Anatomy of the coronary circulation in living man. Coronary arteriography

Coronary sinus anatomical features: Description and procedural implications during coronary sinus Reducer implantation

OBJECTIVES

We hypothesized that some coronary sinus (CS) anatomies allow a more straightforward CS Reducer (CSR) implantation.

BACKGROUND

Recent decades have seen a rise in patients with chronic angina. When complete revascularization and maximal medical therapy fail to reduce symptoms, CSR has become a new therapeutic option.

METHODS

We identified a classical C-shape-a near horizontal course of the proximal portion of a circular CS-in a retrospective analysis of 47 CSR implantations and compared the procedural time, fluoroscopic time, contrast use, presence of valves or bifurcations and procedural complications with the non-C-shape CS anatomy.

RESULTS

We found a significant difference in procedural (20.0 [19.0-24.7] min vs. 24.5 [20.7-51.0] min; p = .028 and fluoroscopic time (9.5 [7.5-14.5] min vs. 11.0 [7.9-30.0] min; p = .016). There was no significant difference in contrast use. The presence of bifurcations or valves along the CS course did not influence the procedural timings.

CONCLUSION

This study is the first systematic evaluation of CS anatomy and its procedural implications. We identified a favorable C-shape anatomy which allows for a more straightforward implantation. Operators should be aware of the different implications of CS anatomy, their influence on guiding catheter stability and overall procedure complexity.

Lower Muscle Strength and Increased Visceral Fat Associated With No-reflow and High Gensini Score in STEMI

Background:

The impact of fat distribution, muscle mass, and muscle strength on no-reflow and severity of coronary artery disease in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear.

Objective:

To investigate association between muscle strength and fat and muscle mass and severity of coronary atherosclerosis.

Methods:

We included 218 patients with STEMI who had undergone primary percutaneous coronary intervention. We evaluated the no-reflow phenomenon in infarct-related artery and calculated Gensini scores from initial angiograms as indicative of coronary atherosclerosis severity. The patients were divided into 2 groups as patients with no-reflow and with thrombolysis in myocardial infarction grade 3 flow and patients with low (<55) Gensini and with high (≥55) Gensini. Patients’ total fat, muscle mass, visceral fat mass, and muscle strength were measured via body composition analyzer and handgrip dynamometer.

Results:

High Gensini patients had a greater body mass index (BMI) and lower handgrip strength and more visceral fat ( P = .05, P = .017, and P < .001, respectively). The patients with no-reflow had significantly lower handgrip strength and more visceral fat (both, P < .001). In multivariate regression analysis, visceral fat and handgrip strength were associated with high no-reflow rate and high Gensini scores in patients with STEMI ( P = .001, P = .014, P = .022, and P = .010; respectively).

Conclusion:

Increased visceral fat and lower handgrip strength may be related to increased no-reflow rate and coronary plaque burden in STEMI. Visceral fat and muscle strength may be better prognostic markers than weight, BMI, total fat, and muscle mass in coronary artery disease.

Compromised atrial coronary anatomy is associated with atrial arrhythmias and atrioventricular block complicating acute myocardial infarction

BACKGROUND

The relevance of the atrial coronary anatomy in the pathogenesis of atrial arrhythmias and atrioventricular (AV) block complicating acute myocardial infarction (AMI) remains unclear.

OBJECTIVES

We evaluated the location of the infarct-related coronary lesion relative to the principal atrial branches (ie, sinoatrial nodal, AV nodal, left atrial circumflex) in 454 patients with ST-elevation AMI in the CAPTORS II trial.

METHODS

Patients underwent systematic 60-minute postfibrinolytic angiograms, and coronary anatomy was correlated with evidence of atrial arrhythmias and AV block on sequential electrocardiograms.

RESULTS

Patients with either sinoatrial nodal or left atrial circumflex compromise (n = 34) had a higher incidence of "early" (ie, up to 90 minutes postfibrinolysis) atrial arrhythmias vs those without (23.5% vs 7.1%; P = .004). Patients with AV nodal compromise (n = 207) had a higher incidence of "early" AV block vs those without (12.1% vs 3.6%; P = .001).

CONCLUSION

These findings support the etiological role of acute atrial ischemia in the development of early atrial arrhythmias and AV block complicating AMI.

Quantitative coronary angiography with deformable spline models

Although current edge-following schemes can be very efficient in determining coronary boundaries, they may fail when the feature to be followed is disconnected (and the scheme is unable to bridge the discontinuity) or branch points exist where the best path to follow is indeterminate. In this paper, we present new deformable spline algorithms for determining vessel boundaries, and enhancing their centerline features. A bank of even and odd S-Gabor filter pairs of different orientations are convolved with vascular images in order to create an external snake energy field. Each filter pair will give maximum response to the segment of vessel having the same orientation as the filters. The resulting responses across filters of different orientations are combined to create an external energy field for snake optimization. Vessels are represented by B-Spline snakes, and are optimized on filter outputs with dynamic programming. The points of minimal constriction and the percent-diameter stenosis are determined from a computed vessel centerline. The system has been statistically validated using fixed stenosis and flexible-tube phantoms. It has also been validated on 20 coronary lesions with two independent operators, and has been tested for interoperator and intraoperator variability and reproducibility. The system has been found to be specially robust in complex images involving vessel branchings and incomplete contrast filling.

Dual left anterior descending coronary artery: angiographic description of important variants and surgical implications

Twenty-three cases of an anatomic variant of the left anterior descending artery (LAD) are described. This variant is termed "dual LAD" and consists of two branches which supply the usual distribution of the LAD. One branch (short LAD) terminates in the proximal aspect of the anterior interventricular sulcus (AIVS). A second, longer branch has a variable course outside the AIVS and returns to the AIVS distally. The long LAD arose from the LAD proper in 21 cases and from the RCA in two cases. The initial course of the long LAD was on the epicardial surface of the left ventricle (17 cases), right ventricle (three cases), or within the interventricular septum (three cases). Recognition of these variants is important for correct surgical identification of the short and long LADs.

Congenital atresia of the left main coronary artery ostium

Three patients with the rare anomaly of congenital absence of the ostium of the left main coronary artery are presented. In two of the patients, aged 50 and 52 respectively, the diagnosis was established during selective coronary cineangiography for a severe anginal syndrome. The third patient, a 16-year-old-girl, underwent cardiac catheterization for investigation of a congenital heart malformation, when a single right coronary artery was demonstrated with absence of the main coronary artery ostium. Two patients underwent successful aortocoronary bypass grafting. In view of the occurrence of sudden death and massive myocardial infarction in adult patients shown to have severe or complete obstruction of the left main coronary artery, it is suggested that adult patients with this condition, who require open-heart surgery for any other cardiac disorder, should undergo aortocoronary bypass grafting concurrently even prior to the development of anginal symptoms. Children shown to have this anomaly should be subjected to long-term follow-up and have an aortocoronary bypass graft performed when symptoms of coronary insufficiency develop.