Ischemic Heart Disease: From Diagnosis to Treatment

Foreword
Contents
Surgical Anatomy of Coronary Arteries: Morphogenesis, Normal and Pathological Anatomy
1 Development of Coronary Blood Vessels
2 Normal Coronary Anatomy
2.1 Origins from the Sinuses of Valsalva
2.2 Right Coronary Artery
2.3 Left Coronary Artery
2.4 Left Anterior Descending Artery
2.5 Left Circumflex Artery
3 Variants from Normal Coronary Anatomy
4 Coronary Artery Anomalies
4.1 Anomalies of CA Connection
4.2 Anomalies of Intrinsic CA Anatomy
5 Conclusion
References
Pathogenesis of Atherosclerosis: A Multifactorial Process
1 Introduction
2 Epidemiology, Natural History, and Risk Factors
3 Vascular Lesions
4 Response to Injury Theory
5 Role of Endothelium
6 Role of Smooth Muscle Cells
7 Role of the Adventitia
8 Role of Hemodynamics
9 Plaque Growth
10 Atherosclerosis as an Inflammatory Disease
11 Atherosclerosis and Coronary Artery Disease
12 Genetics of Atherosclerosis and Coronary Artery Disease
13 Atherosclerosis and CAD/ICD: From Theory to Clinical Practice
14 Summary
References
Prevention of Coronary Atherosclerosis
1 Introduction
2 Public Health Approaches to Screening and Treating Traditional Modifiable Risk Factors
2.1 Hypertension
2.2 Dyslipidaemia
2.3 Diabetes Mellitus
2.4 Smoking
2.5 Obesity
3 Community Measures to Optimise Cardiovascular Health
4 Risk Scores
5 Atypical Risk Factors
6 A Need for New Solutions
6.1 CT Coronary Calcium Score
6.2 Polygenic Risk Score as an Aid to Improve Risk Identification
6.3 Unmet Need for Blood-Based Biomarker of Atherosclerosis Itself
7 Integration of Technology: Community Education and Novel Approaches to Shared Decision-Making
8 Summary and Conclusion
References
History of Ischemic Heart Disease
1 Introduction
2 Ancient Egypt
3 Arabia
4 Seventeenth–Nineteenth-Century Europe
5 Coronary Arteriography
6 The Treatment of Coronary Artery Disease
6.1 Coronary Care Unit
6.2 Surgery
6.3 Drug Therapy
6.4 Angioplasty
7 Conclusion
References
Pathophysiology of Ischemic Syndromes in Coronary Artery Disease
1 Introduction
2 Pathophysiology of Ischemic Coronary Syndromes
3 Stable Angina
4 Coronary Microvasculature Dysfunction
5 Acute Coronary Syndromes
6 Pathogenesis of Coronary Thrombosis and ST-Elevation Myocardial Infarction
7 Pathophysiology of Unstable Angina and Non-ST-Elevation Myocardial Infarction
7.1 Unstable Angina
7.2 Non-ST-Elevation Myocardial Infarction
8 Sudden Cardiac Death
9 Conclusion
References
Epidemiology of Ischemic Heart Disease
1 Introduction
2 Risk Factors
3 Disease Burden
4 Regional Patterns
5 Epidemiological Trends
5.1 Prevalence
5.2 Mortality
6 Clinical and Public Health Policy Implications
References
Non-atherosclerotic Coronary Artery Disease
1 Definitions
2 Spontaneous Coronary Artery Dissection
3 Epidemiology
4 Pathophysiology
4.1 Predisposing and Precipitating Factors
4.2 Diagnosis
4.3 Management
5 Coronary Vasospasm
5.1 Epidemiology
5.2 Pathophysiology
5.3 Risk and Precipitating Factors
5.4 Diagnosis
5.5 Management
6 Coronary Embolism
6.1 Prevalence
6.2 Classification of Coronary Embolism
6.3 Diagnosis
6.4 Management
7 Myocardial Bridging
7.1 Epidemiology
7.2 Pathophysiology
7.3 Diagnosis
7.4 Management
8 Summary
References
Evaluation of Anginal Syndromes Using Standard Clinical Procedures
