Coronary Artery Supply Research Articles

Contemporary State-of-the-Art PCI of Left Main Coronary Artery Disease.

The left main coronary artery (LMCA) supplies over 70% of the myocardium, and significant LMCA disease is associated with high morbidity and mortality. With remarkable advances in percutaneous coronary intervention (PCI), including stent technology, antithrombotic agents, and evolving procedural techniques, PCI has become an important treatment option in clinical practice guidelines for the revascularization of LMCA disease. In contemporary clinical practice, a heart-team approach to shared decision-making, considering clinical/anatomic factors along with patient preferences, is emphasized for patients with significant LMCA disease requiring myocardial revascularization. Furthermore, recent progress in PCI procedures combined with intravascular imaging or functional guidance has resulted in significant improvements in PCI outcomes, especially for complex lesions, including LMCA disease. Nevertheless, owing to inherent anatomic complexities and frequent multivessel involvement, several unmet issues remain regarding the determination of the appropriate treatment approach for significant LMCA disease, for which further clinical research is required. This contemporary review article provides a comprehensive overview of left main PCI based on current guidelines and underlying trial data, addresses important unresolved diagnostic and therapeutic issues, and identifies future perspectives likely to advance progress in this field.

Clinical Significance of Coronary Arterial Dominance: A Review of the Literature.

Coronary dominance describes the anatomic variation of coronary arterial supply, notably as it relates to perfusion of the inferior cardiac territories. Differences in the development and outcome in select disease states between coronary dominance patterns are increasingly recognized. In particular, observational studies have identified higher prevalence of poor outcomes in left coronary dominance in the setting of ischemic, conduction, and valvular disease. In this qualitative literature review, we summarize anatomic, physiologic, and clinical implications of differences in coronary dominance to highlight current understanding and gaps in the literature that should warrant further studies.

Atherosclerotic Disease in a Single Coronary Artery: Right Coronary Artery Supplies Left Anterior Descendens and Left Circumflex Artery with Absent Left Coronary Ostium

We report a case of a 62-year-old man with a right-sided single coronary ostium supplying the complete myocardium. This case was diagnosed based on an aberrant exercise tolerance test and complementary angiography. The patient was revascularized by a coronary artery bypass graft to the single coronary artery because of a significant stenosis in its course.

STUDY OF THE BRANCHING PATTERN OF THE LEFT CORONARY ARTERY IN CADAVERIC HEARTS

BACKGROUND- Coronary artery disease is one of the major causes of the death worldwide. The left coronary artery supplies major part of the left ventricle and as the diseases of the left coronary artery is more , in depth study of the course , branching pattern and variations of the left coronary artery is essential for medical and therapeutic interventions. -To study t AIM he branching pattern of the left coronary artery. MATERIAL AND METHODS: The present study was conducted in 40 adult hearts specimens irrespective of sex , with no obvious pathology that were used during the routine academic dissection for M.B.B.S students in the Department of Anatomy ,JMCH and also from the autopsies done in the Department of Forensic Medicine & Toxicology ,JMCH ,Assam. The hearts were preserved in 10% formalin and dissected in a convenient time later. After removal of the visceral pericardium and sub epicardial fats , coronary arteries were identied alongwith their branches and traced till their termination . The arteries were painted with red fabric colour to enhance the contrast. Photographs were taken and the relevant data were recorded and analyzed statistically. The origin of the left corona RESULTS: ry artery and its branching pattern was studied . In all the specimens the origin of left coronary artery was from left posterior aortic sinus. Out of 40 adult hearts bifurcation was found in 28 specimens (70%) and trifurcation in 12 specimens(30%). Knowledge of the variations of the branching pattern CONCLUSION: of the left coronary artery is useful for the cardiac surgeons for interpretation of arterial occlusions and for performing interventional life saving procedures

Dealing With Failure.

Dealing With Failure.

