Coronary AnomaliesCoronary Anomalies&&

Staged RevascularizationStaged Revascularization

Jason S. Finkelstein, M.D.Jason S. Finkelstein, M.D.Tulane University HSCTulane University HSC

Cardiology DivisionCardiology Division2/5/042/5/04

DefinitionsDefinitions• A coronary artery or arterial branch A coronary artery or arterial branch

is any vessel that carries blood to the is any vessel that carries blood to the cardiac parenchymacardiac parenchyma

• The name and nature of a coronary The name and nature of a coronary artery or branch is defined by that artery or branch is defined by that vessel’s distal vascular territory, not vessel’s distal vascular territory, not by its origin by its origin

DefinitionsDefinitions

• Normal: Coronary anatomy observed Normal: Coronary anatomy observed in >1% of any unselected populationin >1% of any unselected population

• Normal variant: relatively unusual Normal variant: relatively unusual but found in >1% of that populationbut found in >1% of that population

• Anomaly: morphologic feature seen Anomaly: morphologic feature seen in <1% of that population in <1% of that population

Variable FeaturesVariable Features

• OstiumOstium– Location, size, angle of originationLocation, size, angle of origination

• SizeSize

• Proximal courseProximal course

• Mid-courseMid-course

• TerminationTermination

IncidenceIncidence

• Yamanka and Hobbs reviewed the Cleveland Clinic Foundation Yamanka and Hobbs reviewed the Cleveland Clinic Foundation angiographic database from 1960-1988. angiographic database from 1960-1988.

• Total 126,595 coronary angiograms done, and 1686 (1.3%) Total 126,595 coronary angiograms done, and 1686 (1.3%) identified as showing isolated coronary anomaly. identified as showing isolated coronary anomaly.

• 87% had anomaly of origin and distribution. 87% had anomaly of origin and distribution.

• Reports vary that 4-15% of young adults who die of SCD have Reports vary that 4-15% of young adults who die of SCD have some type of coronary anomalysome type of coronary anomaly

– Cath and Cardiovascular Diag. 1990 21:28-40Cath and Cardiovascular Diag. 1990 21:28-40

IncidenceIncidence

• A newer study reviewed 1950 consecutive A newer study reviewed 1950 consecutive angiograms at Texas Heart Instituteangiograms at Texas Heart Institute

• Incidence of coronary variants were 5.6% in Incidence of coronary variants were 5.6% in patients with & w/o CADpatients with & w/o CAD

• 3.8% had congenital AV disease3.8% had congenital AV disease– 27% of these patients had coronary anomalies27% of these patients had coronary anomalies

• Coronary anomalies do not predispose patients to Coronary anomalies do not predispose patients to CADCAD

• Angelini; Coronary artery anomalies; 1999Angelini; Coronary artery anomalies; 1999

Left circumflexLeft circumflex

• Runs along the left AV groove, Runs along the left AV groove, descends beneath the left atrial descends beneath the left atrial appendage, and courses downward appendage, and courses downward toward the crux of the heart for a toward the crux of the heart for a variable distancevariable distance

• If the circumflex artery reaches the If the circumflex artery reaches the crux of the heart and produces a PDA , crux of the heart and produces a PDA , it is generally called “dominant”it is generally called “dominant”

Left Circumflex AnomaliesLeft Circumflex Anomalies

• Absent CircumflexAbsent Circumflex

• Circumflex arising from the Right Circumflex arising from the Right Coronary CuspCoronary Cusp

• Co-dominant patterns (RCA & Circumflex)Co-dominant patterns (RCA & Circumflex)– Circumflex is dominant in 9% of the Circumflex is dominant in 9% of the

populationpopulation

Absent CircumflexAbsent Circumflex

• Large superdominant RCA crosses the crux Large superdominant RCA crosses the crux of the heart and ascends in AV groove and of the heart and ascends in AV groove and perfuses the posterolateral and lateral walls.perfuses the posterolateral and lateral walls.

• Suspect when contrast in LCA reveals Suspect when contrast in LCA reveals unusually long proximal segment and non unusually long proximal segment and non perfusing lateral wall perfusing lateral wall

• In absence of occlusive disease not In absence of occlusive disease not hemodynamically significant. hemodynamically significant.

