Coronary Occlusion – ABC CARDIOL

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Original Article

HALP Score as a Novel Marker Associated with Coronary Collateral Circulation in Patients with Chronic Total Occlusion

Abstract

Background

Coronary collateral circulation (CCC) is a key determinant of myocardial viability and prognosis in patients with chronic total occlusion (CTO). The hemoglobin, albumin, lymphocyte, and platelet (HALP) score reflects nutritional status, immune competence, and systemic inflammation.

Objectives

To investigate the association between HALP score and CCC in patients with CTO.

Methods

This retrospective, single-center study included 269 patients with chronic coronary syndrome and angiographically confirmed CTO. Patients were classified according to Rentrop grades and dichotomized into poor CCC (Rentrop 0–1; n=119) and good CCC (Rentrop 2–3; n=150). HALP score, inflammatory markers, atherogenic indices, and angiographic scores were compared between groups. Multivariate logistic regression and receiver operating characteristic (ROC) analyses were performed. A p-value <0.05 was considered statistically significant.

Results

HALP score increased significantly across Rentrop grades (p<0.001) and was higher in patients with good CCC than in those with poor CCC (75.52±13.91 vs. 35.10±11.29; p<0.001). In multivariable analysis, HALP score (OR:0.88, 95% CI: 0.83–0.93; p49.08 (91.3% sensitivity, 90.8% specificity). Atherogenic lipid indices were not significantly associated with CCC.

Conclusions

HALP score is an independent and readily available marker associated with CCC in CTO patients and may serve as a practical tool for risk stratification, highlighting the importance of inflammatory, nutritional, and immune pathways in collateral development.

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Editorial

Beyond Lesion Complexity: Do We Need a New Score for Chronic Total Occlusions?

Pedro Beraldo de Andrade et al. Thyago Furquim

The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) score is an index that combines readily available laboratory parameters and reflects an individual’s inflammatory and nutritional status. Traditionally used in oncologic and inflammatory diseases, it has recently emerged as a prognostic marker in various cardiovascular conditions, including acute coronary syndromes, heart failure, and non-valvular atrial fibrillation. Lower HALP values have been associated with a pro-inflammatory state, impaired hematologic homeostasis, and poorer nutritional status.

These factors may adversely affect vascular remodeling processes, leading to pathological angiogenesis. In this context, Akkaya and Öztürk retrospectively analyzed 269 patients with chronic total coronary occlusion identified by coronary angiography and demonstrated that the HALP score exhibited excellent discriminatory performance for the detection of well-developed collateral circulation. As reported in the current issue of the Arquivos Brasileiros de Cardiologia, the HALP score was significantly higher in patients with prominent collateral circulation compared with those with poorly developed collaterals (75.5 ± 13.9 vs. 35.1 ± 11.3; p < 0.001), and was an independent predictor of this angiographic finding (OR: 0.88; 95% CI: 0.83–0.93; p 49.08, yielding a sensitivity of 91.3% and a specificity of 90.8%. In a similar study, Süleymanoğlu et al. retrospectively evaluated 240 patients with chronic total coronary occlusion and confirmed that the HALP score was positively associated with collateral circulation quality, as assessed by the Werner classification, remaining a strong independent predictor in multivariable analysis.

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Review Article

Beyond STEMI-NSTEMI Paradigm: Dante Pazzanese's Proposal for Occlusion Myocardial Infarction Diagnosis

José Nunes De Alencar et al. Fausto Feres Mariana Fuziy Nogueira De Marchi Kleber Gomes Franchini … Matheus Kiszka Scheffer Sandro Pinelli Felicioni Ana Carolina Muniz Costa Rinaldo Carvalho Fernandes Hugo Ribeiro Ramadan Pendell Meyers Stephen W. Smith

Abstract

Although the existing framework for classifying acute myocardial infarction (AMI) into STEMI and NSTEMI has been beneficial, it is now considered to be falling short in addressing the complexity of acute coronary syndromes.

The study aims to scrutinize the current STEMI-NSTEMI paradigm and advocate for a more nuanced framework, termed as occlusion myocardial infarction (OMI) and non-occlusion myocardial infarction (NOMI), for a more accurate diagnosis and management of AMI.

A comprehensive analysis of existing medical literature was conducted, with a focus on the limitations of the STEMI-NSTEMI model. The study also outlines a new diagnostic approach for patients presenting with chest pain in emergency settings.

The traditional STEMI-NSTEMI model falls short in diagnostic precision and effective treatment, especially in identifying acute coronary artery occlusions. The OMI-NOMI framework offers a more anatomically and physiologically accurate model, backed by a wealth of clinical research and expert opinion. It underscores the need for quick ECG assessments and immediate reperfusion therapies for suspected OMI cases, aiming to improve patient outcomes.