1 Preface
2 Acute Coronary Syndromes
2.1 Introduction
2.2 STEMI
2.2.1 Physical Examination
2.2.2 Electrocardiography
2.2.3 Blood Tests
2.2.4 Echocardiography
2.2.5 Other Imaging Techniques
2.3 NSTEMI/Unstable Angina (NSTE-ACS)
2.3.1 Physical Examination
2.3.2 Electrocardiography
2.3.3 Blood Tests
2.3.4 Echocardiography
2.3.5 Other Imaging Techniques
3 Chronic Coronary Syndromes
3.1 Introduction
3.2 Medical History
3.3 Stable vs. Unstable Angina
3.4 Alternative Presentations
3.5 Physical Examination
3.6 Differential Diagnoses
3.6.1 Angina Without Obstructive Coronary Artery Disease
3.6.2 Obstructive Coronary Artery Disease Without Angina
3.7 Electrocardiography
3.8 Blood Tests
3.9 Echocardiography
4 Conclusions
References
Cardiovascular Biomarkers in Acute Myocardial Infarction
1 Introduction
2 Brief Notes on Historical Cardiac Biomarkers
2.1 Aspartate Transaminase (AST)
2.2 Lactate Dehydrogenase (LDH)
2.3 Creatine Kinase (CK) Total Enzyme Activity and Isoforms
2.4 Myoglobin
3 Troponins
3.1 Troponin Test in Laboratory Medicine
3.2 Pre-analytical and Analytical Interferences, and Method Standardization
3.3 Biological Variability
4 Natriuretic Peptides
5 Additive Biomarkers
5.1 C-Reactive Protein
5.2 Hemochrome-Related Biomarkers
6 Emerging Biomarkers
6.1 Other Biomarkers
6.2 Noncoding RNAs
7 Conclusion
References
Electrocardiogram in Ischemic Heart Disease
1 Introduction
2 ECG Findings During Acute Myocardial Ischemia
2.1 Repolarization Abnormalities (ST-T Wave)
2.2 Depolarization Abnormalities (QRS Changes)
2.3 Evolution of ECG Changes
2.4 Other Ischemic Patterns
2.5 Localization of Ischemia or Infarction
2.6 Conduction System Disease in the Setting of Myocardial Infarction
2.6.1 Anteroseptal Myocardial Infarction
2.6.2 Lateral Infarcts
2.6.3 Posterior Infarcts
2.7 ECG Diagnosis of Myocardial Infarction in the Presence of Bundle Branch Blocks
2.8 ECG Differential Diagnosis of Ischemia and Infarction
2.8.1 ST-Segment Elevation
2.8.2 T Wave Inversion
3 Cardiac Arrhythmias in the Setting of Ischemic Heart Disease
3.1 Supraventricular Arrhythmias
3.1.1 Sinus Bradycardia
3.1.2 Sinus Tachycardia
3.1.3 Atrial Tachyarrhythmias
3.2 Ventricular Arrhythmias
3.2.1 Premature Ventricular Complexes (PVCs)
3.2.2 Accelerated Idioventricular Rhythm
3.2.3 Ventricular Tachycardia (VT)
3.2.4 Ventricular Fibrillation (VF)
References
Exercise Testing and Its Role in Ischemic Heart Disease
1 Principles of Exercise Testing
2 Clinical Indications to Exercise Testing
3 Setup and Performance of Exercise Testing
4 Interpretation of Exercise Testing in Patients with Suspected Ischemic Heart Disease
5 Exercise Echocardiography and Nuclear Medicine
6 Cardiopulmonary Exercise Testing in Ischemic Heart Disease
7 Special Populations
8 Conclusions
References
Echocardiography Evaluation of Ischemic Heart Disease
1 Echocardiographic Assessment of Myocardial Ischemia
1.1 Coronary Artery Anatomy
1.2 Pathophysiology of Myocardial Ischemia
1.3 Stress Echocardiography in Ischemic Heart Disease
1.4 Assessment of Regional Wall Motion Abnormalities
1.4.1 Assessment of Coronary Flow Velocity Reserve
1.5 Assessment of Viability
1.6 Contrast Echocardiography in Ischemic Heart Disease
1.6.1 Risk Stratification and Prognosis
