Predominant location of coronary artery atherosclerosis in the left anterior descending artery. The impact of septal perforators and the myocardial bridging effect

Introduction Coronary artery atherosclerosis presents characteristic patterns of plaque distribution despite systemic exposure to risk factors. We hypothesized that local hemodynamic forces induced by the systolic compression of intramuscular septal perforators could be involved in atherosclerotic processes in the left anterior descending artery (LAD) adjacent to the septal perforators’ origin. Therefore we studied the spatial distribution of atherosclerosis in coronary arteries, especially in relation to the septal perforators’ origin. Material and methods 64-slice computed tomography angiography was performed in 309 consecutive patients (92 male and 217 female) with a mean age of 59.9 years. Spatial plaque distribution in the LAD was analyzed in relation to the septal perforators’ origin. Additionally, plaque distribution throughout the coronary artery tree is discussed. Results The coronary calcium score (CCS) was positive in 164 patients (53.1%). In subjects with a CCS > 0, calcifications were more frequent in the LAD (n = 150, 91.5%) compared with the right coronary artery (RCA) (n = 94, 57.3%), circumflex branch (CX) (n = 76, 46.3%) or the left main stem (n = 42, 25.6%) (p < 0.001). Total CCS was higher in the LAD at 46.1 (IQR: 104.2) and RCA at 34.1 (IQR: 90.7) than in the CX at 16.8 (IQR: 61.3) (p = 0.007). In patients with calcifications restricted to a single vessel (n = 54), the most frequently affected artery was the LAD (n = 42, 77.8%). In patients with lesions limited to the LAD, the plaque was located mostly (n = 37, 88.1%) adjacent to the septal perforators’ origin. Conclusions We demonstrated that coronary calcifications are most frequently located in the LAD in proximity to the septal branch origin. A possible explanation for this phenomenon could be the dynamic compression of the tunneled septal branches, which may result in disturbed blood flow in the adjacent LAD segment (milking effect).

[1]  J. Rees,et al.  Myocardial bridging of the coronary arteries. , 1989, Clinical radiology.

[2]  K. Watson,et al.  Mechanism of calcification in atherosclerosis. , 1994, Trends in cardiovascular medicine.

[3]  G. Farrer-brown,et al.  Vascular supply of interventricular septum of human heart. , 1969, British heart journal.

[4]  Lorenzo Bonomo,et al.  Coronary artery plaque formation at coronary CT angiography: morphological analysis and relationship to hemodynamics , 2009, European Radiology.

[5]  K. Ibukuro,et al.  Anatomy of right superior septal artery demonstrated on the coronary CT scan , 2012, Acta radiologica.

[6]  A. Nowakowski,et al.  The Role of Septal Perforators and “Myocardial Bridging Effect” in Atherosclerotic Plaque Distribution in the Coronary Artery Disease , 2015, Polish journal of radiology.

[7]  Brian P. Helmke,et al.  Hemodynamics and the Focal Origin of Atherosclerosis , 2001, Annals of the New York Academy of Sciences.

[8]  M. Yoshiyama,et al.  Absence of left ventricular concentric hypertrophy: a prerequisite for zero coronary calcium score , 2011, Heart and Vessels.

[9]  P. Bream,et al.  The anomalous septal perforating artery. Its origin from the first diagonal, first marginal, or circumflex artery. , 1981, Radiology.

[10]  J. Strong,et al.  Coronary Calcification: Relationship to Clinically Significant Coronary Lesions and Race, Sex, and Topographic Distribution , 1965, Circulation.

[11]  T. Akasaka,et al.  Systolic coronary flow reversal and abnormal diastolic flow patterns in patients with aortic stenosis: assessment with an intracoronary Doppler catheter. , 1993, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[12]  B. Helmke,et al.  Hemodynamics and the focal origin of atherosclerosis: a spatial approach to endothelial structure, gene expression, and function. , 2001, Annals of the New York Academy of Sciences.

[13]  K. Cunningham,et al.  The role of shear stress in the pathogenesis of atherosclerosis , 2005, Laboratory Investigation.

[14]  Philippe C. Cattin,et al.  Prediction Rules for the Detection of Coronary Artery Plaques: Evidence From Cardiac CT , 2009, Investigative radiology.

[15]  P. Bream,et al.  Right superior septal perforator artery: its angiographic description and clinical significance. , 1979, AJR. American journal of roentgenology.

[16]  B. Koo,et al.  Subclinical Coronary Artery Disease as Detected by Coronary Computed Tomography Angiography in an Asymptomatic Population , 2010, Korean circulation journal.

[17]  Y. Akasaka,et al.  Histopathologic profiles of coronary atherosclerosis by myocardial bridge underlying myocardial infarction. , 2013, Atherosclerosis.

[18]  Yiannis S. Chatzizisis,et al.  Myocardial bridges are free from atherosclerosis: Overview of the underlying mechanisms , 2009 .

[19]  R. Frye,et al.  A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. , 1975, Circulation.

[20]  H. Furukawa,et al.  Distribution of coronary atherosclerosis in patients with coronary artery disease , 2010, Heart and Vessels.

