Coronary Anomalies

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Coronary AnomaliesStaged Revascularization

• Jason S. Finkelstein, M.D.
• Tulane University HSC
• Cardiology Division
• 2/5/04

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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 vessels distal
  vascular territory, not by its origin

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Definitions

• Normal Coronary anatomy observed in gt1 of any
  unselected population
• Normal variant relatively unusual but found in
  gt1 of that population
• Anomaly morphologic feature seen in lt1 of that
  population

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Variable Features

• Ostium
• Location, size, angle of origination
• Size
• Proximal course
• Mid-course
• Termination

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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 2128-40

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Incidence

• A newer study reviewed 1950 consecutive
  angiograms at 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

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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

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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

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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.

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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

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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

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Staged Revascularization
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Multiple Complex Plaques in AMI

• Retrospective study analyzing 253 angiograms
• Single complex plaques were identified in 153 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

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Results

• Multiple complex plaques were less likely to
  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

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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

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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

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Single or Staged Multivessel PCI

• End Points
• Cardiac death
• Q-wave MI
• CABG
• Repeated PCI
• Hemodynamic instability requiring IABP
• Vascular complications

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Single or Staged Multivessel PCI

• Results
• 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 MIs 0.7 v. 3.9
• Restenosis 15.5 v. 17
• Nikolsky et al, Amer Heart Journal 1431017-26

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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 cost-effective

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Primary PCI for AMI with Multi-vessel CAD

• 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 (plt0.001)
• Global EF increased from 50 to 57 predischarge
• Kahn et al, JACC 1990161089-96

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Staged MIDCAB and PCI

• 11 patients selected for procedure with class 3
  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

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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

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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
  short term
• Overall acceptance depends on the functional
  success of the 2 procedures

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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

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History

• Pt is given IV Tridil, morphine, ASA, and Oxygen
  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