Anatomy of the coronary arteries in Eurasian wild boar (Sus scrofa)

Abstract Coronary circulation determines the proper functioning of the heart muscle and blood circulation in the body. Cardiovascular diseases in humans are creating an ever-increasing demand for more research into their pathogenesis, diagnosis and treatment. Animal models of organs are an indispensable part of research for the development of human medicine. Due to the high genetic similarity, the most commonly used donor is the domestic pig. The Eurasian wild boar is the ancestor of the domestic pig and an invasive species not covered by European protection programmes. Given its analogous structure and genotype to the pig, it could potentially also become an organ donor. The aim of this study was to analyse the normal coronary anatomy of the Eurasian wild boar and compare it to humans, domestic pigs and other animal species. The study was conducted on 60 wild boar hearts. Twenty-eight slides were prepared using acrylic, while liquid latex was injected into 32 hearts. The blood vessels were then manually prepared using surgical instruments for examination. Both the right coronary artery and the left coronary artery of the boar diverge from the ascending aorta from opposite aortic sinuses. The left coronary artery begins its course in the left aortic sinus, starting between the left appendage and the pulmonary trunk. It then heads inferiorly. The right coronary artery supplies blood to the right atrium and right ventricle. The study points to the wild boar coronary system’s individual morphological features and notes the common arterial patterns in mammals.

Ostial Stenosis of Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery in an Adult

An anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), a rare congenital anomaly, the enlarged right coronary artery supplies the left ventricle through retrograde collaterals before preferentially directing into the lower-pressure pulmonary artery system, resulting in coronary steal. The infant type is characterized by the absence of collateral vessels, and global myocardial ischemia is a major cause of death in infancy. If not treated, up to 90% of them will die during the 1st year of life. Myocardial ischemia or infarction left ventricular (LV) dysfunction with or without mitral regurgitation, life-threatening arrhythmias, or sudden cardiac death may all be manifestations of symptomatic adult-type ALCAPA. In those patients who have survived to adulthood without surgery, pathophysiological mechanisms enabling adequate LV perfusion, such as a large number of well-formed functioning collaterals, and in a few cases, the presence of ostial stenosis of the left coronary artery (LCA), provide selective survival advantage. We review the correlation between clinical presentation, pathophysiological findings, and angiographic features of ostial stenosis of LCA in the setting of adult-type ALCAPA.

Public Awareness of the Need to Call the Emergency Medical Services Following the Onset of Acute Myocardial Infarction and Associated Factors in Jazan Region, Saudi Arabia

Background: Acute Myocardial Infarction is usually a complication of an ongoing atherosclerotic pathophysiological process inside the distribution of the coronary arterial supply. For many years, acute myocardial infarction has been one of the leading causes of death worldwide. One of the major complications of acute myocardial infarction is the event of “cardiac arrest”. However, with an early approach to emergency medical services and early seeking of healthcare, the potential mortality chance can be reduced. Despite the significance of the situation and its vulnerability, delays in approaching emergency medical services exist due to variable influences. This study had investigated the reasons behind the delays and the awareness of the general public on acute myocardial infarction and its associated symptoms.
 Methods: This study is a cross-sectional type of research that was conducted in October 2021 through November 2021 period that invited 427 participants through social media platforms.
 Results: The online questionnaire was distributed and administered by 427 subjects. The mean age of the participants was (27.62 years, SD=11.692) with a minimum age of 18 years and a maximum age of 89 years. The majority of the study participants were females (n=237, 55.5%), of those who called during the daytime, 97.4% of them have mentioned that they would call the EMS directly but when investigated about the time to wait before calling EMS, 55.3% of the participants who chose to call during the daytime would call in less than an hour.
 Conclusion: For initiating public campaigns and providing the public with the consequences of an ignored myocardial infarction and the potential mortality that could be associated with delaying the emergency medicine services approach.

PCI versus CABG for left main coronary artery disease: is the jury still out?

The left main coronary artery supplies blood to 75% or more of the left ventricle. Therefore, if this artery is acutely occluded, patients are at high risk of dire outcomes and researchers have focused on evaluating therapeutic approaches to treat left main coronary artery disease. In an individual patient data meta-analysis of seven randomised trials that included a total of 2649 patients and 345 deaths, 10·2% of the patients randomly assigned to coronary artery bypass grafting (CABG) versus 15·8% of those randomly assigned to medical therapy (eg, antiplatelets and β blockers) died within 5 years (absolute risk difference 5·6%, 95% CI 3·0–8·2).

