Outcomes in Anomalous Aortic Origin of a Coronary Artery Following a Prospective Standardized Approach.
- 作者列表："Molossi S","Agrawal H","Mery CM","Krishnamurthy R","Masand P","Sexson Tejtel SK","Noel CV","Qureshi AM","Jadhav SP","McKenzie ED","Fraser CD Jr
BACKGROUND:Anomalous aortic origin of a coronary artery (CA) is the second leading cause of sudden cardiac death in young athletes. Management is controversial and longitudinal follow-up data are sparse. We aim to evaluate outcomes in a prospective study of anomalous aortic origin of CA patients following a standardized algorithm. METHODS:Patients with anomalous aortic origin of a CA were followed prospectively from December 2012 to April 2017. All patients were evaluated following a standardized algorithm, and data were reviewed by a dedicated multidisciplinary team. Assessment of myocardial perfusion was performed using stress imaging. High-risk patients (high-risk anatomy-anomalous left CA from the opposite sinus, presence of intramurality, abnormal ostium-and symptoms or evidence of myocardial ischemia) were offered surgery or exercise restriction (if deemed high risk for surgical intervention). Univariate and multivariable analyses were used to determine predictors of high risk. RESULTS:Of 201 patients evaluated, 163 met inclusion criteria: 116 anomalous right CA (71%), 25 anomalous left CA (15%), 17 single CA (10%), and 5 anomalous circumflex CA (3%). Patients presented as an incidental finding (n=80, 49%), with exertional (n=31, 21%) and nonexertional (n=32, 20%) symptoms and following sudden cardiac arrest/shock (n=5, 3%). Eighty-two patients (50.3%) were considered high risk. Predictors of high risk were older age at diagnosis, black race, intramural course, and exertional syncope. Most patients (82%) are allowed unrestrictive sports activities. Forty-seven patients had surgery (11 anomalous left CA and 36 anomalous right CA), 3 (6.4%) remained restricted from sports activities. All patients are alive at a median follow-up of 1.6 (interquartile range, 0.7-2.8) years. CONCLUSIONS:In this prospective cohort of patients with anomalous aortic origin of a CA, most have remained free of exercise restrictions. Development of a multidisciplinary team has allowed a consistent approach and may have implications in risk stratification and long-term prognosis.
背景: 冠状动脉 (CA) 的异常主动脉起源是年轻运动员心源性猝死的第二大原因。管理是有争议的，纵向随访数据是稀疏的。我们的目标是评估CA患者异常主动脉起源的前瞻性研究的结果，遵循标准化算法。 方法: 从2012年12月至2017年4月，对主动脉起源异常的CA患者进行前瞻性随访。所有患者均按照标准化算法进行评估，并由专门的多学科团队审查数据。使用负荷成像进行心肌灌注的评估。高风险患者 (高风险解剖-来自对侧窦的异常左CA，存在尿流，异常开口-以及心肌缺血的症状或证据) 提供手术或运动限制 (如果认为手术干预的高风险)。单变量和多变量分析用于确定高风险的预测因子。 结果: 在评估的201例患者中，163例符合纳入标准: 116例异常右CA (71%)，25例异常左CA (15%)，17例单发CA (10%)，5例异常回旋CA (3%)。患者表现为偶然发现 (n = 80，49%)，有劳力性 (n = 31，21%) 和非劳力性 (n = 32，20%) 症状，并在心脏骤停/休克后出现 (n = 5，3%)。82例患者 (50.3%) 被认为是高风险。高风险的预测因素是诊断时的年龄较大，黑人种族，壁内病程和劳力性晕厥。大多数患者 (82%) 允许非限制性的体育活动。47例患者进行了手术 (11例左CA异常和36例右CA异常)，3例 (6.4%) 仍然限制体育活动。所有患者均存活，中位随访时间为1.6 (四分位距，0.7-2.8) 年。 结论: 在这一前瞻性队列的主动脉起源异常的CA患者中，大多数仍然没有运动限制。一个多学科团队的发展允许一个一致的方法，并可能对风险分层和长期预后产生影响。
METHODS::We present the case of a 61-year-old woman with a large tumoral infiltration extending from the pelvis throughout the inferior vena cava inferior to the right atrium, protruding into the right ventricle and right ventricular outflow tract. She had been treated 10 years before for low-grade endometrial stromal sarcoma by hysterectomy and adnexectomy followed by hormone- and radio-therapy. Due to cancer recurrence, she underwent peritonectomy, appendectomy, and resection of terminal ileum.
METHODS:AIMS:Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. METHODS AND RESULTS:Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. CONCLUSIONS:In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.
METHODS:BACKGROUND:Aortopulmonary window is an uncommon congenital heart disease, with untreated cases not surviving beyond childhood. However, very rarely it can present in adult patients with features of pulmonary hypertension. Clinically these patients cannot be differentiated from other more common conditions with left to right shunt. Transthoracic echocardiography if performed meticulously, can depict the defect in aortopulmonary septum. RESULTS:We report a case of large unrepaired aortopulmonary window in a 23 years old patient, diagnosed on transthoracic echocardiography.