortic insufficiency (AI). Computed tomography angiography of the aorta showed a dilation of the thoracic aorta and suprarenal abdominal aorta. Syphilitic serology was positive. The patient underwent angioplasty, resulting in a satisfactory outcome, and subsequently received optimal treatment. Following a consultation with a cardiovascular surgeon and vascular team, it was decided to proceed with mechanical aortic valve replacement and aorto-coronary double bypass surgery, but vascular surgery of the ascending aortic aneurysm was not possible at once.

Discussion

Tertiary syphilis should always be considered when faced with isolated coronary ostial involvement, aortic aneurysm, and/or AI. What makes our case special is that the patient had almost all the cardiovascular complications of tertiary syphilis. Primary syphilis should always be prevented, diagnosed early, and treated appropriately with antibiotic therapy.

Coronary artery lesions in Takayasu arteritis

Introduction

Takayasu arteritis (TAK) is a granulomatous inflammation of vessels of large diameter, mainly affecting the aorta and its proximal branches, which is more common in young women. The incidence of coronary artery disease in TAK is unknown and not sufficiently studied.

Material and methods

A literature review was performed for the period 2003 to 2023 using a search of the PubMed and Scopus scientific databases. We used the following key words to search the academic journal databases: "Takayasu arteritis", "coronary angiography", "myocardial revascularization", "coronary artery disease", "angina pectoris", and "myocardial infarction".

Results

The analysis of studies showed that coronary artery lesions (CAL) in TAK are not uncommon, being identified particularly in children and young individuals. Pathology of the coronary arteries increases the morbidity and mortality of TAK patients. In TAK, the ostia and proximal segments of the coronary arteries are more frequently affected, presenting as stenosis or occlusion with the development of stable coronary artery disease, unstable coronary artery disease, acute myocardial infarction, and sudden death. The diagnosis of TAK and coronary artery pathology is often complicated due to nonspecific manifestations and frequently the absence of symptoms. The treatment of patients with TAK with CAL is challenging and requires both pharmacological therapy and interventional or surgical methods of myocardial revascularization.

Conclusions

Takayasu arteritis is a more prevalent cause of CAL development, especially in young patients, than previously believed, and cardiovascular death due to CAL is not rare. Early diagnosis of TAK with CAL, particularly occlusion or hemodynamically significant stenosis, and the prompt initiation of appropriate treatment prevent dangerous complications, reduce mortality, and improve prognosis.

Exploring Cardiovascular Manifestations in Vasculitides: An In-Depth Review

Systemic vasculitides encompass a cluster of autoimmune diseases that affect blood vessels, and are characterized by immune-mediated injury to either small- or large-sized blood vessels. Individuals afflicted with systemic vasculitides experience notable morbidity and mortality attributable to cardiovascular manifestations. Noteworthy among these are ischemic heart disease, venous thromboembolism, aortic involvement, valvular irregularities, myocarditis, and pericarditis. This narrative review investigated and evaluated the prevalent cardiovascular disturbances commonly associated with different types of vasculitides. This review also discusses the mechanisms that underlie these manifestations. It also provides a thorough explanation of the many diagnostic techniques essential for detecting the disease at its occult stage. It is essential for healthcare professionals to have knowledge of the cardiovascular complications caused by vasculitides, as this enables them to promptly recognize these symptoms and employ suitable diagnostic techniques early on. By doing so, timely detection can be ensured, which will subsequently aid in initiating appropriate treatment strategies that are vital for decreasing morbidity and mortality in patients with systemic vasculitides.

Autoimmune Heart Disease: A Comprehensive Summary for Forensic Practice

Autoimmune heart disease is a non-random condition characterised by immune system-mediated aggression against cardiac tissue. Cardiac changes often exhibit nonspecific features and, if unrecognised, can result in fatal outcomes even among seemingly healthy young individuals. In the absence of reliable medical history, the primary challenge lies in differentiating between the various cardiopathies. Numerous immunohistochemical and genetic studies have endeavoured to characterise distinct types of cardiopathies, facilitating their differentiation during autopsy examinations. However, the presence of a standardised protocol that forensic pathologists can employ to guide their investigations would be beneficial. Hence, this summary aims to present the spectrum of autoimmune cardiopathies, including emerging insights such as SARS-CoV-2-induced cardiopathies, and proposes the utilisation of practical tools, such as blood markers, to aid forensic pathologists in their routine practice.

Clinical characteristics and risk factors of coronary artery lesions in chinese pediatric Takayasu arteritis patients: a retrospective study

BACKGROUD

To summarize the clinical characteristics and identify the risk factors for pediatric Takayasu arteritis (TAK) with coronary artery lesions (CALs).

METHODS

Clinical data of pediatric TAK patients in our center were retrospectively assessed. Independent risk factors for CALs were identified using multivariate logistic regression analysis. Survival analysis was used to compare differences in survival rates between the groups.

RESULTS

Among the 66 pediatric TAK cases, the incidence of accompanying CALs was 39.4%. In the CAL group, 19 (73.1%) cases started within 36 months. None of the patients had symptoms of angina or ischemia on electrocardiogram (ECG), the CALs were detected using coronary ultrasound. The CALs most commonly were the left main and right coronary arteries. The lesions were mostly small or middle coronary artery aneurysms; some children may have giant coronary aneurysmal dilations, thrombosis and heart failure. The age of onset and symptom onset to diagnosis in TAK patients with CAL were lower than those in TAK patients without CAL(P < 0.005). TAK patients with CAL had significantly higher CRP,WBC, PLT,TNF-α and IL-2R levels (P < 0.05), lower HGB (P = 0.01), lower rate of renal artery stenosis (RAS) (P = 0.009). In multivariate logistic regression, the risk factors for pediatric TAK combined with CAL included the age of TAK onset (OR = 0.9835, 95% CI: 0.9710-0.9946, P = 0.006) and RAS (OR = 0.1901, 95% CI: 0.0386-0.7503, P = 0.03). In addition, there was no significant difference in survival rates between the two groups after regular treatment.