Effect of permanent right internal mammary artery occlusion on right coronary artery supply: A randomized placebo-controlled clinical trial

This was a prospective superiority trial in 100 patients with chronic coronary artery disease randomly allocated (1:1) to RIMA vascular device occlusion (verum group) or to RIMA sham procedure (placebo group). The primary study end point was RCA collateral flow index (CFI) as obtained during a 1-minute ostial RCA balloon occlusion at baseline before and at follow-up examination 6 weeks after the trial intervention. CFI is the ratio between simultaneous mean coronary occlusive divided by mean aortic pressure both subtracted by central venous pressure. Simultaneously obtained secondary study end points were the registration of angina pectoris and quantitative intracoronary ECG ST-segment shift. CFI change during the follow-up period was +0.036 ± 0.068 in the verum group and -0.021 ± 0.097 in the placebo group (P = .0011). Angina pectoris during the same RCA balloon occlusions had disappeared at follow-up in 14/49 patients of the verum group and in 4/49 patients of the placebo group (P = .0091). Simultaneous intracoronary ECG ST-segment shift change revealed diminished myocardial ischemia at follow-up in the verum group and more severe ischemia in the placebo group. Permanent RIMA device occlusion augments RCA supply to the effect of diminishing clinical and electrocardiographic signs of myocardial ischemia during a brief controlled coronary occlusion.

Left Main PCI—Current Evidence, Techniques, and Triumph

The left main coronary artery (LMCA) supplies majority of the left ventricular myocardium and atherosclerotic obstruction is associated with significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for LMCA disease in the past. The LMCA has special characteristics anatomically, poses different challenges with regard to percutaneous coronary intervention (PCI), and is often associated with multivessel disease. However, advancements in technology have established PCI to be a standard, safe, and reasonable alternative to CABG with comparable outcomes. Contemporary PCI of LMCA disease includes proper selection of the patients and correct technique, and is aided by intravascular ultrasound, optical coherence tomography, and physiological assessment with fractional flow reserve. In this review article, we discuss the anatomy, plaque characteristics of LMCA, current evidence from registries and randomized trials comparing with CABG, technical aspects of stent implantation, adjuvant technologies, mechanical circulatory supports, and triumph of PCI.

P1338 Anomalous left coronary artery from pulmonary artery syndrome diagnosed in adulthood: case of a mother of five

Abstract Funding Acknowledgements Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary Introduction Bland-White-Garland syndrome or ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome is a rare congenital disorder with a prevalence of 1: 300,000. This condition is one the most common causes of infant myocardial infarction. It can ultimately lead to heart failure before the age of one, however when pronounced left and right coronary artery collateralization is present, patients may remain asymptomatic until older age. Due to the development and availability of non-invasive imaging techniques, these patients diagnosed more frequently in recent years. Case description: We present a 53-year-old patient with treated hypertension and five uncomplicated pregnancies. At the age of 40, the patient was referred to coronary angiography due to her dyspnea on exertion. The examination showed that the left main coronary artery (LMCA) originates from the pulmonary artery 7 mm above the pulmonary valve and the right coronary artery is significantly dilated. Based on the mild complaints and good left ventricle systolic function, conservative therapy was recommended by the cardiac surgery team. Since 2018 the patient has had gradually worsening complaints despite of the therapy adjusted for chronic heart failure. Q-waves were depicted on the 12-lead ECG in aVL and V1-V6 leads. Echocardiography showed dilated left ventricle (LV), LV hypertrophy, diffuse hypokinesia, decreased LV systolic function and diastolic dysfunction. At our clinic, we performed cardiac magnetic resonance imaging (CMR) which showed moderately reduced LV ejection fraction, diffuse LV hypokinesia, increased LV volume, septal LV hypertrophy. We visualized the retrograde flow on the LMCA, the shunt volume at the anomalous artery was 1,27 L/min. The CMR also showed irreversible damage of the subendocardial region of the myocardium via late gadolinium enhancement in the area supplied by the LMCA. Since we planned to reevaluate the surgical possibilities, the collateral network with tortuous and dilated left and right coronary arteries were visualized by coronary CT angiography. The surgical team at our institute decided to perform myocardial revascularization and restoration of dual coronary artery supply. Discussion ALCAPA is usually diagnosed in infancy however, in about 10-15% of cases the disease is only recognized in adulthood. The long-term morphological and functional characteristics of the syndrome may include reversible/irreversible ischemic damage, systolic and diastolic dysfunction, mitral regurgitation, significant collateral circulation, left-to-right shunt, dilated coronary arteries. Surgical myocardial revascularization and restoration of dual coronary artery supply is recommended even in adult patients. Abstract P1338 Figure. CTA reconstruction and LGE CMR