1.7 Emerging Echocardiographic Approaches to the Assessment of Ischemia
2 Echocardiographic Assessment of Myocardial Infarction
2.1 Diagnosis of Myocardial Infarction
2.2 Mechanical Complications of MI
2.3 Prognostic Role of Echocardiography After Acute Myocardial Infarction
3 Echocardiographic Assessment of Ischemic Heart Failure
3.1 Assessment of Ventricular Remodeling and Dysfunction
3.2 Secondary Ischemic Mitral Regurgitation
References
Cardiac Catheterization and Coronary Arteriography
1 Introduction and History of Cardiac Catheterization
2 Indications for Cardiac Catheterization
2.1 Indications for Coronary Angiography in Acute Coronary Syndromes
2.2 Indications to Coronary Angiography in Acute Coronary Syndromes
3 Contraindications to Cardiac Catheterization
4 Cardiac Catheterization Laboratory: A Modern Setup
5 Radiation Exposure During Cardiac Catheterization
6 Vascular Accesses
7 Transfemoral Approach
7.1 Femoral Access Hemostasis
7.2 Radial Approach
7.3 Distal Radial Approach
7.4 Radial Access Hemostasis
8 Angiographic Coronary Artery Anatomy and Projections
8.1 Angiograph Views
8.2 Catheters
8.3 Guiding Catheter Shapes
9 Periprocedural Drugs
9.1 Heparin
9.2 Bivalirudin
9.3 Enoxaparin
9.4 Fondaparinux
9.5 Limitations of Cardiac Catheterization for the Detection of Coronary Artery Disease Severity
9.5.1 Fractional Flow Reserve (FFR)
9.5.2 Intravascular Imaging (OCT and IVUS)
9.6 Complications of Cardiac Catheterization
9.6.1 Ostial Coronary Dissections
9.6.2 Vascular Complications
9.6.3 Stroke
9.7 Arrythmias
9.8 Contrast-Induced Nephropathy
9.9 Infections
References
Computed Tomography Cardiac Imaging: Coronary Artery Disease and Ischemia
1 Introduction
2 Coronary Anatomy Segmentation
3 Congenital Coronary Artery Anomalies
4 Coronary Atherosclerosis
5 CCT Prognostic Value
6 CCT Plaque Characterization
7 Myocardial CT Perfusion and FFR-CT
8 Dual-Energy CT and Multi-Energy CT
9 Conclusions
References
Magnetic Resonance Imaging of the Myocardium, Coronary Arteries, and Anomalous Origin of Coronary Arteries
1 Introduction
2 CMR in Acute Coronary Syndrome
2.1 Imaging Myocardial Edema, Necrosis, and Fibrosis
2.2 Complications of Acute Myocardial Infarction
2.3 Differential Diagnosis of MINOCAs
2.4 Postinfarction Myocardial Remodeling
3 CMR in Stable Coronary Syndromes
3.1 Imaging Myocardial Ischemia
3.2 Stress CMR with Vasodilators
3.3 Stress CMR with Dobutamine
3.4 Ischemia with Nonobstructive Coronary Arteries (INOCAs)
4 Imaging the Coronary Arteries with CMR
4.1 Sequences for Coronary Imaging
4.2 Anomalies of Coronary Artery Origin
4.3 Anomalies of Coronary Artery Course
5 Technical Limitations
6 Future Perspectives
7 Conclusions
References
Diagnosis of Acute Myocardial Infarction
1 Definitions of Acute Myocardial Infarction
2 Diagnosis
3 Emergency Care: Strategy Room
3.1 Initial Diagnosis
3.2 Clinical Presentation
3.3 12-Lead Electrocardiogram (ECG)
3.4 ECG Special Situations
4 Nondiagnostic ECG
5 Echocardiography in Emergency for Initial Diagnosis
6 Cardiac Arrest
7 Cardiogenic Shock
8 Cardiac Biomarkers
8.1 Serial Troponin Values
9 Invasive Imaging
10 Noninvasive Imaging
10.1 Computed Tomography Coronary Angiography
11 Structural and Functional Imaging
11.1 Diagnostic Doubts
11.2 Risk Assessment
12 Special New Conditions
