Anterior Interventricular Sulcus Research Articles

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery Diagnosed in Adulthood

Introduction: An anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare heart malformation, with 90% of patients dying during the first year of life. If the right coronary artery compensation and multiple collateral circulation are sufficiently established, the patient's myocardial ischemia symptoms are mild and appear later, which is called the adult type ALCAPA. Case Description: A 42-year-old woman presented to our hospital with one-month history of the aggravation of active shortness of breath which gradually progressed to nocturnal paroxysmal shortness of breath and cough. Admission physical examination suggested mild edema of both lower limbs. Transthoracic echocardiography (TTE) showed that a small vessel shadow was abnormally connected to the pulmonary artery (PA), and moderate pulmonary artery hypertension. Coronary computed tomography angiography (CTA) showed an anomalous origin of the left main coronary artery (LMCA) dividing into the left anterior descending (LAD) and left circumflex (LCX) artery from the PA, with no clear connection to the left coronary sinus. The right coronary artery (RCA) was significantly dilated and originated from the normal Valsalva sinus. It was accompanied by multiple collateral circulations, most of which traveled anterior to the right ventricular free wall and anterior interventricular sulcus, and some emanated from the posterior descending branch of the posterior interventricular sulcus and walked toward the posterolateral wall of the left ventricle. Conclusion: Coronary computed tomography angiography (CTA) can be used to visualize the abnormal origin and distribution of the coronary artery's course and may be the first choice in the diagnosis of ALCAPA.

CT Images in Follicular Lymphoma: Changes after Treatment Are Predictive of Cardiac Toxicity in Patients Treated with Anthracycline-Based or R-B Regimens

The aim of this study is to evaluate changes in epicardial adipose tissue (EAT) and cardiac extracellular volume (ECV) in patients with follicular lymphoma (FL) treated with R-CHOP-like regimens or R-bendamustine. We included 80 patients with FL between the ages of 60 and 80 and, using computed tomography (CT) performed at onset and at the end of treatment, we assessed changes in EAT by measuring tissue density at the level of the cardiac apex, anterior interventricular sulcus and posterior interventricular sulcus of the heart. EAT is known to be associated with metabolic syndrome, increased calcium in the coronary arteries and therefore increased risk of coronary artery disease. We also evaluated changes in ECV, which can be used as an early imaging marker of cardiac fibrosis and thus myocardial damage. The R-CHOP-like regimen was associated with lower EAT values (p < 0.001), indicative of a less active metabolism and more adipose tissue, and an increase in ECV (p < 0.001). Furthermore, in patients treated with anthracyclines and steroids (R-CHOP-like) there is a greater decrease in ejection fraction (EF p < 0.001) than in the R-B group. EAT and ECV may represent early biomarkers of cardiological damage, and this may be considered, to our knowledge, the first study investigating radiological and cardiological parameters in patients with FL.

Dual left anterior descending coronary artery and anomalous origin of left circumflex artery: a novel coronary anomaly revealed by CCTA.

In the rare coronary anomaly of Dual LAD, two segments of the vessel reside within the anterior interventricular sulcus. In our case, the short LAD originated from the Left Coronary Sinus (LCS), while the long LAD emerged from the Right Coronary Sinus (RCS). The LCx arose from the RCS, and the RCA displayed typical features. This anomaly was deemed incidental, prompting routine follow-up. It underscores the significance of integrating CCTA for a thorough assessment, offering crucial insights for patient management.

Rare case of single left coronary artery in a Japanese cadaver.

A single left coronary artery with a single orifice in the left aortic sinus was observed during anatomical practice in an 81-year-old male Japanese cadaver. The single left coronary artery bifurcated into the anterior interventricular branch (IVa) and circumflex (CXa) branches. The IVa descended into the anterior interventricular sulcus to supply the apex of the heart, leaving a branch that traversed the upper part of the infundibulum to supply the anterior upper region of the right ventricle. The CXa curved leftward in the atrioventricular sulcus to reach the posterior surface, after which it continued to emerge into the anterior surface. The vascular running pattern showed that CXa directly supplied blood to the upper right ventricle (but not the conus branch), with three branches connected to the apex. The atrial arteries showed no anomalous distribution patterns. These findings are useful during surgical procedures, including cardiac catheterization.