LCx arising from RCA or right LCx arising from RCA or right sinussinus• A very common anomaly (0.67% of population)A very common anomaly (0.67% of population)

• Courses posterior to the aorta and enters the left AV Courses posterior to the aorta and enters the left AV groove and supplies lateral wallgroove and supplies lateral wall

• Suspect when contrast in LCA reveals unusually long Suspect when contrast in LCA reveals unusually long proximal segment and non perfusing lateral wall proximal segment and non perfusing lateral wall

Angelini. P, Coronary artery anomalies; 1999Angelini. P, Coronary artery anomalies; 1999

LCx arising from right aortic LCx arising from right aortic sinussinus

• Clinical significance:Clinical significance:

– Prolong catheterization Prolong catheterization

– CT surgeons should be informed to avoid CT surgeons should be informed to avoid accidental compression during valve accidental compression during valve replacementreplacement

– Regarded as a benign anomalyRegarded as a benign anomaly

Staged RevascularizationStaged Revascularization

Multiple Complex Plaques in Multiple Complex Plaques in AMIAMI• Retrospective study analyzing 253 Retrospective study analyzing 253

angiogramsangiograms

• Single complex plaques were identified in Single complex plaques were identified in 153 pts (60.5%)153 pts (60.5%)

• Multiple complex plaques were identified Multiple complex plaques were identified in 100 patients (39.5%)in 100 patients (39.5%)

• Clinical outcomes were recorded over 1 Clinical outcomes were recorded over 1 year such as in-hospital outcomes, year such as in-hospital outcomes, recurrent AMI, UA, repeat revasc, deathrecurrent AMI, UA, repeat revasc, death

Results:Results:

• Multiple complex plaques were less likely Multiple complex plaques were less likely to undergo angioplasty (86% vs. 95%)to undergo angioplasty (86% vs. 95%)

• Required more urgent bypass (27 v. 5%)Required more urgent bypass (27 v. 5%)• Increased incidence of ACS (19% v. 2.6%)Increased incidence of ACS (19% v. 2.6%)• Repeat angioplasty (32 % v. 12.4%)Repeat angioplasty (32 % v. 12.4%)• CABG (35% vs. 11%)CABG (35% vs. 11%)• Higher mortality after 1 year (17% v. 12%)Higher mortality after 1 year (17% v. 12%)

– Not statistically significantNot statistically significant

– Goldstein, et al; NEJM: 343 (13) 915-923Goldstein, et al; NEJM: 343 (13) 915-923

Proposed conclusionsProposed conclusions

• Multiple complex lesions identifies Multiple complex lesions identifies patients at increased risk for CV eventspatients at increased risk for CV events

• Aggressive medical management with Aggressive medical management with statins & anti-inflammatory agentsstatins & anti-inflammatory agents

• Multi-vessel staged PCI or surgical Multi-vessel staged PCI or surgical interventionintervention

Single or Staged Multivessel Single or Staged Multivessel PCIPCI• 264 consecutive patients264 consecutive patients• PCI conducted in 129 pts in a single PCI conducted in 129 pts in a single

sessionsession• 135 pts had staged PCI135 pts had staged PCI• Mean interval between staged Mean interval between staged

sessions was 45.6 +/- 22.3 dayssessions was 45.6 +/- 22.3 days• Lesion suggested by stress testing Lesion suggested by stress testing

was treated firstwas treated first

Single or Staged Multivessel Single or Staged Multivessel PCIPCI

• End Points:End Points:– Cardiac deathCardiac death– Q-wave MIQ-wave MI– CABGCABG– Repeated PCIRepeated PCI– Hemodynamic instability requiring IABPHemodynamic instability requiring IABP– Vascular complicationsVascular complications

Single or Staged Multivessel Single or Staged Multivessel PCIPCI• Results:Results:

– MACE (30 day follow up) 2.9% v. 7.0%MACE (30 day follow up) 2.9% v. 7.0%– 1 yr follow up 26.1 v. 36%1 yr follow up 26.1 v. 36%– Lower rate of reinterventions 23.1% v. 33.6%Lower rate of reinterventions 23.1% v. 33.6%– Lower rate of MI’s 0.7% v. 3.9%Lower rate of MI’s 0.7% v. 3.9%– Restenosis 15.5% v. 17%Restenosis 15.5% v. 17%

Nikolsky et al, Amer Heart Journal; 143:1017-26Nikolsky et al, Amer Heart Journal; 143:1017-26

