Coronary Anomalies & Staged Revascularization

1. Coronary Anomalies&Staged Revascularization Jason S. Finkelstein, M.D. Tulane University HSC Cardiology Division 2/5/04

2. 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

3. 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

4. Variable Features • Ostium • Location, size, angle of origination • Size • Proximal course • Mid-course • Termination

5. 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

6. 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

7. 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”

8. 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

9. 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.

10. 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

11. 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

12. Staged Revascularization

13. 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

14. 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

15. 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

16. 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

17. Single or Staged Multivessel PCI • End Points: • Cardiac death • Q-wave MI • CABG • Repeated PCI • Hemodynamic instability requiring IABP • Vascular complications

18. 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 MI’s 0.7% v. 3.9% • Restenosis 15.5% v. 17% Nikolsky et al, Amer Heart Journal; 143:1017-26

19. 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

20. 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 (p<0.001) • Global EF increased from 50 to 57% predischarge • Kahn et al, JACC 1990;16:1089-96

21. 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

22. 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

23. 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

24. 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

25. 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