Abstract 17709: Central Coronary Venous Troponin Concentrations as a Guide to the Identification of the Culprit Vessel in Multivessel Coronary Artery Disease
Background: In patients with non ST elevation acute coronary syndromes (NSTE ACS) culprit vessel identification remains a challenge. Notably, in the FAME trial routine multivessel stenting was not superior to FFR-guided revascularization. We hypothesized that a culprit stenosis in the LAD can be identified because troponin concentrations assessed in the great cardiac vein (GCV) would be higher than elsewhere in the coronary venous tree. In addition, in case of a RCX/RCA culprit we expected the concentration to be higher elsewhere in the coronary venous tree.
Methods: we studied 36 consecutive patients with NSTE ACS who underwent early coronary angiography. In case of normal coronary arteries or a total occlusion a patient was excluded. Right sided catheterization and cannulation of the coronary sinus was performed. The catheter was introduced in the GCV with subsequent blood sampling. This procedure was repeated at the orifice of posterolateral vein and the middle cardiac vein. The culprit was assessed by a blinded committee using ECG, echo and coronary angiography.
Results: As proof of concept 12 patients with single vessel disease were studied. All 5 with a LAD culprit had the highest troponin concentration in the GCV. In 6/7 patients with a non-LAD culprit the highest concentration was measured distally from the GCV in the coronary venous tree. As a pilot validation set, performed in multivessel disease patients with a definite culprit, the distinction LAD/non-LAD was correct in 14/15. In 9 patients in whom the culprit was unclear, the GCV concentration was highest in two.
Conclusion: Despite careful study by a blinded committee, the culprit vessel can not be identified with certainty in ~25% of patients with NSTE ACS using conventional information. Assessment of the troponin concentration in the great cardiac vein can reliably distinguish between LAD and non-LAD culprits. Additional studies will address the diagnostic accuracy with regard to RCX and RCA culprits.
- © 2011 by American Heart Association, Inc.