An unusual Echo finding in a patient with TOF: unusual RAC sign

We report a 13 years old girl with cyanotic heart disease who presented to the OPD of a tertiary care facility for the first time. Her echocardiography showed features of tetralogy of fallot and dilated coronary sinus. An unusual structure was visualized below the aortic valve in PLAX and 4 chamber view. It also had systolic colour flow in it (Figures 1-4). Origin of the structure could not be traced so a cardiac CT was planned for delineation of the anatomy. DISCUSSION; Tetralogy of fallot is associated with multiple other abnormalities, one of which is abnormal coronary origins1. Our patient had normal coronary origins although the coronary arteries were markedly dilated and LAD had a brief retro-aortic course before emerging onto the anterior interventricular groove. RAC (retro-aortic coronary) sign is well known sign on echocardiography for retro-aortic course of one of the coronary arteries.2 A typical RAC sign is shown in figure 6. Since our patient did not have normal sized coronaries so typical RAC sign was not seen on echo. The typical location of the structure of interest and systolic colour flow demonstration in it raised the suspicion of it being a coronary artery. Dilated coronary sinus was due to Left persistant SVC which is also one of the associations of TOF. CONCLUSION; RAC sign is typical for retro-aortic coronary artery course. Slight variation in the appearance can occur due to variability in anatomic features of the coronary of interest. But still it is fairly reliable to predict the course of a coronary artery.

Case Analysis of a Unique RIII‐C Single Coronary Artery with Type IV Dual LAD and Right‐Dominant Triple PDA

INTRODUCTIONCoronary artery anomalies (CAAs) are rare congenital variations of normal coronary artery anatomy. Examples of CAAs include a single coronary artery (SCA) (instead of separate, left and right vessels) arising from the aortic trunk to supply the entire myocardium (prevalence = 0.024% to 0.066%), two left anterior descending arteries (LAD) (instead of one) occupying the anterior interventricular sulcus (prevalence = 0.02% to 1%), and three posterior descending arteries (PDA) (instead of one) occupying the posterior interventricular sulcus (prevalence uncertain). Reports of rare CAAs, especially those previously undocumented to occur simultaneously, serve as valuable references for medical education and clinical practice. The present study describes an especially unique CAA discovered in a human cadaveric heart where a SCA gives rise to distinct dual LAD and triple PDA. The study aims to characterize the involved CAAs and investigate the anatomy, histology, and clinical considerations of this unique coronary anatomy.METHODSThe SCA, dual LAD, and triple PDA CAAs were discovered during routine cadaveric dissection in a medical education curriculum. The heart was eviscerated, and the CAAs were carefully cleaned of extraneous tissue, photographed, and measured. The SCA was characterized using Lipton’s classifications, and the dual LAD was classified according to the thirteen variations (“Types”) of dual LAD described in the literature. Masson’s Trichrome histological staining was performed to examine CAA tissue integrity via light microscopy. Courses of the CAAs were superimposed on volume rendered computerized tomographic angiography (CTA) images depicting normal coronary anatomy for comparison.RESULTSThe SCA arose from a solitary coronary ostium in the right coronary sinus and traveled 0.57 cm from the aortic trunk before quadfurcating into the right coronary artery (RCA), long LAD, left main coronary artery (LMCA), and descending septal artery (DSA). The RCA maintained normal anatomic course before terminating in a right‐dominant triple PDA. The long LAD coursed pre‐pulmonic along the anterior interventricular sulcus for 13.89 cm before terminating near the apex of the heart. The LMCA tracked retro‐aortic, between the aorta and the atrial wall, for 5.67 cm before bifurcating into the left circumflex artery (LCX) and short LAD. The short LAD paralleled long LAD within the anterior interventricular sulcus for 10.8 cm before anastomosing with the second PDA near the apex. Additional anastomoses were noted near the apex of the heart between the long LAD, short LAD, second PDA, third PDA, diagonal branches of the short LAD, and left marginal artery. The DSA coursed between the aorta and pulmonary trunk before entering the interventricular septum.CONCLUSIONSThe heart presented in this study was supplied by a unique (Lipton’s) RIII‐C SCA with Type IV dual LAD and right‐dominant triple PDA. Unexpected complications can arise from cardiac procedures involving patients with unknown CAAs such as these. This report may serve as a key reference for cardiothoracic surgeons, interventional cardiologists, coronary angiographers, and medical educators when considering simultaneous occurrence of these rare CAAs.

