Intravascular optical coherence tomography (OCT) is a recently developed technology that is becoming more and more increasingly available in the catheter laboratories. OCT is an easy and safe tool that can provide the operator with many valuable information aiding intervention and making the intervention safer and more predictable. OCT can guide all steps of intervention including target lesion assessment before intervention, stent selection, stent optimization, and post-stenting assessment. This review will summarize the role of OCT in guiding percutaneous coronary intervention.
Aortic angioscopy using non-obstructive general angioscopy (NOGA) is a novel, video-based technique that allows visualization of the inner aorta. Dual infusion method improves the visual field and the use of an Ikari-L guiding catheter allows easy access to the aorta, enabling NOGA of not only the coronary artery but also aorta. Imaging techniques such as computed tomography angiography (CTA), magnetic resonance, and transesophageal echocardiography have been used to evaluate the aorta and the findings are usually confirmed based on pathology. NOGA has a spatial and temporal resolution superior to these techniques, detecting various types of spontaneous ruptured aortic plaques (SRAPs) and injuries. SRAPs detected using NOGA are not comparable to those detected using CTA. NOGA can also demonstrate subintimal changes and blood flow through the aortic wall. Although aortic angioscopy is yet at its dawn, several case reports have showed its ability to decode aortic dissection pathogenesis and to evaluate the merits and demerits of stent graft implantation. NOGA is a unique invasive modality to visualize the inner aorta and to sample SRAPs. NOGA is an epoch-making modality that can be used to simultaneously evaluate the arterial and venous systems.
Coronary artery bypass grafting (CABG) is strategy for complex coronary artery disease (CAD) practiced worldwide that has become to be performed in relatively elderly patients in recent years, regarding to the development of off-pump CABG. As the population of elderly patients with cognitive disorders increases, a certain proportion of CABG candidates are likely to have some degree of cognitive impairment, especially dementia. The discussions about the CABG candidates with dementia are still insufficient, although several reports have suggested that 9.6%&ndash20% of CABG candidates may have preoperative dementia. An analysis indicated higher rate of hospital mortality and delirium in dementia patients, but ideal strategies for managing such patients remain controversial. An estimated 20%&ndash35% of CABG patients may have preoperative mild cognitive impairment (MCI), which is associated with an increased risk of morbidity and poor physical recovery after CABG. This preoperative cognitive decline was identified as a predictive factor for post-operative cognitive decline (POCD). Several randomized control trial have compared the cognitive outcomes between elderly high-risk patients after CABG with or without cardiopulmonary bypass, finding no significant cognitive differences between on- and off-pump treatments at 3 to 12 months after CABG. In addition, any late cognitive decline is likely associated with the progression of underlying cerebrovascular disease rather than surgical procedure itself or cardiopulmonary bypass. Preoperative evaluations of the cognitive function may contribute to appropriate postoperative management, reduce the incidence of delirium and improve the overall surgical outcome.
Anomalous aortic origin of a coronary artery is a congenital anomaly that carries a risk of a life-threatening cardiovascular event, such as sudden cardiac death or myocardial infarction. Some therapeutic guidelines have been proposed, but specific indications and treatment procedures remain controversial. In general, all patients with anomalous aortic origin of the left coronary artery are indicated for surgical repair, whereas surgical indications for anomalous aortic origin of the right coronary artery have not been established. Various surgical therapies (e.g., coronary artery bypass graft, unroofing, reimplantation, and pulmonary artery translocation) have been reported. The unroofing procedure is presumably a reasonable and safe approach for revascularization in patients with anomalous aortic origin of a coronary artery with a long intramural course, despite the risk of aortic insufficiency or recurrent sudden cardiac arrest. Among surgical procedures, reimplantation is conceivably the most physiologically appropriate and durable procedure. However, the procedure is technically demanding procedure because of the requirement for extensive dissection and vessel mobilization. Currently, optical surgical intervention is proposed based on coronary anatomy. With increasing numbers of treated patients and improved diagnostic tools, based on both anatomy and function, this anomaly may be definitely resolved in the near future.
A myocardial bridge (MB) is an anatomical variant in which the myocardial muscle partially covers the epicardial coronary arteries, in particular, the left anterior descending coronary artery (LAD). Although this variant has been considered clinically benign, it can lead to significant clinical issues, such as arrhythmia, myocardial ischemia, conduction disturbances, myocardial infarction and sudden death in a subset of patients. Autopsy and CT studies have identified MB in ~ 25% of patients, whereas only 10% of patients have angiographically detectable systolic compression. Intravascular imaging is more sensitive than angiography for detecting minor MB compression. Imaging and autopsy studies have shown a greater plaque burden in the LAD segment proximal to the MB than within the tunneled LAD segment, and this can be associated with a series of severe cardiovascular events. In general, symptomatic patients should be treated conservatively with medical management comprising beta-blockers and non-dihydropyridine calcium-channel blockers to reduce arterial compression by the muscular band and slow the heart rate, thereby increasing the diastolic period. Various strategies including surgery have been attempted to treat refractory symptoms, depending on the status of patients.