CONCLUSION

This study showed that the occurrence of CAL in pediatric TAK patients has a relatively more rapid clinical course, and a stronger inflammatory state at the time of diagnosis. The earlier the age of TAK onset and without RAS are more likely to cause CAL.

Cardiovascular Disease in Large Vessel Vasculitis: Risks, Controversies, and Management Strategies

Takayasu's arteritis (TAK) and giant cell arteritis (GCA) are the 2 most common primary large vessel vasculitides (LVV). They share common vascular targets, clinical presentations, and histopathology, but target a strikingly different patient demographic. While GCA predominantly affects elderly people of northern European ancestry, TAK preferentially targets young women of Asian heritage. Cardiovascular diseases (CVD), including ischemic heart disease, cerebrovascular disease, aortic disease, and thromboses, are significantly increased in LVV. In this review, we will compare and contrast the issue of CVD in patients with TAK and GCA, with respect to prevalence, risk factors, and mechanisms of events to gain an understanding of the relative contributions of active vasculitis, vascular damage, and accelerated atherosclerosis. Controversies and possible mitigation strategies will be discussed.

Long-term outcomes and prognostic factors after aortic valve surgery in patients with Takayasu arteritis

BACKGROUND

Aortic regurgitation (AR) is a common cardiovascular complication in patients with Takayasu arteritis (TAK), and complication after aortic valve surgery (AVS) is not rare. This study aimed to identify the long-term postoperative outcomes for significant AR in patients with TAK compared with those in patients without TAK.

METHODS

We included 35 patients with TAK with moderate-to-severe AR who underwent AVS and compared their postoperative outcomes with those of 105 age- and operation period-matched patients with severe AR but without TAK. The risk factors for poor outcomes [all-cause death and major adverse cardiac and cerebrovascular events (MACCE)] in patients with TAK were analyzed using multivariate Cox regression.

RESULTS

The 10-year overall survival rate was 70.5% in patients with TAK and 89.4% in those without TAK (p = 0.048). The MACCE and reoperation rates were significantly higher in patients with TAK (10-year freedom from MACCE, 58.2% vs. 86.4% [p < 0.001]; 10-year freedom from reoperation, 64.5% vs. 98.3% [p < 0.001]). Eighteen of the 35 patients with TAK (51.4%) had poor outcomes, and multivariate analysis revealed that significant coronary artery involvement [hazard ratio (HR), 4.178; 95% confidence interval (CI), 1.222-14.282; p = 0.023] and decreased estimated glomerular filtration rate (HR, 0.968; 95% CI 0.947-0.989; p = 0.003) were associated with poor outcomes.

CONCLUSION

The long-term postoperative outcomes for AR were poorer in patients with TAK than in those without TAK. The poor outcomes in patients with TAK were associated with coronary artery involvement and decreased renal function.

Coronary-to-coronary bypass grafting in aortoarteritis: a case report

Takayasu's arteritis (TA) is an idiopathic vasculitis affecting the aorta and its major branches. In TA, coronary artery involvement is rare and it mainly consists of stenosis or occlusion of the coronary ostia. In TA, as the arterial tree is diseased, often, arterial grafts are unsuitable for grafting so the saphenous vein grafts (SVG) are commonly used. We present a case of a young female with TA with an ostial left main stenosis who has undergone a right coronary-to-left anterior descending artery SVG and put on immunosuppression and steroids. She was asymptomatic with a patent graft during 7 years follow-up.

CT Imaging Findings in Non-Atherosclerotic Coronary Artery Disease

급성 관동맥 증후군(acute coronary syndrome)은 대부분 죽상경화 관상동맥 질환(atherosclerotic coronary artery disease)에 의해 발생하지만, 비죽상경화 관상동맥 질환에서도 발생할 수 있다. 고식적 관상동맥 혈관조영술은 동맥 내강의 협착이나 확장 등의 형상에 대한 정보만을 제공하고, 동맥경화반이나 동맥벽에 대한 평가가 어려워 관상동맥 이상의 원인 질환의 진단에 낮은 특이도를 보인다. 반면, 관상동맥 전산화단층촬영 혈관조영술은 혈관경화반의 특징, 혈관벽의 조영증강뿐 아니라 연접한 대동맥이나 폐동맥의 변화 등도 함께 관찰할 수 있어, 비죽상경화 관상상동맥질환의 진단 및 다양한 원인 감별에 도움이 된다. 따라서 이 종설에서는 다양한 비죽상경화 관상동맥 질환들을 소개하고, 이의 병태생리 및 대표적인 관상동맥 전산화단층촬영 혈관조영술의 영상 소견에 대해 설명하고자 한다.

Concurrent coronary artery and subclavian arterial aneurysms in Takayasu arteritis

Background

Aneurysmal coronary artery involvement and subclavian artery aneurysm are extremely uncommon in Takayasu arteritis.

Case presentation

We present a case with concurrent coronary artery and subclavian artery aneurysms.

Conclusions

This case report stresses multimodality and multisystem imaging in Takayasu arteritis to know the disease load in the patient and to know the possibility of a rare type of involvement (medium and large vessel) in Takayasu arteritis patient.

Acute myocardial infarction with left main coronary artery ostial negative remodelling as the first manifestation of Takayasu arteritis: a case report

Background

Takayasu arteritis is a chronic inflammatory disease involving the aorta and its major branches. Acute myocardial infarction rarely but not so much presents in patients with Takayasu arteritis, and the preferable revascularization strategy is still under debate.