ALCAPA: 3D MDCT presents an intuitive perspective

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is one of the rare congenital anomalies with exceptional presentation till adulthood. The complications include left ventricular dysfunction, severe mitral regurgitation and myocardial infarction. We report a case of a young female with dyspnea and murmur with left to right shunt which was finally diagnosed as ALCAPA by multi-detector cardiac computed tomography (MDCT). A 45-year-old female presented with dyspnoea on exertion New York Heart Association [(NYHA) II class] and chest heaviness for seven days. Physical examination reveals 2/6 systolic diffuse murmur over the left sided chest with predominance over the pulmonary area. Electrocardiogram (ECG) reveals sinus rhythm with infrequent premature ventricular contractions (PVCs) and echocardiography reveals left to right shunt flow with inconspicuous ends. Cardiac computed tomography (CT) study reveals very interesting and unusual findings. Only one coronary artery was found to originate from the aortic root (Figure 1A and Figure 1B). Right coronary artery (RCA) originates from the right coronary sinus as a large-sized and ecstatic artery with a highly tortuous course and abundant collaterals (Figure 1C). No coronary origin was detected from the left coronary cusp. Surprisingly, the left coronary equivalent artery was revealed, originating from the main pulmonary artery with course toward anterior interventricular groove and branching into left anterior descending and left circumflex coronary arteries with normal courses (Figure 1D and Figure 1E). Finally, cardiac CT unveiled the definitive diagnosis of anomalous left coronary artery from the pulmonary artery (ALCAPA). Approximately 90% of the infants with ALCAPA die during the first year of their life and very few survive till adulthood [1]. The adult cohort of ALCAPA is increasing due to better advanced cardiac imaging techniques like multidetector computed tomography (MDCT). It is characterized by exuberance in collateral coronary circulation from RCA to left coronary artery (LCA); thus allowing survival up to adulthood, coronary “steal” phenomenon from RCA to LCA and pulmonary “steal” phenomenon as LCA to PA [2]. In the adult type of ALCAPA, re-establishment of dual coronary system by ligation of the LCA from the pulmonary artery with coronary artery bypass grafting and reimplantation of LCA coronary button to aorta with interposition graft are the preferred methods of surgical approach [3].

Regularities in the distribution of myocardial bridges over the branches of the coronary arteries

The article highlights peculiarities of localization of myocardial bridges. It is believed that the coronary arteries and their branches are located in the subepicardial tissue. However, some researchers describe cases of intramural localization of their sections. Myocardial bridges – a set of fibers of the ventricular myocardium located over a certain area of the subepicardial branch of the coronary artery - represent variants of such localization.The aim of the study was to establish the patterns of macroscopic anatomy and topography of myocardial bridges investigating anatomical sections of the human heart in the adult and elderly people. Material and methods. The study involved 65 formalin-fixed sample preparations of the human heart of the adult and elderly people who died of conditions that were not associated with heart diseases. The authors measured transverse and longitudinal dimensions of the ventricular complex of the heart, and calculated the transverse-longitudinal index. Subepicardial vessels were prepared without prior injection. The number of myocardial bridges over the main branches of the coronary arteries was counted and their length was measured. The type of blood supply to the heart was determined according to a three-member classification, depending on the source of discharge of the posterior interventricular branch. Results. Myocardial bridges were observed on 44 (67.6%) sample preparations. As a rule, they were located over the branches of the left coronary artery (91.5%). They were typically located in the proximal half of the anterior interventricular sulcus. The length of the bridges ranged from 2.5 to 64 mm (Me = 13 mm). A direct positive correlation was found between the length of the ventricular complex of the heart and the length of the bridges. The relationship between the type of blood supply to the heart and the presence of bridges was not revealed. In 26 preparations, a cone artery departed from the right coronary sinus of the aorta, in addition to the right coronary artery, and bridges were observed in 17 sample preparations. Conclusion. Myocardial bridges are more typical for the branches of the left coronary artery compared to the right. They are typically localized in the proximal third of the anterior interventricular sulcus. There is a dependence between the length of the bridges and the length of the ventricular complex of the heart. The distribution and number of myocardial bridges does not depend on the type of blood supply to the heart, but is associated with the independent discharge of the cone artery from the aorta.