P4583Effect of permanent right internal mammary artery occlusion on right coronary artery collateral function. a randomized controlled trial

Abstract Background Extracardiac coronary artery supply via the pericardiophrenic branch of the internal mammary arteries (IMA) has been well documented anatomically. Recently, a proof-of-concept study has found functional relevance of these anastomoses in patients with coronary artery disease (CAD) during a brief right coronary artery (RCA) occlusion. Purpose The aim of the present randomized controlled, single-blind trial was to investigate the effect of permanent right IMA (RIMA) occlusion on RCA collateral flow index (CFI) and on the occurrence of angina pectoris. We hypothesized that the change in RCA CFI from baseline to follow-up examination is higher in the group of patients with than without permanent RIMA occlusion. Methods One hundred patients with CAD were randomly allocated (1:1) to permanent RIMA device occlusion at baseline or to no RIMA occlusion (sham control group). The primary study endpoint was CFI change in the RCA from baseline to the 6-week follow-up examination. CFI is the ratio between mean coronary occlusive and aortic pressure both subtracted by central venous pressure as obtained during a 1-minute proximal RCA balloon occlusion. RCA CFI was measured at baseline before RIMA occlusion or the sham procedure and at the follow-up invasive exam. At the end of the same occlusion, occurrence of angina pectoris was assessed. Percutaneous coronary intervention (PCI) of the RCA was deferred until after follow-up RCA CFI measurement. Results There were 51 patients in the RIMA occlusion (verum) group and 49 patients in the sham control group. PCI in the left coronary territory was performed at baseline for clinical reasons in 27 patients of the verum group and in 25 patients of the sham control group. There were no differences in clinical characteristics at baseline between the groups (age 68±12 years, 88 men). RCA CFI change during the 6 weeks of follow-up was equal to +0.028±0.077 in the verum group and −0.026±0.079 in the sham control group (p=0.0017). Angina pectoris during CFI measurement had disappeared at follow-up exam in 30% of the verum group and in 2% of the sham control group (p=0.0013). Conclusions Right coronary collateral function is augmented 6 weeks after permanent RIMA occlusion when compared to sham treatment. This manifests as less frequent angina pectoris during myocardial ischemia among patients with RIMA occlusion. Acknowledgement/Funding This study was supported by a grant from the Swiss National Science Foundation for Research (grant #32003B_163256/1 to CS).

Right coronary artery supply to acardiac mass.

A 73-year-old patient with previously percutaneously treated coronary artery disease and a history of smoking was referred for routine preoperative screening in preparation for a transurethral tumour resection. He reported dyspnoea. Physical examination revealed normal cardiac auscultation without signs of heart failure. Echocardiography identified a mass of 56 by 32 mm in the left atrium (Fig. 1a) near the anterior leaflet of the mitral valve attached to the atrial septum (asterisk). Subsequently, MRI revealed that the mass was a myxoma. Preoperative coronary angiography showed no significant coronary artery stenoses. When contrast was injected into the right coronary artery a clear side branch (Fig. 1b) with contrast blush to a structure in the left atrium was seen, corresponding to a left atrial tumour (asterisk). As is known from the literature, left atrial myxomas are often vascularised by the circumflex artery, closely followed by the right coronary artery [1, 2]. Complete tumour resection followed, which left the patient in good health.

Plasma Epinephrine Level and its Causal Link to Takotsubo Syndrome Revisited: Critical Review with a Diverse Conclusion.

