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Background: Risk stratification using non-invasive imaging of the coronary vessels is emerging as an optimal standard of care for patients with dyslipidemias. Of particular interest is the evaluation of the left main coronary artery (LMCA), where calcium deposition appears to be a predictor of cardiovascular events. Methods: In coronary patients, we evaluated wall thickness and internal diameter of the LMCA examined by transthoracic echocardiography (TTE) and compared these with findings obtained by optical frequency domain imaging (OFDI), this latter also used to evaluate calcium deposition. Results: A significant positive correlation between TTE and OFDI for the anterior wall thickness (r = 0.41, p = 0.043) and internal diameter (r = 0.36, p = 0.048) of the LMCA was detected. Echocardiographic wall measurements were higher in patients with fibro-calcific plaques. The receiver operating characteristic (ROC) curve showed that an anterior wall thickness of LMCA &ge, 1.4 mm was predictive of fibro-calcific plaque (area under the curve = 0.815 and p = 0.006), sensitivity and specificity being 76.9% and 80%, respectively (Youden&rsquo, s Index = 0.56). Conclusions: Measurement of anterior wall thickness of the LMCA by TTE and OFDI appears to be closely correlated and may predict the presence of coronary calcification.

Background: Risk stratification using non-invasive imaging of the coronary vessels is emerging as an optimal standard of care for patients with dyslipidemias. Of particular interest is the evaluation of the left main coronary artery (LMCA), where calcium deposition appears to be a predictor of cardiovascular events. Methods: In coronary patients, we evaluated wall thickness and internal diameter of the LMCA examined by transthoracic echocardiography (TTE) and compared these with findings obtained by optical frequency domain imaging (OFDI), this latter also used to evaluate calcium deposition. Results: A significant positive correlation between TTE and OFDI for the anterior wall thickness (r = 0.41, p = 0.043) and internal diameter (r = 0.36, p = 0.048) of the LMCA was detected. Echocardiographic wall measurements were higher in patients with fibro-calcific plaques. The receiver operating characteristic (ROC) curve showed that an anterior wall thickness of LMCA ≥ 1.4 mm was predictive of fibro-calcific plaque (area under the curve = 0.815 and p = 0.006), sensitivity and specificity being 76.9% and 80%, respectively (Youden’s Index = 0.56). Conclusions: Measurement of anterior wall thickness of the LMCA by TTE and OFDI appears to be closely correlated and may predict the presence of coronary calcification.

Background: Syntax 1 and recently Syntax 2 (SS2) scores are validated risk prediction models in coronary disease. Objectives: To find out the long term outcomes following stenting for unprotected left main bifurcation disease (LMD) and to validate and compare the performance of the SYNTAX scores 1 and 2 (SS1 and SS2 PCI) for predicting major adverse cardiac events (MACE) in Indian population. Methods: Single-center, retrospective, observational study involving patients who underwent percutaneous coronary intervention (PCI) with at least one stent implanted for the LMD. Discrimination and calibration models were assessed by ROC curve and the Hosmer-Lemeshow test. Results: Data of 103 patients were analyzed. The mean SS1 and SS2 scores were 27.9 and 30.7 and MACE was 16.5% at 4 years. The target lesion revascularization (TLR) rate at 4 years was 11(10.7%). There were 4 deaths (3.8%). The mean left ventricular ejection fraction (LVEF) was the only variable in SS2, which predicted cardiac events. ROC curve analysis showed both models to be accurate in predicting TLR and mortality following LM PCI. SS2 score showed a better risk prediction than SSI with AUC for TLR (SSI 0.560 and SS2PCI 0.625) and AUC for mortality (SS1 0.674 and SS2PCI 0.833). Hosmer-Lemeshow test validated the accuracy of both the risk models in predicting the events. Conclusions: Both risk models were applicable for Indian patients. The SS2 score was a better predictor for mortality and TLR. In the SS2 score, the LVEF was the most useful predictor of events after LM PCI. Keywords: Left main coronary, Bifurcation stenting, Syntax score, Outcomes

Background: Acute coronary syndrome (ACS) resulting from culprit lesion in left main coronary artery (LMCA) can cause rapid hemodynamic deterioration. It is important to identify these patients early to facilitate timely revascularization. ST segment elevation in aVR greater than or equal to V 1 (aVR-V 1 ≥ 0) has been suggested as a sensitive predictor of LMCA disease. As a result of balanced forces, we hypothesized that ST deviation in V 6 greater than or equal to ST deviation in V 1 (V 6 -V 1 ≥ 0) might be a good determinant of LMCA disease. Methods: We compared admission 12-lead ECGs of ACS resulting from culprit LMCA lesion (n = 75, group I) with ACS resulting from culprit left anterior descending lesion (n = 81, group II). Group I was selected over a period of 10 years. We compared V 6 -V 1 ≥ 0 to aVR-V 1 ≥ 0 in both groups. We also looked at ratios of ST deviations in V 6 ,V 1 (V 6 /V 1 ≥ 1) and aVR,V 1 (aVR/V 1 ≥ 1) in patients where ST segment in V 1 was not isoelectric (group I = 54 and group II = 55). Results: ST deviation in V 6 was significantly greater in group I as compared to group II (P < 0.001). The reliabilities of V 6 -V 1 ≥ 0, V 6 /V 1 ≥ 1, aVR-V 1 ≥ 0, and aVR/V 1 ≥ 1 in predicting LMCA disease were determined. Conclusion: This is the largest series of ECG analysis on ACS resulting from culprit LMCA lesion. V 6 -V 1 ≥ 0 and V 6 /V 1 ≥ 1 were more sensitive in predicting LMCA as culprit vessel in comparison to previously reported greater ST segment elevation in aVR than V 1 .