Dual left anterior descending coronary artery (type III) and the presence of myocardial bridges: a post-mortem examination

An observational examination of the heart was performed in the Department of Anatomy, during the routine autopsy of an 89-year-old man. The heart was fixed in 10% formalin and an analysis of arterial vasculature was performed (used morphometric abbreviations below [mm]: L - length; D - diameter of origin). Trifurcation of the left main coronary artery (L = 17.4; D = 8.1) was observed during the study, which originated in the left aortic sinus and was followed by three branches: proper left anterior descending artery (pLAD; L = 11.2; D = 7.4), intermediate branch (L = 98.6; D = 3.5) and left circumflex artery (L = 104.2; D = 4.9), respectively. In the pLAD division, there was noted LAD1 (long) which was running in the interventricular septum (L = 32.2) and further in the subepicardial segment (L = 109.3) in the anterior interventricular groove towards the apex (AC) (LAD1; L = 141.4; D = 6.3) and LAD2 (short) running subepicardial in the anterior interventricular groove in the AC direction (LAD2; L = 68.4; D = 3.2). Four diagonal branches (DB) and 9 septal perforators (SP) were observed in the course of LAD1; regarding the LAD2 there were 6 SP only. It is worth noting that the first SP supplying the interventricular septum came from LAD2. Another interesting aspect of the observation was the occurrence of 4 myocardial bridges on the LAD1, LAD2, DB1 arteries and on the second obtuse marginal branch (OM2), respectively. This case describes a rare anatomical anomaly of the LAD course and reminds clinicians of the need for careful planning of cardiac surgeries and percutaneous interventions on the coronary arteries.

Unique variant of dual left anterior descending artery

CT angiography in a 45-year-old woman with atypical chest pain revealed two left anterior descending (LAD) arteries in the anterior interventricular sulcus (AIS). The longer LAD (white arrowhead in [figure...

Three‐dimensional Visualization of Spatial Relationships Between Coronary Veins and Arteries.

Knowledge of the mutual relationship between the main arteries and veins of the heart is crucial for the safety and effectiveness of interventional and electrophysiological procedures. Thus, the aim of this study was to assess the spatial relationships of main coronary blood vessels using virtual three‐dimensional visualizations. Seventy patients that underwent contrast‐enhanced electrocardiogram‐gated multi‐slice computed tomography of the heart were investigated. Coronary vasculature was segmented and visualized in three dimensions using semi‐automatic algorithms (Mimics Innovation Suite 22.0, Materialise). Right coronary artery dominance was identified in 81.4%, whereas left artery dominance in 11.4% and codominance in 7.1%. The coronary sinus, great cardiac vein and the middle cardiac vein were observed in all patients. Within the inferior interventricular sulcus, the artery was mainly located on the right side of the middle cardiac vein (87.1%), in 58.6% of cases these vessels crossed each other, mostly in their distal part. The coronary sinus was accompanied by the left circumflex artery in 88.6%, but their mutual course was highly variable. In 42.3% the circumflex artery crossed coronary sinus once, in 32.9% twice and in 2.9% three times. The left anterior descending artery was located on the right side of the great cardiac vein in 90.0%, in 51.1% these vessels crossed each other, mainly in middle sector of anterior interventricular sulcus. In conclusion, main coronary arteries and veins cross each other on many levels. Three‐dimensional pre‐procedural coronary vessels visualization is useful tool that may help to plan the procedure and increase its safety and efficiency.