12.1 Acute Myocardial Infarction in COVID-19 Pandemic Outbreak
13 STEMI (STE-ACS)
14 NSTEMI (NSTE-ACS)
14.1 Clinical Manifestations and Initial Diagnosis
15 Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA)
16 MINOCA Diagnostic Workup
References
Indications for Myocardial Revascularization
1 Introduction
2 European Guidelines
3 AHA/ACC Guidelines
4 SYNTAX Trial and Its Extension
References
Multidisciplinary Approach to Treatment of Ischaemic Heart Disease: The Role of the Heart Team
1 Introduction
2 Advantages of a Multidisciplinary Approach
3 Patient and Carer Involvement
4 Clinical Composition, Attendance and Frequency
5 Facilities and Technical Considerations
6 Administration and Managerial Support
7 The Type and Range of Cases to Be Discussed
8 Minimum Data Discussed and Method of Presentation
9 Multidisciplinary Team Considerations and Functioning in Non-surgical Cardiology Centres
10 Timing and Integration into Job Planning
11 Documentation, Feedback and Audit of Outcomes
References
Pharmacological Treatment of Ischemic Heart Disease
1 Introduction
2 Pathophysiological Mechanisms of Ischemia and Potential Targets
3 Medical Therapy of Ischemic Heart Disease
3.1 Vasodilators
3.1.1 Nitrates
3.1.2 Nicorandil
3.1.3 Dihydropyridine Calcium Channel Blockers
3.2 Drugs Reducing Myocardial Oxygen Consumption
3.2.1 Non-dihydropyridine Calcium Channel Blockers
3.2.2 Beta-Blockers
3.2.3 Ivabradine
3.3 Myocyte Metabolism Modulators
3.3.1 Trimetazidine
3.3.2 Ranolazine
4 Novel Perspectives from Animal Models and Human Studies
4.1 Novel Compounds with Vasodilatory Effects
4.2 Novel Modulators of Myocardial Metabolism
4.3 Angiogenetic Factors
4.4 Cell Therapy
5 Conclusions
References
Percutaneous Myocardial Revascularization
1 Historical Notes
2 Vascular Access
3 Coronary Devices
3.1 Balloon Catheters
3.2 Coronary Stents
3.3 Intracoronary Imaging
4 Calcific Coronary Lesions
5 PCI of Bifurcations
6 Left Main PCI
7 Chronic Total Occlusions
References
Anomalous Aortic Origin of a Coronary Artery: Clinical and Surgical Perspective
1 Clinical Management
1.1 Clinical Presentation
1.2 Anatomy and Mechanisms of Ischemia
1.3 Diagnosis
1.4 Cardiac MR
1.5 Decision-Making
2 Surgical Management
2.1 Unroofing Technique
2.2 Unroofing Procedure for Intraseptal Left Coronary Artery
2.3 Pulmonary Trunk Translocation
2.4 Coronary Reimplantation
2.5 Anatomical Correction: The Ostioplasty Technique
References
Surgical Myocardial Revascularization with Cardiopulmonary Bypass
1 Introduction
2 History
3 Preoperative Evaluation
4 Surgical Intervention
4.1 Incision
4.2 Establishment of Cardiopulmonary Bypass
4.3 Distal Anastomoses
4.4 Proximal Anastomosis
5 Outcome
5.1 Evidence for Outcomes in CABG: Observational Studies
5.2 Evidence for Outcomes in CABG: Randomized Trials
References
Surgical Myocardial Revascularization Without Cardiopulmonary Bypass
1 Patient Selection
2 Criteria for Optimal Exposure
3 Conditioning of the Patient Before Exposing the Different Sides of the Heart
4 The Exposure of the Anterolateral Wall
5 The Exposure of the Posterolateral Wall
6 The Exposure of the Proximal Right Coronary Artery
7 Conclusion
Graft Materials, Harvesting Methods, and Treatment of Grafts in Surgical Myocardial Revascularization
