Document Detail


Discrepancy between myocardial ischemia and luminal stenosis in patients with left internal mammary artery grafting to left anterior descending coronary artery.
MedLine Citation:
PMID:  14668779     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: Left internal mammary artery (LIMA) grafting to the left anterior descending artery (LAD) is known to have long-term patency. However, myocardial ischemia in the territories supplied by LIMA to LAD is still demonstrated. The aim of this study is to examine the relationships between the extent, location, and clinical outcome of myocardial ischemia in LAD territories (ILAD) by use of myocardial perfusion imaging (MPI) and angiographic characteristics of such a bypass conduit. METHODS AND RESULTS: We studied 38 consecutive patients with prior coronary artery bypass grafting who showed stress-induced ischemia in LIMA to LAD territories by MPI single photon emission computed tomography between the years 1996-2000. All patients underwent quantitative coronary angiography within 6 months of the nuclear study. Single photon emission computed tomography parameters of ILAD were assessed by location (septum, apex, anterior, and anterolateral) and included extension score (1-4 per patient), severity score (0-3 per territory), and total sum score. LIMA to LAD quantitative coronary angiography parameters included minimal lumen diameter, lesion length, reference diameter, and diameter stenosis (percentage). LAD and LIMA diameters and ratio (in normal segments) were determined within 10 mm proximal and distal to the anastomotic site. The study group was compared with 18 control subjects without ischemia or stenosis treated with LIMA to LAD. The patients were followed up for cardiac death at an interval of 3.2 +/- 1.5 years from the time of MPI testing. The patients' mean age was 66 +/- 12 years (31 men and 7 women); the mean period after surgery was 6.2 +/- 1.5 years. The ILAD distribution was as follows: septum, 12 (32%); apex, 20 (52%); anterior, 24 (63%); and anterolateral, 18 (47%). The mean extension score was 1.9 +/- 1.0, and the mean total sum score was 3.4 +/- 2.3. Of 38 patients with ILAD, only 17 (45%) had greater than 50% luminal stenosis (2 LIMA and 15 anastomosis or distal). Among clinical variables during stress testing, the prevalence of angina was significantly higher in the luminal stenotic patients versus patients without stenosis (P =.04). A significant correlation was found between anterior wall ischemia and reference diameter (r = -0.7, P =.002) and between total sum score and minimal lumen diameter (r = -0.48, P =.05). Of note, the LAD-to-LIMA ratio was significantly lower in patients with ILAD and without luminal stenosis compared with the control group (0.73 +/- 0.16 vs 0.87 +/- 0.15, P =.004). Cardiac death occurred in 8 patients (21%), 5 patients with luminal stenosis versus 3 patients without stenosis (P = not significant). CONCLUSIONS: In patients with LIMA to LAD anastomosis, myocardial ischemia could occur even without angiographic luminal stenosis and apparently reflects a mismatch between LAD and LIMA diameters at distal anastomotic sites. Regarding the similar prevalence of cardiacdeath, invasive evaluation and aggressive treatment are recommended in all patients with ischemia in LIMA/LAD territories.
Authors:
Nili Zafrir; Jyotfna Madduri; Israel Mats; Tuvia Ben-Gal; Alejandro Solodky; Abid Assali; Alexander Battler; Ran Kornowski
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Publication Detail:
Type:  Clinical Trial; Controlled Clinical Trial; Journal Article    
Journal Detail:
Title:  Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology     Volume:  10     ISSN:  1071-3581     ISO Abbreviation:  J Nucl Cardiol     Publication Date:    2003 Nov-Dec
Date Detail:
Created Date:  2003-12-11     Completed Date:  2004-05-04     Revised Date:  2004-11-17    
Medline Journal Info:
Nlm Unique ID:  9423534     Medline TA:  J Nucl Cardiol     Country:  United States    
Other Details:
Languages:  eng     Pagination:  663-8     Citation Subset:  IM    
Affiliation:
Nuclear Cardiology Unit, Rabin Medical Center, Petach Tiqva, Israel. zafrirmd@isdn.net.il
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MeSH Terms
Descriptor/Qualifier:
Aged
Arteries / radionuclide imaging,  surgery
Coronary Angiography
Coronary Artery Bypass / adverse effects*
Coronary Stenosis / diagnosis,  etiology*,  radionuclide imaging*
Coronary Vessels / radionuclide imaging,  surgery*
Exercise Test
Female
Humans
Male
Mammary Arteries / radiography,  radionuclide imaging,  transplantation*
Myocardial Ischemia / diagnosis,  etiology*,  radionuclide imaging*

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