A UNIQUE HEART TEAM APPROACH FOR ANOMALOUS DUAL LAD AND RECURRENT ANGINA

Dual left anterior descending (LAD) coronary artery is an exceedingly rare congenital anomaly. It is defined as the presence of two separate segments of the vessel occupying the anterior inter-ventricular sulcus (AIVS). Some coronary artery anomalies can present with serious sequelae such as angina

Coronary dominance pattern in Myocardial bridged hearts

Posterior interventricular artery (PIA) present in the posterior interventricular groove over the inferior surface of the heart. Human hearts consist of either Right coronary predominance or Left coronary predominance. Left coronary predominant people are more prone to get ischemic heart diseases. In left coronary predominance entire left ventricle except a part of the right ventricle adjoining anterior interventricular groove supplied by the left main coronary artery. Left coronary dominance has a poor prognosis in acute coronary syndrome when compared with the right coronary predominance. Myocardial bridging may be benign or malignant. So myocardial bridging with left coronary dominance may be a risk factor to the ischemic heart disease. The aim of the present study is to find out the coronary dominance pattern in myocardial bridged hearts in cadavers. Ninety cadaveric hearts were procured from the Department of Anatomy, IMS & SUM Hospital Bhubaneswar. After a simple dissecting procedure, myocardial bridges and coronary dominance patterns were observed. Myocardial bridging was present over the left anterior interventricular artery in 51(56.7%) hearts. Out of 51 myocardial bridged hearts, right coronary predominance is present in 45 (88.24%) hearts and left coronary predominance present in 6(11.76%) hearts. Along with the left dominance, if myocardial bridge present over the left epicardial coronary artery, there may be an increased frequency of myocardial ischemia.

A new measurement site for echocardiographic epicardial adipose tissue thickness and its value in predicting metabolic syndrome.

Echocardiographic epicardial adipose tissue (EAT) thickness is defined as the thickness of the low-isoechoic area on the free wall of the right ventricle in the parasternal long-axis and short-axis views. Recent studies have suggested that it might support current risk stratification strategies in identifying an increased risk of metabolic syndrome. The aim of this study is to explore a new measurement site which can better reflect EAT thickness and to assess its value in predicting metabolic syndrome. A total of 975 Chinese adults were measured for EAT thickness on the right ventricular anterior free wall (EAT-rv) and on the anterior interventricular groove (EAT-ivg) with echocardiography. The correlation between EAT thickness and metabolic syndrome was analyzed, as was the agreement between epicardial adipose volume (EAV) and EAT thickness. Independent risk factors of EAT thickness were identified and the predictive value of EAT thickness was assessed. Epicardial adipose tissue thickness was higher in older participants and those with obesity, diabetes, hypertension, hypertriglyceridemia, and metabolic syndrome, and it was lower in male participants. The EAT-ivg was higher in the participants with hypo-high-density-lipoprotein cholesterolemia than in those without the disorder, but the EAT-rv values were not statistically different. The kappa value was 0.524 between EAT-rv and EAV, and 0.783 between EAT-ivg and EAV. Advanced age, large waist circumference and female gender were independent risk factors of high EAT-ivg, while high-density-lipoprotein (HDL) cholesterol was a protective factor. The EAT-ivg was associated with metabolic syndrome. The area under the curve of EAT-ivg applied in predicting metabolic syndrome was greater than that of EAT-rv (0.715 vs 0.648). The EAT-ivg was more consistent with EAV than EAT-rv, was independently associated with metabolic syndrome and had a higher value in predicting metabolic syndrome than EAT-rv. Therefore, the anterior interventricular groove can serve as a new measurement site which better reflects EAT thickness.