[21]  T. Akasaka,et al.  Intramyocardial coronary flow characteristics in patients with hypertrophic cardiomyopathy: non-invasive assessment by transthoracic Doppler echocardiography , 2003, Heart.

[22]  G. Gagnon,et al.  A COMPARATIVE STUDY IN THREE DIMENSION OF THE BLOOD SUPPLY OF THE NORMAL INTERVENTRICULAR SEPTUM IN HUMAN, CANINE, BOVINE, PROCINE, OVINE AND EQUINE HEART. , 1964, Diseases of the chest.

[23]  M. von Lüdinghausen,et al.  Right superior septal artery with “normal” right coronary and ectopic “early” aortic origin: A contribution to the vascular supply of the interventricular septum of the human heart , 2001, Clinical anatomy.

[24]  S. Khosla,et al.  Rotational atherectomy for left anterior descending artery septal perforator stenosis , 1999, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[25]  J. Edwards,et al.  Relationship of Various Factors to the Degree of Coronary Atherosclerosis in Women , 1950, Circulation.

[26]  Y. Chatzizisis,et al.  Difference in the topography of atherosclerosis in the left versus right coronary artery in patients referred for coronary angiography , 2010, BMC cardiovascular disorders.

[27]  J. Hamilton,et al.  Regions of Low Endothelial Shear Stress Colocalize With Positive Vascular Remodeling and Atherosclerotic Plaque Disruption: An In Vivo Magnetic Resonance Imaging Study , 2013, Circulation. Cardiovascular imaging.

[28]  Cornelius Weiller,et al.  In Vivo Wall Shear Stress Distribution in the Carotid Artery: Effect of Bifurcation Geometry, Internal Carotid Artery Stenosis, and Recanalization Therapy , 2010, Circulation. Cardiovascular imaging.

[29]  R. Virmani,et al.  34th Bethesda Conference: Task force #2--What is the pathologic basis for new atherosclerosis imaging techniques? , 2003, Journal of the American College of Cardiology.

[30]  E. Tuzcu,et al.  Atherosclerotic plaque distribution in the left anterior descending coronary artery as assessed by intravascular ultrasound. , 2003, The American journal of cardiology.

[31]  D. Grönemeyer,et al.  Natural History and Topographic Pattern of Progression of Coronary Calcification in Symptomatic Patients: An Electron-Beam CT Study , 2001, Arteriosclerosis, thrombosis, and vascular biology.

[32]  C. Nishimura,et al.  Anatomic Properties of Myocardial Bridge Predisposing to Myocardial Infarction , 2009, Circulation.

[33]  M. Stuber,et al.  Regional Coronary Endothelial Function Is Closely Related to Local Early Coronary Atherosclerosis in Patients With Mild Coronary Artery Disease: Pilot Study , 2012, Circulation. Cardiovascular imaging.

[34]  T Ishii,et al.  The effects of a myocardial bridge on coronary atherosclerosis and ischaemia , 1998, The Journal of pathology.

[35]  G. Burch,et al.  Blood Supply of the Human Interventricular Septum , 1958, Circulation.

[36]  M. Budoff,et al.  Relation of coronary artery calcium to left ventricular mass and geometry in patients with essential hypertension , 2003, Blood pressure monitoring.

[37]  H. Shimada,et al.  The significance of myocardial bridge upon atherosclerosis in the left anterior descending coronary artery , 1986, The Journal of pathology.

[38]  J. Gardin,et al.  Relation of echocardiographic left ventricular mass, geometry and wall stress, and left atrial dimension to coronary calcium in young adults (the CARDIA study). , 2005, The American journal of cardiology.

[39]  Y. Akasaka,et al.  Significance of anatomical properties of myocardial bridge on atherosclerosis evolution in the left anterior descending coronary artery. , 2006, Atherosclerosis.

[40]  Y. Ishikawa,et al.  Atherosclerosis suppression in the left anterior descending coronary artery by the presence of a myocardial bridge: an ultrastructural study. , 1991, Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc.

[41]  J. Wasilewski,et al.  [Role of shear stress and endothelial mechanotransduction in atherogenesis]. , 2011, Kardiologia polska.

[42]  K. Shimada,et al.  Characteristic patterns of the longitudinal and circumferential distribution of calcium deposits by parent coronary arteries observed from computed tomography angiography , 2016, Heart and Vessels.

[43]  T. Akasaka,et al.  Phasic coronary flow characteristics in patients with hypertrophic cardiomyopathy: a study by coronary Doppler catheter. , 1994, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[44]  A. M. Scher,et al.  Absence of atherosclerosis in human intramyocardial coronary arteries: a neglected phenomenon. , 2000, Atherosclerosis.

[45]  R. Detrano,et al.  Quantification of coronary artery calcium using ultrafast computed tomography. , 1990, Journal of the American College of Cardiology.

[46]  Montenegro Mr,et al.  Topography of atherosclerosis in the coronary arteries. , 1968 .

[47]  W. Cheong,et al.  An intravascular ultrasound appraisal of atherosclerotic plaque distribution in diseased coronary arteries. , 2012, American heart journal.