Case presentation

A 22-year-old female with Takayasu arteritis presented with acute myocardial infarction. Coronary angiography and intravenous ultrasound (IVUS) showed that the right coronary artery (RCA) was occluded and that there was severe negative remodelling at the ostium of the left main coronary artery (LMCA). The patient was treated by primary percutaneous transluminal coronary angioplasty (PTCA) with a scoring balloon in the LMCA, without stent implantation. After 3 months of immunosuppressive medication, the patient received RCA revascularization by stenting. There was progressive external elastic membrane (EEM) enlargement of the LMCA ostium demonstrated by IVUS at 3 and 15 months post-initial PTCA.

Conclusion

Here, we report a case of Takayasu arteritis with involvement of the coronary artery ostium. Through PTCA and long-term immunosuppressive medication, we found that coronary negative remodelling might be reversible in patients with Takayasu arteritis.

Serum concentrations of small dense low-density lipoprotein cholesterol and lipoprotein(a) are related to coronary arteriostenosis in Takayasu arteritis

Background

Serum small dense low‐density lipoprotein cholesterol (sdLDL‐C) and lipoprotein(a) [Lp(a)] levels are related to coronary disease, but their specific associations with coronary arteriostenosis in Takayasu arteritis (TA) have not been ascertained. This study explored the correlations between serum sdLDL‐C and Lp(a) levels and coronary arteriostenosis in TA patients as well as the degree of artery stenosis.

Methods

This retrospective study included 190 TA patients and 154 healthy subjects. TA patients were divided into three categories based on the degree of coronary stenosis: Group I, stenosis >50%; Group II, stenosis 1%–50%; and Group III, stenosis 0%. Independent risk factors for coronary arteriostenosis in TA were identified by logistic regression, followed by receiver operating characteristic curve analysis to determine the specificity and sensitivity of risk factors and Youden's Index score calculation to determine the cutoff points.

Results

Takayasu arteritis patients had significantly higher serum levels of sdLDL‐C and Lp(a) than healthy controls (p < 0.0001). The total cholesterol, triglyceride, LDL‐C, sdLDL‐C, and Lp(a) levels and the sdLDL‐C/LDL‐C ratio in Group I were significantly higher than those in Groups II and III (p < 0.05). An elevated serum sdLDL‐C level elevated the risk of coronary arteriostenosis by 5‐fold (cutoff value, 0.605 mmol/l). An increased serum Lp(a) level increased the risk of coronary arteriostenosis by 3.9‐fold (cutoff value, 0.045 g/l). An elevated sdLDL‐C/LDL‐C ratio increased the risk of coronary arteriostenosis by 2.1‐fold (cutoff value, 0.258).

Conclusions

Serum sdLDL‐C and Lp(a) levels and sdLDL‐C/LDL‐C ratio may be used as diagnostic factors for coronary arteriostenosis in TA patients.

Fulminant Vasculitis Complicated by ST-Elevation Myocardial Infarction and Stroke

Acute coronary syndrome is a rare complication of vasculitis. We present a case of fulminant medium-vessel vasculitis, most likely PAN, complicated by STEMI and stroke, that was successfully treated with percutaneous revascularization, high-quality stroke care, and immunosuppression. This case highlights the importance of prompt diagnosis and treatment of vasculitis and the recognition of coronary and cerebral ischemia as potentially serious complications.

Coronary artery aneurysms in children is not always Kawasaki disease: a case report on Takayasu arteritis

Background

Coronary artery (CA) aneurysms in children are a rare but potentially life-threatening finding and are highly associated with Kawasaki disease (KD).

Case presentation

We describe a four-year-old female with a vasculitis and CA aneurysms. She had a prolonged course with recurrent fever and systemic inflammation several times upon discontinuation of steroid treatment. Due in part to the CA aneurysms, she initially was diagnosed with KD but due to the unusual clinical course, further evaluation was performed. Abdominal and chest MRI/A revealed diffuse aortitis suggestive of a large vessel vasculitis, specifically Takayasu arteritis. With treatment targeted for Takayasu arteritis, there was resolution of fever and inflammation and the CA aneurysms improved.

Conclusions

This case demonstrates the utility in broadening the differential diagnosis in cases of presumed KD with CA involvement in which the clinical course is atypical for KD.

The Role of Echocardiography in Evaluation of Takayasu's Arteritis: A Report of Two Cases

Takayasu's arteritis (TA) is a large-vessel chronic inflammatory vasculitis that leads to thrombotic vascular occlusion. This can lead to varied presentations including limb claudication, ischemic stroke, hypertension, and heart failure. Although contrast computed tomography angiography is the main modality for imaging of the aorta and its branches, transthoracic echocardiography can be an easy-to-access, point-of-care, initial screening tool for evaluating the aorta and other cardiac structures. We present echocardiographic images from two cases that demonstrate the important cardiac structural and vascular afflictions of TA.

Risk assessment model for heart failure in Chinese patients with Takayasu's arteritis

OBJECTIVES

We aimed to construct and validate a risk assessment model to identify risk factors for heart failure (HF) in patients with Takayasu's arteritis (TAK).

METHODS

Three hundred sixty-five patients with TAK were recruited in the East China Takayasu Arteritis Cohort from January 2012 to December 2019. Patients were assigned into training and validation sets following a 2:1 ratio according to the date of enrollment. Clinical characteristics were compared between heart failure (HF) and non-HF subgroups in the training set, and a risk assessment model for HF and its scoring algorithm was established based on logistic regression, which was tested in the validation set.

RESULTS

Among total of 74 (20.27%) TAK patients exhibited HF, and 55 cases (74.32%) were in the training set. The risk factors for HF of TAK patients included onset age >38 years, serum tumor necrosis factor (TNF)-α concentration >10 pg/ml, aortic valve involvement, coronary artery involvement, and pulmonary hypertension. We constructed the model without TNF-α (Model 1) and with TNF-α (Model 2). Patients in the training set with the score ≥ 3 appeared to be associated with an increased risk of HF with an area under curve (AUC) of 0.88 and 0.90 in Model 1 and Model 2 respectively. The AUC reached to 0.88 and 0.89 in the validation set that proved the accuracy of the model.