The OMI-NOMI framework offers a new avenue for future research and clinical application. It advocates for a more comprehensive understanding of the underlying mechanisms of acute coronary syndromes, leading to individualized treatment plans. This novel approach is expected to ignite further scholarly debate and research, particularly in the Brazilian cardiology sector, with the goal of enhancing diagnostic accuracy and treatment effectiveness in AMI patients.

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Original Article

Overview of Percutaneous Coronary Interventions for Chronic Total Occlusions Treated at Brazilian Centers Participating in the LATAM CTO Registry

Antonio Carlos Botelho da Silva et al. João Eduardo Tinoco de Paula Carlos M. Campos Marcelo Harada Ribeiro … Evandro Martins Filho Marcos Danillo Peixoto Oliveira Leandro Assumpção Côrtes Aníbal Pereira Abelin Cleverson Neves Zukowski Gustavo Cervino Martinelli Fábio Sândoli de Brito Antônio José Muniz Marcelo José de Carvalho Cantarelli Pedro Beraldo de Andrade César Rocha Medeiros Breno de Alencar Araripe Falcão Felipe Costa Fuchs Leonardo Sinnott Silva Tammuz Fattah Ramiro Caldas Degrazia José Armando Mangione Cristiano Guedes Bezerra Sandra Baradel João Brum Silveira Luiz Fernando Ybarra Daniel Weillenmann Carlos Gottschall Viviana Lemke Franciele Rosa da Silva Marcia Moura Schmidt Karlyse Claudino Belli Pedro Piccaro de Oliveira Alexandre Schaan de Quadros

Abstract

Background

Major advances have been seen in techniques and devices for performing percutaneous coronary interventions (PCIs) for chronic total occlusions (CTOs), but there are limited real-world practice data from developing countries.

Objectives

To report clinical and angiographic characteristics, procedural aspects, and clinical outcomes of CTO PCI performed at dedicated centers in Brazil.

Methods

Included patients underwent CTO PCI at centers participating in the LATAM CTO Registry, a Latin American multicenter registry dedicated to prospective collection of these data. Inclusion criteria were procedures performed in Brazil, age 18 years or over, and presence of CTO with PCI attempt. CTO was defined as a 100% lesion in an epicardial coronary artery, known or estimated to have lasted at least 3 months.

Results

Data on 1196 CTO PCIs were included. Procedures were performed primarily for angina control (85%) and/or treatment of moderate/severe ischemia (24%). Technical success rate was 84%, being achieved with antegrade wire approaches in 81% of procedures, antegrade dissection and re-entry in 9%, and retrograde approaches in 10%. In-hospital adverse cardiovascular events occurred in 2.3% of cases, with a mortality rate of 0.75%.

Conclusions

CTOs can be treated effectively in Brazil by using PCI, with low complication rates. The scientific and technological development observed in this area in the past decade is reflected in the clinical practice of dedicated Brazilian centers.

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Original Article

Relationship between Systemic Immune-Inflammation Index and Coronary Collateral Circulation in Patients with Chronic Total Occlusion

Mehmet Koray Adali et al. Ipek Buber Gursel Sen Samet Yilmaz

Abstract

Background

Inflammation plays a key role in the initiation and progression of coronary artery disease (CAD). The systemic immune-inflammation index (SII) is a novel inflammatory parameter that has been shown to be associated with CAD.

Objective

This study aimed to investigate the relationship between SII and coronary collateral circulation (CCC) in patients with stable CAD and chronic total occlusion (CTO).

Methods

The patients were divided into two groups, with poor CCC and good CCC, according to the Rentrop Classification. Ninety-four patients had poor CCC, and 81 patients had good CCC. Inflammation parameters were calculated from the laboratory results. The statistical significance level applied was 0.05.

Results

High SII level (OR: 1.003, 95% CI: 1.001-1.004, p<0,001), absence of CTO in RCA (OR: 0.204, 95% CI: 0.096-0.436, p<0,001) and low Gensini score (OR: 0.980, 95% CI: 0.962-0.998, p=0,028) were significantly associated with poor CCC. The cutoff value of SII was 679.96 for the highest predictive power of poor CCC, with a sensitivity of 74.5% and specificity of 43.2%. Mortality rates were similar between the two groups during a mean follow-up of 21.5±10.8 months (p=0.107).

Conclusions

High SII level, the absence of CTO in the right coronary artery, and low Gensini score were significantly related to poor CCC. The rapid and cost-effective use of new inflammatory markers in clinical practice guides the prognosis of CAD.

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Original Article

Left Atrial Appendage Closure with the LAmbre Device – Initial Multicentre Experience in Brazil

Francisco Chamié et al. Enio Guerios Daniel Peralta e Silva Valério Fuks Rômulo Torres

Abstract

Background

Left atrial appendage (LAA) closure has been an alternative to oral anticoagulation (OAC) for stroke prevention in patients with non-valvular atrial fibrillation (NVAF).

