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Coronary arteries are the vessels which supply blood (oxygen and nutrients) to the heart; this supply may be disrupted due to buildup of cholesterol and fatty deposits, called plaques, on the inner walls of the arteries (atherosclerosis) causing narrowing of the vessel lumen.

Coronary lesions branch out as they progress to supply various cardiac structures. A bifurcation lesion is a stenosis or abnormal narrowing of greater than 50% that occurs in a coronary artery at the origin of the side branch or adjacent to the origin of the side branch. Branching points a.k.a bifurcation points in the coronary arteries are prone to develop atherosclerosis as the shear stress is higher at the branch points.

The figure shows how a bifurcation stenosis appears schematically as well as on angiography.

bifurcation lesion

Why bifurcation lesions are important?

A vast majority of coronary arteries obstructions happen at the branching point. About 15-20% of patients of referrals for bypass surgery are because of the presence of coronary narrowing at bifurcation location. They are considered a tough lesion to treat by angioplasty and stent.

How are bifurcation lesions diagnosed?

Bifurcation lesions are identified on coronary angiography. Only lesions affecting side branch blood vessels more than 2.25 mm is considered important and called bifurcation lesions. The main vessel that gives branches is called main vessel and the branches that originate from it are called side branches. The point at the division of the main vessel and side branch is called a bifurcation point.

How is a bifurcation lesion unique?

Bifurcation lesions can involve the coronary artery either before or after the bifurcation point. In addition, side branches could be either diseased or free from disease. Based on the location and severity of the cholesterol plaque at the bifurcation point, sub types of bifurcation lesions have been identified.

The challenge of performing angioplasty and stent for a bifurcation stenosis lies in the ability to preserve the main vessel and the side branch. Stents being metallic tubes risk occluding the side branch when placed across the side branch. This apprehension of losing the side branch, is one of the primary reasons for patients to be sent for bypass surgery instead of angioplasty and stent.

Coronary-bifurication

Can angioplasty and stent be performed for a bifurcation lesion?

Angioplasty and stent can be eminently performed for a bifurcation stenosis. Over the last 2 decades numerous techniques in stent implantation have been developed to treat the bifurcation lesions. Some of these techniques include:

Provisional T stent technique
Tap technique
Double kiss crush technique
Culotte technique

Advent of these techniques enabled experienced operators to perform angioplasty and stent successfully with chances of repeat narrowing seen in 3-6% patients at the site of stenting. Risk of losing a side branch after stenting is reduced to 1% once the new techniques are employed.

Dr. C Raghu is an expert in bifurcation lesion angioplasty and the center where he has been trained, ICPS Paris France is considered the “Mecca” for bifurcation lesion angioplasty techniques development.

How does a bifurcation lesion angioplasty differ from a normal angioplasty?

Bifurcation lesion angioplasty, involves utilization of novel stent techniques mentioned above. In addition, angioplasty operator experience is a major factor in determining outcomes. Choosing the “right” stent that allows side branch access, use of specialized technologies such as fractional flow reserve (FFR), expertise in deploying 2 stents especially the process of “stent crush” and the handling of two balloons through a single catheter – kissing balloon are key points for the best results in a stent procedure.

What are the chances of side branch occlusion in a bifurcation lesion angioplasty?

Contemporary bifurcation angioplasty using Intravascular imaging employing contemporary stenting techniques in the hands of expert bifurcation angioplasty operators carries a 99% success rate with a chance of losing side branch in 1% and repeat narrowing at the end of 9 months being 3-6%. These results are comparable and if not superior to bypass surgery as angioplasty entails a short hospital stay and fast recovery.

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Coronary Bifurcation Lesions Blog

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Heart failure is not a single disease instead it is a constellation of symptoms. In this disease the heart is unable to meet the requirements of the body by its inability to pump or be able to do so by increasing the filling pressures so that it might pump effectively.

Aortic stenosis is a disease where the valve between left ventricle and aorta is narrowed. Normally the left ventricle is the chamber which pumps blood to the entire body through the aortic valve.

Congenital heart diseases are diseases that are present from birth and affect the normal heart functioning. These are the most frequently occurring congenital disorder, responsible for 28% of all congenital birth defects. The birth prevalence of CHD is reported to be 8-12/1000 live births. Considering a rate of 9/1000, about 1.35 million babies are born with CHD each year globally.

What are the Causes of Congenital Heart Defects?

In most cases, no obvious cause of congenital heart disease is identified. However, some things are known to increase the risk of the condition, including:

Down’s syndrome – a genetic disorder that affects a baby’s normal physical development and causes learning difficulties
the mother having certain infections, such as rubella, during pregnancy
the mother taking certain types of medicine during pregnancy, including statins and some acne medicines
the mother smoking or drinking alcohol during pregnancy
the mother having poorly controlled type 1 diabetes or type 2 diabetes
other chromosome defects, where genes may be altered from normal and can be inherited (run in the family)

Many cases of congenital heart disease can be diagnosed before a baby is born during an ultrasound scan in pregnancy. At times a focused foetal heart scan called foetal echocardiography in specialized centers helps to diagnose the cardiac problem before birth. However, it’s not always possible to detect congenital heart defects in this way.

congenital heart disease

Signs and Symptoms of Congenital Heart Disease

Congenital heart disease can have a number of symptoms, particularly in babies and children, including:

Rapid heartbeat
Rapid breathing
Swelling of the legs, tummy or around the eyes
Extreme tiredness and fatigue
A blue tinge to the skin or lips (cyanosis)
Tiredness and rapid breathing when a baby is feeding

These problems are sometimes noticeable soon after birth, although mild defects may not cause any problems until later in life.