CONCLUSIONS

We presented a risk assessment model of HF in TAK, which may help clinicians alert the complication of HF in the patients with specifically cardiac impairments. Key Points • Heart failure was not rare in Chinese Takayasu's arteritis patients, and there were approximately 20% of patients with heart failure in ECTA cohort. • Cardiac involvements on echocardiography include pathological valvular and atrioventricular abnormalities. • The onset age >38 years, serum tumor necrosis factor (TNF)-α concentration >10 pg/ml, aortic valve involvement, coronary artery involvement, and pulmonary hypertension were risk factors for heart failure in Takayasu's arteritis patients. • We constructed the model without TNF-α (Model 1) and with TNF-α (Model 2). Patients with the risk assessment model score of ≥ 3 appeared to be associated with an increased risk of heart failure.

Three-year outcome with drug-coated balloon percutaneous coronary intervention in coronary Takayasu arteritis: A case review

We describe the first long-term follow-up of a young patient with active Takayasu arteritis who presented with an acute coronary syndrome, treated endovascularly with percutaneous coronary intervention without stenting. A drug-coated balloon was used with high-resolution coronary imaging guidance in the form of optical coherence tomography on a critical ostial left anterior descending coronary artery lesion. A repeat procedure was undertaken after 4 months confirming a durable coronary angioplasty result and the patient remained symptom-free beyond 3 years. Coronary stenting in this population is associated with early and aggressive stent failure. Hence, this is an innovative approach. We believe that the stent, regardless of whether it is first, second or subsequent generation, leaves a permanent foreign body within the vasculature that becomes the seed for inflammatory reactions, resulting in recurrent in-stent restenotic fibrosis irrespective of concurrent immunotherapy or the degree of disease activity.

Coronary artery bypass for Takayasu's arteritis involving the aortic root in a child

The patient was a 12-year-old female who presented with angina pectoris, aortic root dilatation, and aortic regurgitation (AR) caused by Takayasu's arteritis (TA). After the management of systemic inflammation, she underwent off-pump coronary artery bypass with the radial artery (RA), which extended from the left axillary artery to the left descending coronary artery, via left mini-thoracotomy. Postoperative angiography revealed the growth of the RA graft. The patient is well 4 years after surgery without progression of AR. Off-pump coronary artery bypass is a palliative therapy. Moreover, it could be a feasible option in a child with TA involving the aortic root.

Pivotal role of cardiac magnetic resonance imaging in a new case of Takayasu arteritis

Takayasu arteritis (TA), also known as the pulseless disease, is a form of vasculitis of unknown cause that chiefly affects the aorta and its major branches, most frequently in young women. The earliest detectable abnormality in TA is a thickening of the vessel wall, but diffuse aortic wall calcification is very rare and is a late manifestation. Besides, the involvement of the coronary arteries is not a common finding in TA and frequently involves the right coronary artery (RCA). Multi-modality imaging has a fundamental role in the diagnosis of vasculitis and its complications. In this report, we want to present an unusual case with TA, diffuse aortic wall calcification and left main coronary artery ostial lesion, which is a rare combination.

Revascularization Versus Medical Therapy in Takayasu's Arteritis Patients with Coronary Artery Involvement

Introduction

Treatment strategies to improve clinical outcomes in Takayasu's arteritis (TA) with coronary lesions have ranged from pharmacological therapy to invasive procedures, such as coronary angioplasty, stenting, and surgery. However, the therapeutic strategy for this kind of patient is still unclear. This study aimed to investigate the clinical characteristics and influence of revascularization versus medical therapy in TA patients with coronary artery involvement.

Methods

We analyzed the medical records of 806 TA patients between January 2008 and December 2019. Clinical features and treatment were analyzed, and patients were categorized into medical treatment and revascularization. Additionally, patients were sorted as percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) based on the strategy of revascularization.

Results

Ninety cases with coronary lesions induced by TA were enrolled. Among 90 cases, 39 patients adopted conservative treatment, and 51 patients received revascularization (28 subjects with PCI, 23 participants with CABG). The median follow-up time was 63 (45–91) months. There is no significant difference in cardiovascular death between medical treatment and revascularization (2/39, 5.1% vs. 5/51, 9.8%, P = 0.971). The analysis of subgroup indicated that the mortality caused by cardiovascular disease was also similar in the CABG and PCI (2/28, 7.1% vs. 3/23, 13.0%, P = 0.772). However, the proportion of restenosis is much higher in the PCI compared with that of CABG (39.3%, 8.7%, P = 0.022, respectively). Heart failure is an independent predictor of death in these patients.

Conclusions

There is no significant difference in cardiovascular death between medical treatment and revascularization. The analysis of the subgroup indicated that the mortality caused by cardiovascular disease was also similar in the CABG and PCI, but the restenosis is much higher in the PCI compared with that of CABG. Heart failure is an independent predictor of death in these patients.

The relationships of serum homocysteine levels and traditional lipid indicators with disease activity and coronary artery involvement in Takayasu arteritis