Objective Heavily calcified left-main coronary diseases (LMCA) remain a formidable challenge for percutaneous interventions (PCI). This study was to investigate the safety and efficacy of using rotational atherectomy (RA) in treating such lesions in actual practice. Methods From February 2004 to March 2012, all consecutive patients who received RA for heavily-calcified LMCA lesions in our cath lab were enrolled. The relevant clinical and angiographic characteristics at the time of index PCI, as well as the clinical follow-up outcomes, were retrieved and analyzed. Results A total of 34 consecutive patients were recruited with a mean age 77.2 ± 10.2 years. There were 82.4% presented with acute coronary syndrome and 11.8% with cardiogenic shock. Chronic renal disease and diabetes were seen in 64.7% and 52.9%, respectively. Triple-vessel coronary disease was found in 76.5% of them. The mean SYNTAX score was 50 ± 15 and EuroSCORE II scale 5.6 ± 4.8. The angiographic success rate was 100% with a procedural success rate of 91.2%. The mean number of burrs per patient was 1.7 ± 0.5. Crossing-over stenting was used in 64.7%. Most stents were drug-eluting (67.6%). Intra-aortic ballon pump was used in 20.6% of the procedures. Three patients died during hospitalization, all due to presenting cardiogenic shock. No major complication occurred. Among 31 hospital survivors, the major adverse cardiac events (MACE) rate was 16.1%, all due to target lesion revascularization or target vessel revascularization. Conclusions In high-surgical-risk elderly patients, plaque modification with RA in PCI of heavily-calcified LMCA could be safely accomplished with a minimal complication rate and low out-of-hospital MACE.

Ten patients with solitary stenosis of the left main coronary artery underwent coronary artery bypass grafting. All patients suffered from unstable angina and were in NYHA class III or IV. Two of them required intravenous infusion of nitroglycerin preoperatively. The degree of stenosis of the left main coronary artery was 75% in 3 patients, 90% in 5, 95% in one and total obstruction in the other one. Five patients received saphenous vein grafts to the LAD and circumflex artery and the other 5 patients received IMA grafts to the LAD and saphenous vein grafts to the circumflex arteries. In 2 patients with 75% stenosis of the left main coronary artery we found narrow internal mammary artery grafts, the so called "string sign", on postoperative angiography. Although several causes of string sign were proposed previously, we supposed that the main cause of the "string sign" was the competition for flow between the IMA graft and the native coronary artery or grafted coronary artery. Postoperatively, all patients showed improvements in cardiac function and were in NYHA class I. No evidence of ischemic findings was found in postoperative exercise stress tests.

PURPOSE: The aim of this study was to correlate left main (LM) coronary artery dimensions with the presence of atherosclerosis by multidetector-row computed tomography (MDCT) coronary angiography (CA) and to assess coronary atherosclerotic plaques with a semiquantitative method. MATERIALS AND METHODS: Sixty-two consecutive patients (41 men, mean age 60+/-11) with suspected coronary artery disease underwent 64-MDCT coronary angiography. LM dimensions (length, ostial and bifurcation diameters), quantitative [location, Hounsfield unit (HU) attenuation] and qualitative (composition, shape) analysis of plaques within the LM were performed. All patients underwent conventional CA. RESULTS: Thirty patients (mean age 55+/-10) without plaques in the LM presented the following average dimensions: length 10.6+/-6.1 mm, ostial diameter 5.5+/-0.7 mm, bifurcation diameter 4.9+/-0.9 mm. LM plaques (n=36) were detected in 32 patients (mean age 64+/-10) with the following LM average dimensions: length 11.3+/-4.0 mm, ostial diameter 6.0+/-1.2 mm and bifurcation diameter 6.0+/-1.2 mm. Plaques were calcified (40%, mean attenuation 742+/-191 HU), mixed (43%, mean attenuation 387+/-94 HU) or noncalcified (17%, mean attenuation 56+/-14 HU) and were frequently eccentric (77%). Age was significantly different in the two groups (p

A 46-year-old woman with a history of rheumatic heart disease and mitral and aortic valve replacement with mechanical bileaflet prosthesis was admitted with acute anterior wall ST-segment elevation myocardial infarction and cardiogenic shock after discontinuation of anticoagulant therapy. She