Types of Congenital Heart Disease

There are many types of congenital heart disease and they sometimes occur in combination. Some of the more common defects include:

Septal defects – where there’s a hole between 2 of the heart’s chambers (commonly referred to as a “hole in the heart”)
Coarctation of the aorta – where the main large artery of the body, called the aorta, is narrower than normal
Pulmonary valve stenosis – where the pulmonary valve, which controls the flow of blood out of the lower right chamber of the heart to the lungs, is narrower than normal
Transposition of the great arteries – where the pulmonary and aortic valves and the arteries they’re connected to have swapped positions
Underdeveloped heart – where part of the heart doesn’t develop properly making it difficult for it to pump enough blood around the body or lungs.

congenital heart disease

Treating Congenital Heart Disease

Treatment for congenital heart disease usually depends on the defect you or your child has.

Mild defects, such as holes in the heart, often don’t need to be treated, as they may improve on their own and may not cause any further problems.

Surgery or interventional procedures are usually required if the defect is significant and causing problems. Modern surgical techniques can often restore most or all of the heart’s normal function.

However, people with congenital heart disease often need treatment throughout their life and therefore require specialist review during childhood and adulthood. This is because people with complex heart problems can develop further problems with their heart rhythm or valves over time.

Most surgery and interventional procedures aren’t considered to be a cure. The affected person’s ability to exercise may be limited and they may need to take extra steps to protect themselves from getting infections.

It’s important that a person with heart disease and their parents or carers discuss these issues with their specialist medical team.

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Women especially at young age are experiencing an unprecedented increase in heart attacks and strokes. We attempt In this article to make the reader aware of the reasons for this.

How are women different from men for developing heart attack?

Women tend to develop cardiac disease 7-10 years later compared to men that is attributed to the protective effect of estrogen hormone, which is present till menopause.

What are the traditional risk factors for developing heart disease?

Both men and women are prone to develop cardiac problems if they have one or multiple risk factors listed below. They are called traditional because they have been in practice for the past 6 decades.

Non-modifiable risk factors

Modifiable risk factors

· Age

· Male gender

· Family history of cardiac disease (< 60 years)

· Smoking

· Diabetes

· Hypertension

· Hyperlipidemia

· Obesity

Despite the absence of many of these risk factors, women worldwide are increasingly dying due to cardiac ailments.

Do traditional risk factors confer a disparate risk for developing cardiac problems in women?

Women are sensitive than men for the development of heart diseases when they have associated traditional risk factors.

For example:

Diabetes: Women with diabetes have a 7-fold increase in cardiac events compared to only 3-fold increase in diabetic men.
Smoking and tobacco use has been shown to enhance the risk by an additional 25% in women compared to men for development of heart attacks. In fact tobacco use has been responsible for 50% of cardiac events in women and confers a 3-fold increased events. Normally women develop heart attacks 7-10 years later than men due to the protective benefits of estrogen hormone. This protective effect is lost with tobacco use and if they develop diabetes.

Unique risk factors for cardiac problems in female gender include:

Pre-eclampsia (High BP during pregnancy associated with complications)
Diabetes during pregnancy
Polycystic Ovary syndrome
Early menopause
Autoimmune diseases

Early menopause and risk of heart attack:

About 10% of women experience menopause naturally before the age of 45 years. This is called early menopause. Because of lack of estrogen in post menopausal women, it predisposes to cardiac events.

Compared to women of similar age, those who attain natural or surgical menopause (removal of uterus – Hysterectomy) less than 45 years are at 50% higher risk of developing heart attack and 20% increased risk of death. Those women who attained surgical menopause tend to have higher cardiac events compared to natural menopause. So women should be dissuaded to undergo uterus removal surgery unless there is a clear evidence that the procedure is definitely required. Hormone replacement therapy has been tried to mitigate this risk but in vain. Current guidelines are against hormone replacement therapy for early menopause.

What can we do to prevent these cardiac events in women?

Targeting traditional risk factors – diabetes, hypertension, lipids, sedentary life styles, inappropriate food choices and obesity form the bedrock strategy for reducing the risk of developing heart attacks.

But for women further measures are needed to address the unique risk factors for women. The American College of Cardiology in its 2019 guidelines notified pre eclampsia, early menopause and autoimmune disease as “risk enhancers” for cardiac disease. They also added that physicians should have a low threshold to treat those patients with risk enhancers by life style measures and cholesterol lowering drugs to reduce the risk of developing heart attacks.

Finally women should realize that they are no longer at low risk for developing cardiac ailments and need to understand there are new risk factors that put them at “enhanced risk” for developing heart attacks.

Carotid artery disease is a condition that arises when the fat deposits accumulate and block the blood vessels that deliver blood to the brain.

Cardiac catheterization is a minimally invasive procedure used to detect and treat cardiovascular diseases. This procedure involves the insertion of a catheter (a thin hollow tube) into the large arteries or veins present in the neck, arm or groin, which is then guided to the heart using a special X-ray.

Critical limb ischemia occurs due to is a severe blockage of the arteries which leads to reduced blood flow to the extremities (hands, feet and legs). It results in severe pain and even skin ulcers or sores.

Mitral stenosis is a form of valvular heart disease caused by the narrowing of the mitral valve. Mitral valve lies between the left atrium and left ventricle of the heart which is made up of two flaps of tissue called leaflets.

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