Serum homocysteine (HCY) levels have been associated with the occurrence of coronary stenosis and disease activity in large-vessel vasculitis. However, whether increases in serum HCY levels and traditional lipid indicators are associated with coronary artery involvement and disease activity in Chinese Han Takayasu arteritis (TA) patients is unknown. This study aims to investigate the clinical and laboratory features of TA by assessing their association with disease activity in TA patients, and to explore the risk factors associated with coronary artery involvement in these patients. Serum HCY levels and traditional lipid indicators were tested in one hundred ninety TA patients and one hundred fifty-four healthy controls. We analyzed the relationships of serum HCY levels and traditional lipid indicators with disease activity and analyzed the risk factors for coronary artery involvement. Twenty-one TA patients were found to have coronary artery stenosis (≥ 50%). TA patients had significantly higher levels of HCY than did healthy controls (p < 0.0001). Serum levels of HCY and low-density lipoprotein cholesterol (LDL-C); the ratios of LDL-C to high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC) to HDL-C, and triglycerides (TG) to HDL-C; and the values of atherogenic index of plasma (AIP) were significantly higher in patients with active TA than in patients with inactive TA and in TA patients with coronary artery involvement than in TA patients without coronary artery involvement. By contrast, the serum levels of HDL-C were significantly lower in patients with active TA than in patients with inactive TA and in TA patients with coronary artery involvement than in TA patients without coronary artery involvement (p < 0.05). In addition, the serum levels of TC and TG were significantly higher in TA patients with coronary artery involvement than those in TA patients without coronary artery involvement. Elevated serum HCY levels increased the risk of coronary artery involvement by 1.3-fold (p = 0.011, odds ratio [OR] = 1.275, 95% confidence interval [CI]: 1.056-1.539), and the cutoff value for serum HCY was 9.55 μmol/L. Elevated serum TG levels increased the risk of coronary artery involvement by 3.5-fold (p < 0.0001, OR = 3.534, 95% CI: 1.907-6.547), and the cutoff value for serum TG was 1.215 mmol/L. The risk of coronary artery involvement was 2.5-fold higher when an elevated TG/HDL-C ratio was present (p < 0.0001, OR = 2.513, 95% CI: 1.567-4.032). This study showed that serum HCY and TG levels and the TG/HDL-C ratio are independent risk factors for coronary artery involvement in TA patients.

Cardiac involvement in the adult primary vasculitides

INTRODUCTION

Heart involvement in vasculitis is rare, but potentially severe. The ascertainment of cardiac disease in vasculitis is complex and requires an integrated multidisciplinary approach involving the Rheumatologist, Radiologist, Cardiologist, and Heart surgeon.

AREAS COVERED

the authors searched PubMed using the keywords 'heart'[Mesh] and vasculitis"[Mesh].

EXPERT OPINION

Virtually any vasculitis can affect the heart, but cardiac involvement is more common in some vasculitides such as Takayasu arteritis, polyarteritis nodosa, and eosinophilic granulomatosis with polyangiitis. Immunosuppressive treatment and when indicated surgery can improve the prognosis.

Intervention in Takayasu Aortitis: When, Where and How?

Takayasu arteritis is a large vessel vasculitis which commonly affects the aorta and its major branches. Active arterial inflammation is characterised by the presence of T and B lymphocytes, natural killer cells, macrophages and occasional multinucleate giant cells. Uncontrolled vascular inflammation can progress to cause arterial stenosis, occlusion or aneurysmal dilatation. Medical treatment involves combination immunosuppression and more recently biologic therapies targeting TNF-α and IL-6. Due to the typical delays in diagnosis and accumulation of arterial injury, open and endovascular surgical intervention are important and potentially life-saving treatment options for Takayasu arteritis. Common indications for surgery include aortic coarctation and ascending aortic dilatation ± aortic valve regurgitation, renal artery stenosis, ischaemic heart disease, supra-aortic disease, mesenteric ischaemia, severe limb-threatening claudication and aneurysm repair. Surgical outcomes are markedly improved in patients with clinically inactive disease and those who receive adequate periprocedural immunosuppression. Decisions regarding surgical approaches are best made as part of a multi-disciplinary team.

Intravascular ultrasound imaging of isolated and non aorto-ostial coronary Takayasu arteritis: a case report

Background

Isolated coronary Takayasu arteritis is a rare form of ischemic heart disease that typically appears as an aorto-ostial lesion. Although several vascular imaging modalities including ultrasonography, computed tomographic angiography, magnetic resonance angiography or catheter angiography, play crucial roles for diagnosing Takayasu arteritis, the intravascular ultrasound imaging of Takayasu arteritis is not well studied.

Case presentation

A 55-year-old woman who was diagnosed with heterozygous familial hypercholesterolemia underwent coronary angiography due to effort angina, which showed ostial left anterior descending coronary artery (LAD) stenosis. Although directional coronary atherectomy followed by drug-coated balloon was successfully performed, 6 months later restenosis occurred at the ostial LAD, and the ostial left circumflex coronary artery (LCx) progressed significantly. The intravascular ultrasound imaging in these lesions was noteworthy, in which the media was partly unrecognizable and an echo intensity similar to fibrotic intimal thickening traversed from the intima to the adventitia, thereby causing the whole image of the coronary artery to become unclear. Directional coronary atherectomy followed by drug-coated balloon procedures for both LAD and LCx lesions were performed again. Systemic examination of computed tomographic angiography found no other stenotic lesions except for those in the coronary arteries. Five months later, the LAD and LCx lesions progressed diffusely, therefore the coronary artery bypass graft was done. The histopathological findings of specimens of the coronary artery that were obtained during the bypass graft showed excessive fibrous thickening of the intima and adventitia, with granulomatous inflammation in the media, which led to the diagnosis of isolated coronary Takayasu arteritis. Systemic corticosteroid therapy was then started.

Conclusions

We described an extremely rare case of isolated and non aorto-ostial Takayasu arteritis. The characteristic intravascular ultrasound images of diseased coronary arteries may help in the diagnosis of coronary Takayasu arteritis.

Coronary artery involvements in Takayasu arteritis: systematic review of reports

Coronary artery involvements in patients with Takayasu arteritis (TA) have not been sufficiently described. By comprehensive retrieval of the pertinent literature published in the past two decades, 59 reports including 141 patients were recruited into this study. In TA patients with coronary artery involvements, the right coronary artery was the most commonly affected. Stenosis was the most common coronary artery lesion, and the coronary ostium was the most commonly affected coronary segment. Acute myocardial infarction was diagnosed in 17 (12.1%) patients of this cohort. Patients receiving surgical treatment showed a higher recovery rate than interventionally treated patients. Interventional therapy was associated with a higher reintervention rate than surgical treatment. The inflammation condition in TA patients can lead to in-stent restenosis and warrant reinterventions. Surgical treatment is a preferable treatment of choice over interventional therapy for the coronary artery lesions of TA patients.