Supernumerary coronary artery. Case report

During the routine dissection of a 60‐year‐old male within our university's Department of Anatomy, we identified a peculiar aspect of the coronary blood supply.The heart is normally supplied by two coronary arteries, however in our case, we identified a supernumerary coronary artery. It arose from the aorta, through a separate ostium, anterior of the right coronary artery's point of origin. This third artery descended diagonally along the anterior surface of the right ventricle. At the heart's apex, it then continued for approximately 2cm along the posterior interventricular sulcus.The right marginal branch took a diagonal descending path to the middle of the posterior interventricular sulcus, close to the terminal point of the third artery. At the same time, the right coronary artery was shortened, and only descended to the first third of the posterior interventricular sulcus.The left coronary artery presented with two branches: the circumflex branch, and a common trunk for the anterior interventricular branch and the left marginal branch. The anterior interventricular branch was shortened, only descending two thirds of the way along the anterior interventricular sulcus. Both it and the left marginal branch were partially covered by myocardial bridges. The circumflex branch terminated near the posterior interventricular sulcus through two ventricular branches.The study and knowledge of coronary variants is critical in identifying potential collateral paths, of which a supernumerary coronary artery is a good example.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Initial experience with cinematic rendering for the visualization of extracardiac anatomy in complex congenital heart defects†.

Detailed anatomical information is essential for planning of surgical therapy in patients with congenital heart disease. We wanted to determine whether cinematic rendering, the novel 3-dimensional visualization technique, could help paediatric cardiac surgeons achieve better preoperative visualization of the extracardiac anatomy in patients with complex congenital heart defects. Therefore, cinematic rendering was compared to the traditional volume rendering technique by means of a questionnaire with predefined criteria. Picture sets from 20 infant patients (mean age = 17 days) were generated from computed tomography data with both the cinematic rendering and the volume rendering techniques. These were presented side by side in a digital high-resolution portfolio without labelling them. Three experienced paediatric cardiac surgeons were provided with these portfolios and a questionnaire. They were asked to evaluate the images individually in predefined categories on a 4-point Likert scale from 1 = 'fully acceptable' to 4 = 'unacceptable'. Cinematic rendering scored significantly better values on the Likert scale in 7 of 9 categories, namely 'spatial impression in general', 'depth perception', 'delineation of the atrial appendages/pulmonary veins/peripheral pulmonary arteries', 'assessability of the anterior interventricular sulcus' and 'assessability of the aortic arch branches'. Cinematic rendering is a valuable software tool, and our data suggest that it provides significantly better visualization than volume rendering. The surgeons appraised improved depth perception and delineation of structures adjacent to the heart as the most significant advantages.

Dual Left Anterior Descending Artery with abberrent left circumflex artery: dual abberrency- a multi-modality imaging based identification.

Dual left anterior descending (LAD) artery with separate origin of the long LAD with left main coronary artery (LMCA) continuing as short LAD is very rare. A 67-year-old diabetic, and hypertensive male was admitted with history of exertional dyspnoea. He underwent coronary angiography, which showed LMCA continuing as short LAD with early termination while single trunk from right coronary sinus was giving rise to long LAD, right coronary artery, and left circumflex artery (LCx). The long LAD, running on the right side of the anterior interventricular groove, entered the groove distally while anomalous LCx which was dominant, was following a retro-aortic course. These were subsequently confirmed on Multidetector computed tomography angiography (MDCT). Therefore, dual LAD with long LAD, dominant anomalous circumflex artery, and right coronary artery sharing a single, and common origin is very rare and to the best of our knowledge, is being reported for the first time.

Anatomy of the coronary artery and cardiac vein in the quail ventricle: patterns are distinct from those in mouse and human hearts.

Coronary vessel development has been investigated in avian and mouse embryonic hearts. Quail embryos are a useful tool to examine vascular development, particularly because the QH1 antibody and transgenic quail line, Tg (tie1:H2B-eYFP), are useful to trace endothelial cells. However, there are only a few descriptions of the quail coronary vessels. Using ink injection coronary angiography, we examined the course of coronary vessels in the fetal quail heart. The major coronary arteries were the right and left septal arteries, which, respectively, branched off from the right and left coronary stems. The right septal artery ran posteriorly (dorsally) and penetrated the ventricular free wall to distribute to the posterior surface of the ventricles. The left septal artery ran anteriorly (ventrally) and penetrated the ventricular free wall to distribute to the anterior surface of the ventricles. The right and left circumflex arteries were directed posteriorly along the atrioventricular sulci. The cardiac veins consisted of three major tributaries: the middle, great, and anterior cardiac veins. The middle cardiac vein ascended along the posterior interventricular sulcus and emptied into the right atrium. The great cardiac vein ran along the anterior interventricular sulcus, entered the space between the left atrium and conus arteriosus and emptied into the right atrium behind the aortic bulb. The anterior cardiac vein drained the anterior surface of the right ventricle and connected to the anterior base of the right atrium. The course of coronary vessels in the quail heart was basically the same as that observed in chick but was different from those of mouse and human.