LimitationsLimitations

• Non-randomized trialNon-randomized trial• None of the results were statistically None of the results were statistically

significantsignificant

• A staged approach is safe and allows A staged approach is safe and allows and has high success ratesand has high success rates

• Single staged procedure was more Single staged procedure was more cost-effectivecost-effective

Primary PCI for AMI with Multi-Primary PCI for AMI with Multi-vessel CADvessel CAD• 285 patients with an evolving MI285 patients with an evolving MI• 163 pts had 2 vessel disease163 pts had 2 vessel disease• 122 pts had 3 vessel disease122 pts had 3 vessel disease• Angioplasty performed on IRA and other Angioplasty performed on IRA and other

vesselsvessels• 1 yr and 3 yr survivals were 92% and 87% 1 yr and 3 yr survivals were 92% and 87%

respectively (p<0.001)respectively (p<0.001)• Global EF increased from 50 to 57% Global EF increased from 50 to 57%

predischargepredischarge

– Kahn et al, JACC 1990;16:1089-96Kahn et al, JACC 1990;16:1089-96

Staged MIDCAB and PCIStaged MIDCAB and PCI

• 11 patients selected for procedure with 11 patients selected for procedure with class 3 and class 4 anginaclass 3 and class 4 angina

• All pts received LIMA to LADAll pts received LIMA to LAD• 9 pts went for PTCA 4 days after MIDCAB9 pts went for PTCA 4 days after MIDCAB• 10/11 patients require no anti-anginal 10/11 patients require no anti-anginal

meds and are symptom free at 1 yrmeds and are symptom free at 1 yr• Advantage of “hybrid” approach is less Advantage of “hybrid” approach is less

invasive and enhanced recoveryinvasive and enhanced recovery

– Izzat et al. IJC 1997 S105-109Izzat et al. IJC 1997 S105-109

Hybrid Revasc. In Pts with AMI Hybrid Revasc. In Pts with AMI & MVD& MVD• 11 patients with ACS and multivessel disease11 patients with ACS and multivessel disease

• Occlusion of target artery was treated by PCI and then Occlusion of target artery was treated by PCI and then followed by MIDCABfollowed by MIDCAB

• Coronary angiography was conducted at 2 weeks, 6 Coronary angiography was conducted at 2 weeks, 6 months 1 & 3 yrs to evaluate anastamosis and months 1 & 3 yrs to evaluate anastamosis and restenosisrestenosis

Matsumoto y, et al; Jpn J CV Surg 2001; Dec 700-5Matsumoto y, et al; Jpn J CV Surg 2001; Dec 700-5

ResultsResults

• Coronary anigography at post-op, 6 months, 1 Coronary anigography at post-op, 6 months, 1 & 3 yrs showed patent grafts with no stenosis& 3 yrs showed patent grafts with no stenosis

• PCI was reconducted on restenotic lesions for PCI was reconducted on restenotic lesions for 3 patients3 patients

• Hybrid revasc. is safe and effective over the Hybrid revasc. is safe and effective over the short termshort term

• Overall acceptance depends on the functional Overall acceptance depends on the functional success of the 2 proceduressuccess of the 2 procedures

HistoryHistory

• Mrs. Z is a 70 yr old AA female with past Mrs. Z is a 70 yr old AA female with past medical history of htn, elevated medical history of htn, elevated cholesterol, tobacco use (quit 15 yrs ago) cholesterol, tobacco use (quit 15 yrs ago) who arrived at Charity ER in the AM who arrived at Charity ER in the AM complaining of substernal chest pain complaining of substernal chest pain associated with nausea & vomiting.associated with nausea & vomiting.

• Pt denied any SOB, diaphoresis, but her Pt denied any SOB, diaphoresis, but her pain is classified as 9/10pain is classified as 9/10

HistoryHistory

• Pt is given IV Tridil, morphine, ASA, and Pt is given IV Tridil, morphine, ASA, and Oxygen in the EROxygen in the ER

• EKG reveals STEMI in V1-V3 and T wave EKG reveals STEMI in V1-V3 and T wave inversions in leads I and aVL. Trop level inversions in leads I and aVL. Trop level was 1.9was 1.9

• Patient was then given IV lopressor, Patient was then given IV lopressor, Lovenox and Integrelin and taken to the Lovenox and Integrelin and taken to the cath labcath lab