Objectives

To report the first results of an initial multicenter experience in Brazil and to investigate the feasibility, safety, and efficacy of LAA closure with the new LAmbre device.

Methods

We collected procedural and follow-up data of 51 consecutive patients with non-valvular atrial fibrillation, restrictions for long-term OAC and suitable anatomy that underwent LAA closure with the LAmbre device in 18 centers in Brazil. Procedural indications were significant bleeding under OAC (47.1%), stroke or persistent LAA thrombus despite OAC (27.5%), bleeding plus stroke (17.6%), other clinical contraindications for OAC (5.9%), and patient’s choice due to sports practice (1.9%).

Results

Twenty-five men (49%) and 26 women (51%), with a mean age of 76±7.7 years, mean CHA2DS2-VASc score of 4.6± 1.7 and mean HAS-BLED score of 3.4± 1.1 were studied. Procedural success rate was 100%. Procedure-related immediate complications were pericardial effusion in two patients, and immediate device embolization in one case. No large residual shunts (> 5 mm) were observed, and small shunts (<5mm) were detected in four patients by color Doppler at the end of the procedure. After a mean follow-up of 18 ± 12 months, there were no deaths, strokes nor any other major complications.

Conclusion

LAA occlusion with the LAmbre device was safe and effective in this small case series. Despite these encouraging initial results, the small number of cases warrants further studies with longer-term follow-up.

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Case Report

LV Pseudoaneurysm after Acute Myocardial Infarction

Eduardo Cavalcanti Lapa Santos et al. Aluísio Roberto Andrade Macedo Júnior André Gustavo Santos Lima Paloma Peter Travassos … Leonardo Godoy de Mello Motta Fernando Augusto Marinho dos Santos Figueira

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Editorial

Computed Tomography Angiography and Cardiac Catheterization: Allies in the Treatment of Chronic Coronary Obstruction

Leonardo Sara da Silva et al. Juliana Kelendjian

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Editorial

A New Pathway to Coronary Occlusion with Elabela?

Ricardo Wang et al. Estevão Lanna Figueiredo Fernando Carvalho Neuschwander

Total coronary occlusion (TCO) is characterized by an obstruction with an estimated duration of more than 3 months and is present in approximately 15–18% of all coronary angiographies performed. Clinical manifestations can range from asymptomatic, through stable angina, to varying degrees of ventricular dysfunction. This mainly depends on the degree of collateral circulation. If it is poor, it may compromise the viability of myocytes and associate with various degrees of necrosis and/or hibernating myocardium. In the presence of well-developed collaterals (Rentrop grade III), the patient may be asymptomatic and have a preserved contractile function. Therefore, the formation of a well-developed collateral circulation, especially before vessel occlusion, is essential for the preservation of myocytes.

Despite advances in the clinical treatment of stable angina, many patients with TCO undergo interventional procedures. Of these, most are referred for coronary artery bypass grafting surgery or percutaneous coronary intervention (PCI) with more advanced techniques, but also with a higher risk of complications. The study of mechanisms potentially stimulating arteriogenesis and angiogenesis (collateral circulation formation) opens up opportunities for the development of drugs that, in turn, would avoid unnecessary interventions and/or could benefit patients with symptoms refractory to optimized conventional clinical treatment and who are poor candidates for interventions (e.g., thin distal bed, diffuse coronary disease).

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Original Article

Association Between Serum Elabela Levels and Chronic Totally Occlusion in Patients with Stable Angina Pectoris

Fethi Yavuz et al. Mehmet Kaplan

Abstract

Background:

The beneficial effects of Elabela on the cardiovascular system have been shown in studies.

Objective:

To compare serum Elabela levels of chronic total occlusion (CTO) patients with control patients with normal coronary arteries, and to investigate whether there is a correlation with collateral development.

Methods:

The study was planned cross-sectionally and prospectively. Fifty patients (28.0% female, mean age 61.6±7.3years) with CTO in at least one coronary vessel and 50 patients (38% female, mean age 60,7±6.38 years) with normal coronary arteries were included in the study. Patients in the CTO group were divided into two groups as Rentrop 0-1, those with weak collateral development, and Rentrop 2-3 with good collateral development. In addition to the age, sex, demographic characteristics and routine laboratory tests of the patients, Elabela levels were measured.

Results:

Demographic characteristics and laboratory values were similar in both groups. While the mean NT-proBNP and troponin were higher in the CTO group, the Elabela mean was lower (p <0.05 for all). In the multivariate regression analysis, NT-proBNP and Elabela levels were found to be independent predictors for CTO. Also, Elabela level was found to be statistically higher in Rentrop class 2-3 patients compared to Rentrop class 0-1 patients (p<0.05).