Etiology, Diagnosis and Management of Aortitis

Aortitis includes conditions with infectious or non-infectious etiology, characterized by inflammatory changes in one or more layers in aortic wall. Age at onset, geographic predilections, distribution and pattern of involvement in aorta, its branches and pulmonary arteries, and systemic associations provide a clue to etiology. Clinical presentations are often non-specific. An integrated approach including clinical, laboratory and imaging assessment is essential to confirm diagnosis and plan treatment. Assessment of disease activity is the key as it influences timing and outcome of treatment. Markers of activity include clinical, laboratory and imaging. Medical management remains the first-line therapy. Revascularization is indicated in the presence of hemodynamically significant stenosis and inactive disease. In the presence of flash pulmonary edema, left ventricular dysfunction or hypertensive encephalopathy, revascularization is performed irrespective of disease activity. Endovascular management is favored over surgery due to its high success and low restenosis rates. Symptomatic aneurysmal disease is usually managed by surgery.

Coronary Ostial Patch Angioplasty With Femoral Artery in Takayasu Arteritis

Takayasu arteritis (TA) occasionally involves the coronary ostium leading to myocardial ischemia. Although surgical coronary ostial angioplasty is desirable for ostial stenosis, the patch materials and long-term results are controversial. We used femoral artery (FA) as a patch material for coronary ostial angioplasty in 3 TA patients. Coronary ostial enlargement with a longitudinal incision followed by rectangular FA patch augmentation was performed to extend the narrowing coronary ostium. In all patients, coronary ostial stenosis was successfully repaired. Ostial angioplasty using an FA patch would be a reasonable surgical strategy to treat coronary ostial stenosis in TA.

Association between Takayasu arteritis and ischemic heart disease: a cohort study

Purpose of the study:

Takayasu arteritis (TA) is an idiopathic large vessel vasculitis, which involves the aorta and its major branches. Our aim was to examine the association between TA and the development of ischemic heart disease (IHD) and its impact on survival.

Study design:

Using data from Clalit Health Services (CHS), the largest Health Maintenance Organization (HMO) in Israel, the proportion of IHD was compared between patients diagnosed with TA and age- and gender-matched controls. Chi-square and t-tests were used for univariate analysis, and a logistic regression model was employed for multivariate analysis. Survival analysis was performed using Kaplan-Meier plots and cox regression.

Results:

The study included 155 TA patients and 755 age- and gender-frequency matched controls. The proportion of IHD in TA patients was increased in comparison with controls (32.3% and 8.9%, p<0.001). In multivariate analysis, IHD was associated with TA (OR=6.576, 95% CI: 4.09–10.64) and male gender (OR=2.29, 95% CI: 1.43–4.26). Survival analysis over 15 years of follow-up showed a higher proportion of all-causes mortality in the TA group. In a multivariate analysis, TA (HR=2.58, 95%CI: 1.64–4.06) and IHD (HR=1.64, 95%CI: 1.05–2.55) were found to be associated with reduced survival.

Conclusions:

TA patients present an increased proportion of IHD, and a reduced 15-years survival rate compared to controls.

Coronary arteritis: a case series

Background

The present article describes two cases of patients with coronary arteritis (CA) whose identification of CA diagnosis (late vs. early) resulted in different clinical courses and outcomes.

Case summary

Case 1 is a 53-year-old woman with multiple coronary risk factors who was admitted with acute coronary syndrome (ACS) and significant stenosis in the left main trunk (LMT). Although clues suggested arteritis (LMT lesion without any other stenosis, occlusion of left internal thoracic artery, etc.), the diagnosis of CA (coronary involvement of unclassified arteritis) was delayed and revascularization, including coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), was performed under uncontrolled inflammatory status. As a result, Case 1 experienced repeated ACS episodes due to graft failure and in-stent restenosis, and repeatedly underwent PCI. Case 2 is a 76-year-old woman with no significant coronary risk factors who was admitted with ACS. This patient was successfully diagnosed with coronary involvement of Takayasu arteritis before revascularization. Coronary artery bypass grafting was performed after stabilizing inflammation with prednisolone, and the patient remains angina-free beyond 1-year post-CABG. In both cases, intravascular imaging clearly identified the localization and degree of inflammation related to CA by demonstrating specific findings (ambiguous typical three-layer structure of arterial wall and extended low-echoic areas within adventitia).

Discussion

Accurate and early diagnosis with meticulous diagnostic and therapeutic strategies appear to be important for favourable clinical outcomes in the medical treatment of patients with coronary involvement of arteritis. Intravascular imaging has the potential to contribute to optimizing clinical management of CA.

A Rare Case of Takayasu Arteritis With Total Left Main Coronary Artery Occlusion

We report the case of a young woman with chest pain and recurrent abortion. The patient was found to have Takayasu arteritis. Drug therapy was started, and emergency bypass surgery was performed. The case showed the possible clinical manifestation of vasculitis as a recurrent abortion, followed by total occlusion of the left main coronary artery. (Level of Difficulty: Intermediate.)

Repeat Revascularization for Severe Recurrent Coronary Artery Disease in a Young Woman With Takayasu Arteritis

A young woman with Takayasu arteritis presented with an acute coronary syndrome with ostial left main coronary artery stenosis. She underwent urgent coronary artery bypass surgery but developed recurrent symptoms 6 months later owing to graft failure. She was treated with percutaneous coronary intervention with resolution of her symptoms. (Level of Difficulty: Beginner.)

Management of Takayasu arteritis: a systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis

Objective

To collect available evidence on management of large vessel vasculitis to inform the 2018 update of the EULAR management recommendations.

Methods

Two independent systematic literature reviews were performed, one on diagnosis and monitoring and the other on drugs and surgical treatments. Using a predefined PICO (population, intervention, comparator and outcome) strategy, Medline, Embase and Cochrane databases were accessed. Eligible papers were reviewed and results condensed into a summary of findings table. This paper reports the main results for Takayasu arteritis (TAK).