1 Graft Materials
1.1 Arterial Grafts
1.2 Venous Grafts
1.3 Alternative Conduits for CABG
1.4 Left Internal Mammary Artery (LIMA)/Left Internal Thoracic Artery (LITA)
1.5 Right Internal Mammary Artery
1.6 Bilateral Internal Mammary Artery
2 Radial Artery
3 Right Gastroepiploic Artery
4 Venous Grafts
4.1 Greater Saphenous Vein
4.2 Short Saphenous Vein
4.3 Cephalic Vein
5 Alternative Conduits for CABG
5.1 ePTFE
5.2 Dacron
5.3 Biologic Prosthesis
5.4 Harvesting Methods
5.4.1 Graft Management in Surgical Myocardial Revascularization (Table 1)
References
Total Arterial Revascularization, Techniques, and Results
1 Arteries vs. Veins
2 Should We Pursue TAR?
3 Which Strategy for TAR?
3.1 Surgeon’s Technical Skill and Team Readiness for TAR
3.2 Patient’s Clinical Presentation
3.3 Coronary Artery Anatomy
3.4 Second Arterial Graft Selection: RITA vs. RA
3.5 Arterial Graft Optimization
3.6 Graft Spasm Prevention
4 Conclusion
References
Management of Patients with Concomitant Coronary and Carotid Artery Disease
1 Introduction
1.1 Stroke Following Coronary Artery Bypass Grafting
1.2 Coronary Artery Disease and Carotid Artery Stenosis
1.3 Coronary Artery Bypass Grafting and Carotid Revascularization
2 Summary of the Relevant Recommendations from the Vascular, Cardiologic, and Cardiac Surgery Guidelines
3 What Is New?
3.1 Tzoumas et al. Vascular 2020 [25]
3.2 Giannopoulos et al. Ann Vasc Surg 2020 [26]
3.3 Santarpino et al. Eur J Vasc Endovasc Surg 2018 [27]
3.4 Weimar et al. Stroke 2017 [28]
3.5 Zhang et al. Thorac Cardiovasc Surg 2017 [29]
3.6 Yang et al. ANZ J Surg 2016 [30]
3.7 Shama et al. Ann Thorac Surg 2014 [31]
3.8 Oakes and Eichenbaum. Anesthesiol Clin 2014 [32]
3.9 Gopaldas et al. Ann Thorac Surg 2011 [33]
4 Future Perspectives and Conclusions
References
Minimally Invasive Myocardial Revascularization
1 Introduction
2 Patient Selection
3 Surgical Technique
4 Outcomes
References
Redo CABG: History, Epidemiology, Surgical Treatment, and Outcomes
1 Background, History, and Epidemiology
2 Indications for Redo CABG
3 Operative Techniques
4 Off-Pump vs. On-Pump Redo CABG
5 Risk Factors and Outcomes
References
Surgical Complications After Acute Myocardial Infarction: Ventricular Septal Defect and Free Wall Rupture
1 Postischemic Ventricular Septal Defect
1.1 Historical Note
1.2 Natural History
1.3 Morphology of VSD
1.4 Pathophysiology, Clinical Features, and Diagnosis
1.5 Indications and Timing of Surgery
1.6 Surgical Techniques
1.7 Percutaneous Closure
1.8 Role of Mechanical Circulatory Support
2 Free Wall Rupture
2.1 Introduction
2.2 Clinical Presentation
2.3 Preoperative Time and Surgical Techniques
2.4 Results
References
Surgical Ventricular Remodeling in Ischemic Cardiomyopathy
1 Introduction
2 Left Ventricular Remodeling
3 Rationale for Surgical Reshaping of Failing Ventricles
4 “One Solution Does Not Fit All!”: How to Select the Right Patient
5 The SVR Technique
6 Details of the Technique for Anterior Remodeling
7 Details of the Technique for Posterior Remodeling
8 Outcomes
8.1 CABG Alone Versus CABG Plus SVR
9 Future Directions
9.1 Biomechanical Insights
10 Conclusions
References
Mitral Regurgitation from Ischemic Heart Disease
1 Mitral Valve Functional Anatomy
2 Pathophysiology of Functional Ischemic Mitral Regurgitation
3 Imaging of Ischemic Functional Mitral Regurgitation
3.1 Echocardiography
3.2 Magnetic Resonance Imaging
4 Treatment of Functional Ischemic Mitral Regurgitation
4.1 Resynchronization Therapy
4.2 Bypass Grafting with or Without Mitral Valve Surgery
4.3 Percutaneous Options for fIMR
References
Cardiac Transplantation and Assist Devices for Ischemic Heart Disease
1 Introduction
2 Purpose and Strategy
3 Types of Support
4 Planning and Configuration
Bibliography
Transmyocardial Laser Revascularization
1 Introduction
2 History
3 Indication
4 Procedural Concepts
4.1 Procedural Technique
4.2 Technical Instruments
4.3 Mechanism of Action
5 Outcomes and Trials
5.1 TMR as a Sole Therapy
5.1.1 Operative Mortality
5.1.2 Long-Term Survival
5.1.3 Angina Management
5.2 TMR Combined with CABG
6 Future Perspectives
References
Stem Cells Therapy for Ischemic Heart Disease
1 Introduction
2 Stem Cells Source
3 MSCs Mechanisms of Action
4 MSCs Preliminary Clinical Outcomes: Acute Myocardial Infarction and Post-ischemic Heart Failure
5 Stem Cells Delivery: How and When to Do It
6 Future Perspectives
References