Conclusion:

In our study, we showed that the average Elabela level was low in CTO patients compared to normal patients. In addition, we found the level of Elabela to be lower in patients with weak collateral development compared to patients with good collateral development. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

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Case Report

Transient Prominent Anterior QRS Forces in Acute Left Main Coronary Artery Subocclusion: Transient Left Septal Fascicular Block

Andrés Ricardo Pérez-Riera et al. Raimundo Barbosa-Barros Rodrigo Daminello Raimundo Luiz Carlos de Abreu … Marcos Célio de Almeida Kjell Nikus

Introduction

The left main coronary artery (LMCA) originates from the left sinus of Valsalva, passes between the main pulmonary artery and the left atrial appendage before entering the coronary sulcus and bifurcates into the left anterior descending (LAD) and the left circumflex (LCX) coronary arteries. In most individuals, the LMCA supplies ≈75% of the left ventricle (LV). Significant stenosis, which may lead to stable angina and/or acute coronary syndrome, places the patient at risk of life-threatening acute left ventricular failure and malignant arrhythmias. Patient prognosis of LMCA disease can be improved with coronary artery bypass grafting (CABG). With technical improvement and effective anti-thrombotic medication, percutaneous coronary intervention (PCI) has evolved as an alternative therapeutic modality. In patients with severe LMCA disease having low to intermediate anatomic complexity, both CABG and PCI are effective methods of revascularization with comparable long-term rates of death, myocardial infarction, and stroke. Patients most suitable for LMCA stenting are those with isolated ostial/mid LMCA disease, protected LMCA disease and those who undergo an elective stenting procedure. In a recent study, 8% mortality and 8% target lesion revascularization rate during one-year follow-up was reported.

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Review Article

Percutaneous Coronary Intervention in Chronic Total Occlusion

Luiz Fernando Ybarra et al. Marcelo J. C. Cantarelli Viviana M. G. Lemke Alexandre Schaan de Quadros

Abstract

Percutaneous coronary intervention in chronic total occlusion is a rapidly evolving area, being considered the last frontier of interventional cardiology. In recent years, the development of new techniques and equipment, as well as the training of specialized personnel, increased their success rates, making it the most predictable procedure available. Although the number of randomized and controlled studies is still limited, results from large multicentered registries allow us to safely offer this intervention to patients, as another treatment option along with the optimized drug treatment and myocardial revascularization surgery. This review summarizes the last and most relevant publications in the subject in order to provide an overall view of the field’s current status.

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Image

Crescent Moon Image as a Peculiar Complication During Percutaneous Coronary Intervention of an In-Stent Chronic Total Occlusion

Mohsen Mohandes et al. Jordi Guarinos Cristina Moreno Sergio Rojas Alfredo Bardají

Case

55-year-old male with history of ischemic cardiomyopathy with previous percutaneous coronary intervention (PCI) in the anterior descending coronary artery (LAD) middle segment was admitted to our hospital for chest pains. A new coronary angiogram showed in-stent chronic total occlusion (ISCTO) of LAD receiving collaterals from right coronary artery (RCA). Left circumflex (LCX) was totally occluded and RCA presented a significant mid-segment lesion. Complete percutaneous revascularization was planned. First attempt to recanalize the LAD failed because the lesion obstructed the passage of the balloon, so a second dedicated attempt was planned. Bilateral injection using radial and femoral arteries was used, and a Confianza Pro 9 (Asahi Intecc, Japan) guidewire was progressively advanced through the ISCTO () and the wire’s position in true lumen was verified by contralateral injection. Considering the lesion, which impeded the balloon’s passage, a microcatheter Tornus (Asahi Intecc, Japan) was utilized to penetrate and advance through and past the occlusion (). After balloon predilatation, intravascular ultrasound sonography (IVUS) verified the position of the wire in a very short segment into true lumen, but outside the previously implanted stent (). Several drug eluting stents (DES) were implanted and the artery was successfully recanalized, although a very distal embolization was detected (). A new IVUS examination showed partial crush of the previous stent in the shape of a crescent moon ().

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Review Article

Experimental myocardium infarction in rats: analysis of the model

Leonardo A. M. Zornoff et al. Sergio A. R. Paiva Marcos F. Minicucci Joel Spadaro

One of the most often used strategies to study the physiopathological alterations caused by coronary occlusion is the use of the experimental infarction model in rats. Among other factors, this is due to the similarities in the physiopathological alterations that occur after the infarction in humans. One must consider, however, that this model has characteristics that can hinder the use as well as the interpretation of eventual outcomes. Thus, this review aims at analyzing the main characteristics of the experimental infarction model in rats, discussing the coronary occlusion technique, the consequences and the methods of morphological and functional assessment of the infarction and its clinical implications.

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