Results

A total of 287 articles were selected. Relevant heterogeneity precluded meta-analysis. Males appear to have more complications than females. The presence of major complications, older age, a progressive disease course and a weaker inflammatory response are associated with a more unfavourable prognosis. Evidence for details on the best disease monitoring scheme was not found. High-quality evidence to guide the treatment of TAK was not found. Glucocorticoids are widely accepted as first-line treatment. Conventional immunosuppressive drugs and tumour necrosis factor inhibitors were beneficial in case series and uncontrolled studies. Tocilizumab failed the primary endpoint (time to relapse) in a randomised controlled clinical trial; however, results still favoured tocilizumab over placebo. Vascular procedures may be required, and outcome is better when performed during inactive disease.

Conclusions

Evidence to guide monitoring and treatment of patients with TAK is predominantly derived from observational studies with low level of evidence. Therefore, higher-quality studies are needed in the future.

Takayasu Arteritis With Coronary Artery Involvement: Differences Between Pediatric and Adult Patients

BACKGROUND

The clinical features, angiographic findings, and outcomes have not been compared between pediatric and adult patients with Takayasu arteritis (TA) with coronary involvement.

METHODS

Of 1056 consecutive patients with TA hospitalized and followed from 1990 to 2018 in our hospital, 38 patients including 9 children and 29 adults (mean age at diagnosis of 14.3 ± 3.3 years and 38.6 ± 12.0 years, respectively) were diagnosed with coronary artery involvement by imaging. Clinical manifestations, coronary lesion characteristics, and outcomes were compared between the pediatric and adult patients.

RESULTS

Compared with adults, pediatric patients with TA with coronary involvement had a significantly shorter disease duration (median, 2 months; interquartile range [IQR], 1-38 vs median, 48 months [IQR, 18-90], P = 0.019) and higher disease activity score (median, 3 [IQR, 2-4] vs median, 2 [IQR, 1-3], P = 0.013) on the first positive coronary assessment. Although all recruited patients except 1 child had coronary stenosis, coronary aneurysmal dilation was found in 6 patients and was more frequent in children than in adults (55.6% vs 3.4%, P = 0.001). Moreover, the children with coronary aneurysmal dilation had a higher incidence of dilation in large vessels than children without aneurysmal dilation (80.0% vs 0%, P = 0.048).

CONCLUSION

Pediatric patients with TA with coronary involvement had higher inflammation status and were more prone to coronary aneurysmal dilation on the first positive coronary assessment compared with adults. Dilation in the aorta and its major branches might be an indicator of coronary aneurysmal dilation in these pediatric patients.

Cardiogenic shock as the first manifestation of large vessel vasculitis in a young patient: case report

Background

Cardiogenic shock secondary to coronary involvement in large vessel vasculitis (LVV) is an unsuspected finding, even more, when no other vascular territories are compromised and when it constitutes the initial clinical manifestation. This case report illustrates a case in which a complete diagnostic study uncovered this aetiology.

Case summary

A 33-year-old woman with cough and chest pain who was diagnosed with acute bronchitis returned with worsening dyspnoea, chest pain, and developed cardiogenic shock. The initial differential diagnoses included myocarditis and takotsubo cardiomyopathy (TCM) owing to a positive troponin I, and echocardiogram with left ventricular dilation, dyskinesia in mid-ventricular and apical segments, systolic dysfunction, and functional mitral regurgitation. A cardiac magnetic resonance showed contractility abnormalities resembling the pattern of TCM but lacked the characteristic myocardial oedema. Subsequently, a coronary angiography expected to result without obstructions showed a critical narrowing of the left main coronary artery. Surgical management consisted of a pericardium patch grafted in the stenotic ostium to restore adequate perfusion. The surgical specimens were sent to the pathology laboratory that reported findings compatible with LVV. Four days after the surgical intervention the patient was discharged alive with a complete recovery of left ventricular systolic function.

Discussion

Chest pain symptoms in a young woman, could be caused by multiple entities, and an ischaemic aetiology from a non-atherosclerotic origin should be kept in mind. A complete study with coronary angiography is crucial to rule out an ischaemic cause even in low-risk groups for atherosclerotic coronary heart disease.

Acute myocardial infarction as the first manifestation of Takayasu arteritis: A case report

RATIONALE

Takayasu arteritis (TA) is a chronic inflammatory disease involving the aorta and its major branches. Initial diagnosis is usually difficult due to the highly variable symptoms. Acute myocardial infarction (AMI) is a very rare presentation in patients with TA. Moreover, the choice of early management for these patients is not well established.

PATIENT CONCERNS

A 34-year-old woman was taken to the Emergency Department of our hospital, presenting with a sudden onset and persistent retrosternal chest pain radiating to both upper extremities for 2 hours. Blood pressures were different between 2 arms with 151/115 mm Hg on the right arm and 140/100 mm Hg on the left arm.

DIAGNOSES

The patient was diagnosed with TA according to the medical history, physical examination, and vascular imaging.

INTERVENTIONS

Primary percutaneous coronary intervention (PPCI) was performed to restore the coronary flow of left anterior descending. Meanwhile, combination of oral glucocorticoids and immunosuppressive agents was administered to halt disease progression of TA.

OUTCOMES

Chest pain was relieved without rest and exertional angina. The patient achieved long-term remission without symptom relapse during our follow-up.

LESSONS

Percutaneous coronary intervention was essential and effective in AMI of TA. Timely immunosuppressive therapy could improve the long-term outcome.