Echocardiographic Epicardial Adipose Tissue Thickness Is Associated with Symptomatic Coronary Vasospasm during Provocative Testing

Epicardial adipose tissue (EAT) is the ectopic visceral fat surrounding the heart, which plays an important role in atherosclerosis of the coronary arteries via endothelial damage. Several studies have also suggested that vasospasm with angina (VSA) causes endothelial dysfunction in the coronary arteries. The aim of this study was to evaluate the thickness of EAT in the anterior interventricular groove (EAT-AIG) using echocardiography in patients who had no obstructive coronary artery disease and were suspected of having VSA. Sixty-five patients who underwent intracoronary acetylcholine provocation testing for clinical indicationswere prospectively enrolled. VSA was diagnosed by coronary artery stenosis increase of >90% and the presentation of chest pain with ischemic changes on electrocardiography. Subjects were divided into two groups, with and without significant coronary spasm (VSA group, 30 patients; non-VSA group, 35 patients), consistent with acetylcholine provocation testing. EAT-AIG thickness was significantly greater in the VSA group than in the non-VSA group (8.2±2.7 vs 6.1±2.5mm, P=.002). By receiver operating characteristic analysis, EAT-AIG thickness had a high C statistic (area under the curve=0.81, P<.001) after adjustment for conventional risk factors (smoking, diabetes mellitus, and dyslipidemia). EAT-AIG thickness had incremental diagnostic value over other conventional risk factors (area under the curve=0.81 vs 0.64, P for comparison=.020). EAT-AIG thickness, which is noninvasively and easily measured using transthoracic echocardiography, can be one of multiple clinical variables associated with VSA.

Outcomes of Catheter Ablation of Idiopathic Outflow Tract Ventricular Arrhythmias With an R Wave Pattern Break in Lead V2: A Distinct Clinical Entity.

In outflow tract ventricular arrhythmias (OT-VAs), an abrupt loss of the R wave in lead V2 compared to V1 and V3 (pattern break in V2-PBV2) suggests an origin close to the anterior interventricular sulcus (anatomically opposite to lead V2) and adjacent to proximal coronaries. We studied the outcome of catheter ablation of OT-VAs with a PBV2. Of 130 consecutive patients with idiopathic left bundle block morphology OT-VAs and transition ≤V4, 12 (9%) had PBV2. Outcomes in this group were compared to the remaining 118 patients. Patients with PBV2 were more likely to be younger (41 ± 18 vs. 50 ± 14 years, P = 0.0384) and women (11 [92%] vs. 70 [59%], P = 0.0302). The earliest activation was at the RVOT in seven, left coronary cusp (LCC) in one, anterior interventricular vein (AIV) in two and the epicardium in two. In five (42%) cases (earliest activation in the AIV in two, epicardium in two, and RVOT below the valve level in one), ablation was aborted due to proximity to the left anterior descending (LAD) coronary artery. After 36 ± 17 months and 1.3 ± 0.5 procedures, VAs elimination was achieved in 58% of patients with PBV2 compared to 89% of the reference population (P = 0.0125) with effective site in five of seven at the most anterior and leftward RVOT adjacent to the pulmonic valve (PV). OT-VAs with PBV2 demonstrate a unique ECG pattern and challenging catheter ablation. Proximity to LAD precludes ablation in about half. Long-term VA suppression could be achieved in only 58% of cases most commonly when the earliest site is at the anterior and leftward RVOT just under the PV.