Background-Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic acute coronary syndrome for which optimal management remains undefined. Methods and Results-We performed a retrospective study of 189 patients presenting with a first SCAD episode. We evaluated outcomes according to initial management: (1) revascularization versus conservative therapy and (2) percutaneous coronary intervention (PCI) versus conservative therapy stratified by vessel flow at presentation. Demographics were similar in revascularization versus conservative (mean age, 44±9 years; women 92% both groups), but vessel occlusion was more frequent in revascularization (44/95 versus 18/94). There was 1 in-hospital death (revascularization) and 1 late death (conservative). Procedural failure rate was 53% in those managed with PCI. In the subgroup of patients presenting with preserved vessel flow, rates of PCI failure were similarly high (50%), and 6 (13%) required emergency coronary artery bypass grafting. In the conservative group, 85 of 94 (90%) had an uneventful in-hospital course, but 9 (10%) experienced early SCAD progression requiring revascularization.

Background-Spontaneous coronary artery dissection (SCAD) is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. The angiographic characteristics of SCAD are largely undetermined. The goal of this study was to determine the prevalence of coronary tortuosity in SCAD and whether it may be implicated in the disease. Methods and Results-Patients with confirmed SCAD (n=246; 45.3±8.9 years; 96% women) and 313 control patients without SCAD or coronary artery disease who underwent coronary angiography were included in this case-control study. Angiograms were reviewed for coronary tortuosity and assigned a tortuosity score. Tortuosity was common in patients presenting with their first SCAD event (78% versus 17% in controls; P<0.0001; tortuosity score, 4.41±1.73 versus 2.33±1.49 in controls; P<0.0001) despite a low prevalence of hypertension (34%). Recurrent SCAD (n=40) occurred within segments of tortuosity in 80% of cases. Severe tortuosity (≥2 consecutive curvatures ≥180°) was associated with a higher risk of recurrent SCAD (hazard ratio, 3.29; 95% confidence interval, 0.99-8.29; P=0.05). Tortuosity score >5 was associated with a trend toward higher risk of recurrent SCAD (P=0.16). Prespecified angiographic markers of tortuosity including corkscrew appearance and multivessel symmetrical tortuosity were associated with extracoronary vasculopathy including fibromuscular dysplasia (P<0.05 for both). Conclusions-Coronary artery tortuosity is highly prevalent in the SCAD population and is associated with recurrent SCAD. Recurrent SCAD most often occurs within segments of tortuosity. Angiographic features of SCAD are associated with extracoronary vasculopathy, including fibromuscular dysplasia. These findings suggest that coronary tortuosity may serve as a marker or potential mechanism for SCAD. (Circ Cardiovasc Interv. 2014;7:656-662.)

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Background Among patients with severe aortic stenosis (AS) and preserved ejection fraction (EF), those with low-gradient and reduced stroke volume may have an adverse prognosis. We investigated the prognostic impact of stroke volume using the recently proposed flow-gradient classification. Methods and Results We examined 1,704 consecutive patients with severe AS (aortic valve area <1.0 cm2) and preserved EF (≥50%) using 2-D and Doppler echocardiography. Patients were stratified by stroke volume index (<35 ml/m2 (LF) vs. ≥35 ml/m2 (NF)) and aortic gradient (<40 mmHg (LG) vs. ≥40 mmHg or (HG)) into 4 groups (NF/HG, NF/LG, LF/HG, LF/LG). NF/LG (n=352, 21%), was associated with favorable survival with medical management (2 year estimate 82% vs. 67% in NF/HG, p<0.0001). LF/LG severe AS (n=53, 3%), was characterized by lower EF, more prevalent atrial fibrillation and heart failure, reduced arterial compliance, and reduced survival (2 year estimate 60% vs. 82% in NF/HG, p<0.001). By multivariable analysis, LF/LG pattern was the strongest predictor of mortality (HR 3.26 (1.71, 6.22) p<0.001 vs. NF/LG). Aortic valve replacement (AVR) was associated with a 69% mortality reduction (HR 0.31 (0.25, 0.39) p<0.0001) in LF/LG and NF/HG, with no survival benefit associated with AVR in NF/LG and LF/HG. Conclusions NF/LG severe AS with preserved EF exhibits favorable survival with medical management and impact of AVR on survival was neutral. LF/LG severe AS is characterized by a high prevalence of atrial fibrillation, heart failure and reduced survival, and AVR was associated with improved survival. These findings have implications for evaluation of AS severity and subsequent management.

TMVR with balloon-expandable aortic valves in extreme surgical risk patients with severe MAC is feasible but associated with high 30-day and 1-year mortality. Most patients who survive the 30-day post-procedural period are alive at 1 year and have sustained improvement of symptoms and transcatheter valve performance. The role of TMVR in patients with MAC requires further evaluation in clinical trials.