Surgical intervention and its role in Takayasu arteritis

Vascular surgery remains an important option in the management of Takayasu arteritis (TA). Its use is predominantly confined to the treatment of symptomatic organ ischaemia or life-threatening aneurysm formation. In most cases, this follows the failure of medical therapy to prevent arterial injury. Open surgery and endovascular approaches are used. The choice between them, at least in part, is determined by the site and nature of the lesion. Open surgery, although more invasive, offers enhanced duration of arterial patency, whereas for endovascular intervention, primary angioplasty without stenting is preferred, with stenting reserved for primary or secondary angioplasty failures. Although there is increasing interest in the role of stent grafts and tailor-made endovascular stents, long-term outcomes remain to be reported. Interventional outcomes are improved and complications reduced by therapeutic control of disease activity before and after surgery. The wider use of combined immunosuppression and the introduction of biologic therapy for refractory TA may reduce future requirements for surgical intervention.

CT and MR Imaging of Cardiothoracic Vasculitis

The term vasculitis includes a variable group of entities in which the common characteristic is inflammation of the walls of blood vessels occurring at some time during the course of the disease. The vasculitides can be divided into primary and secondary vasculitides, depending on the etiology and according to the size of the vessel affected. Both primary vasculitis and secondary vasculitis are associated with cardiac morbidity that is often subclinical. Cardiac involvement is associated with prognostic implications and higher rates of related mortality. Vasculitis of cardiac structures and the assessment of disease extent are important for appropriate management and selection of treatment. Although echocardiography, radionuclide imaging, and catheter-directed coronary angiography remain the cornerstones of cardiac imaging, cardiac computed tomography and magnetic resonance imaging can offer a 360° assessment of cardiac anatomy, function, and complications secondary to vasculitis. Postoperative complications, which are more frequent in patients with active disease, can also be depicted with those imaging modalities. A multidisciplinary approach is important to yield an appropriate estimate of the disease activity and extent and, therefore, to enable better treatment selection and monitoring. Online supplemental material is available for this article. ^©RSNA, 2018.

Surgical strategy for refractory aortitis

In some instances, we encounter cases suffered from inflammatory aortic diseases (aortitis) in Japan, some of which are at the active stages with systemic inflammation. Most of them are refractory with some technical difficulties of surgical treatment. The aortic wall, particularly, at the active stage, is too fragile to hold the surgical sutures. Consequently, the suture reinforcement with Teflon felt is required. In the late stage after surgery, false aneurysms on the suture line, that is, suture detachment potentially occur. To prevent such sequelae in the early and late phases, continuous (life-long) as well as perioperative inflammation control using corticosteroid as an initial drug and/or other immunosuppression agents. This decade, instead of the conventional open surgical repairs, endovascular treatments have widely spread, predominantly for stenotic aortic/arterial lesions. In particular, for more difficult patients suffered from more troublesome Behçet disease, endovascular treatments would have greater advantages to avoid more occasionally occurred pseudo-aneurysm on the other parts as well as the surgical suture lines. The key issues on surgical treatment for refractory aortitis are perioperative inflammation control including the long term with corticosteroid and/or immunosuppressive agents, appropriate open surgical or endovascular treatment approaches, and sufficient reinforcement of surgical suture lines.

Aneurysmal coronary artery disease: An overview

Aneurysmal coronary artery disease (ACAD) comprises both coronary artery aneurysms (CAA) and coronary artery ectasia (CAE). The reported prevalence of ACAD varies widely from 0.2 to 10%, with male predominance and a predilection for the right coronary artery (RCA). Atherosclerosis is the commonest cause of ACAD in adults, while Kawasaki disease is the commonest cause in children and adolescents, as well as in the Far East. Most patients are asymptomatic, but when symptoms do exist, they are usually related to myocardial ischemia. Coronary angiography is the mainstay of diagnosis, but follow up is best achieved using noninvasive imaging that does not involve exposure to radiation. The optimal management strategy in patients with ACAD remains controversial. Medical therapy is indicated for the vast majority of patients and includes antiplatelets and/or anticoagulants. Covered stents effectively limit further expansion of the affected coronary segments. Surgical ligation, resection, and coronary artery bypass grafting are appropriate for large lesions and for associated obstructive coronary artery disease.

Clinical Characteristics of Heart Involvement in Chinese Patients with Takayasu Arteritis

Objective.

To understand the characteristics of heart involvement in Chinese patients with Takayasu arteritis (TA).

Methods.

The medical charts of 411 patients with TA (325 women, 86 men) were retrospectively reviewed. The comparison of clinical manifestations was carried out between the patients with TA with (n = 164) and without (n = 247) heart involvement.

Results.

The median age at disease onset was 23.0 years (18.0–30.0) in 411 patients with TA, and 23.0 years (17.3–30.0) in 164 patients with heart involvement. The disease duration of the heart involvement group (median: 24.0 mos) was significantly longer than those patients without heart involvement (the control group, median: 16.0 mos). Hypertension (57.3% vs 46.6%; p = 0.033), renal dysfunction (17.1% vs 7.7%; p = 0.003), and bruit in the subclavian artery (45.1% vs 34.4%; p = 0.029) were more common in the heart involvement group than patients without. Valvular abnormalities were found in 134 (81.7%) patients in the heart involvement group, myocardial abnormalities in 26 (15.9%), and coronary artery abnormalities in 19 patients (11.6%). The age at onset (yrs) and disease duration (mos) of patients with myocardial, valvular, and coronary arterial abnormalities were 18.8/13.0, 23.8/23.5, and 26.8/57.0, respectively. In the heart involvement group, 22 patients (84.6%) with myocardial abnormalities, 15 (78.9%) with coronary arterial abnormalities, and 89 (66.4%) with valvular abnormalities had Numano type V vessel involvement. The level of high-sensitivity C-reactive protein was higher in the heart involvement group (median: 10.0 mg/l), and the difference was significant when compared to the control group (median: 7.0 mg/l; p = 0.017).

Conclusion.

Patients with TA complicated with cardiac abnormalities are not rare, especially in patients with Numano type V vessel involvement. We suggest that echocardiogram screening may be a helpful tool to understand the whole feature of patients with TA.