Takotsubo syndrome (TS) is a recognized acute cardiac syndrome with a clinical presentation resembling that of an acute coronary syndrome (ACS). The defining feature of TS is the reversible left ventricular wall motion abnormality (LVWMA), which has a unique circumferential pattern resulting in a conspicuous ballooning of the left ventricle during systole, and extending beyond the coronary artery supply territory. The pathogenesis of TS is still elusive and several pathophysiological mechanisms have been proposed. A common portrayal of the syndrome in the literature is that the disease is characterized by massive surge of plasma catecholamines including epinephrine. Based on the assumption of massive plasma epinephrine elevation, some investigators hypothesized that the circulatory plasma epinephrine plays a pivotal role in the pathogenesis of TS. One typical such hypothesis is epinephrine induced switch in signal trafficking causing apical or mid-apical ballooning in TS. In-depth analysis of the literature reveals that no study with certainty has shown "massive" plasma epinephrine elevations in TS. Furthermore, the literature evidences challenging the epinephrine-induced switch in signal trafficking are substantial. In this review, sufficient data, indicating that the plasma epinephrine in TS is either normal or moderately elevated in all studies, are provided. Noteworthy, epinephrine may act as a trigger factor for TS-induction but there is no evidence for a direct causal link between epinephrine and TS.

Concordancia de la motilidad segmentaria evaluada por ecocardiograma transtorácico y resonancia magnética cardíaca en pacientes con infarto agudo de miocardio

IntroductionThe evaluation of segmental contractility is an important marker to determine the extent of the coronary disease manifested by an ischaemic event. Cardiac magnetic resonance is the standard pattern to evaluate this contractility. However, due to lower availability of magnetic resonance equipment, as well as the increased cost of magnetic resonance tests, the use of the transthoracic echocardiogram is the diagnostic method of choice. ObjectiveThe aim of the study is to compare the evaluation of the motility of different myocardial segments and segments grouped by coronary artery supply territories obtained by cardiac magnetic resonance and transthoracic electrocardiogram performed on patients admitted to hospital with acute myocardial infarction. MethodsA cardiac magnetic resonance and transthoracic electrocardiogram was performed on a group of patients that arrived in the Emergency Department due to an acute myocardial infarction, and the results were compared. The cardiac magnetic resonance was the reference value to compare for the ejection fraction and segmental contractility. Comparative tests were performed with 95% confidence limits using a Kappa-Cohen coefficient to evaluate the agreement between the measurements. ResultsNo differences were found between the left ventricular ejection fraction measured by cardiac magnetic resonance and transthoracic electrocardiogram. There was average and good agreement in the coronary and circumflex artery supply territories, respectively. In those associated with the right coronary artery, the concordance was low and average. ConclusionsThere was no difference between the evaluation of the ejection fraction by transthoracic electrocardiogram or that by cardiac magnetic resonance. In the evaluation of segmental motility, cardiac magnetic resonance was better than transthoracic electrocardiogram.

Importance of the coronary circulation for cardiac and metabolic performance in rainbow trout (Oncorhynchus mykiss).

Cardiac oxygenation is achieved via both coronary arterial and luminal venous oxygen supply routes in many fish species. However, the relative importance of these supplies for cardiac and aerobic metabolic performance is not fully understood. Here, we investigated how coronary artery ligation in rainbow trout (Oncorhynchus mykiss), implanted with heart rate loggers, affected cardiorespiratory performance in vivo While coronary ligation significantly elevated resting heart rate, the standard metabolic rate was unchanged compared to sham-treated controls. However, coronary ligation reduced the maximum metabolic rate while heart rate remained unchanged following enforced exercise. Thus, coronary ligation reduced metabolic and heart rate scopes by 29% and 74%, respectively. Our findings highlight the importance of coronary oxygen supply for overall cardiorespiratory performance in salmonid fish, and suggest that pathological conditions that impair coronary flow (e.g. coronary arteriosclerosis) constrain the ability of fish to cope with metabolically demanding challenges such as spawning migrations and environmental warming.

Systemic Right Ventricle in Adults With Congenital Heart Disease: Anatomic and Phenotypic Spectrum and Current Approach to Management.

The systemic right ventricle (SRV) is commonly encountered in congenital heart disease representing a distinctly different model in terms of its anatomic spectrum, adaptation, clinical phenotype, and variable, but overall guarded prognosis. The most common clinical scenarios where an SRV is encountered are complete transposition of the great arteries with previous atrial switch repair, congenitally corrected transposition of the great arteries, double inlet right ventricle mostly with previous Fontan palliation, and hypoplastic left heart syndrome palliated with the Norwood-Fontan protocol. The reasons for the guarded prognosis of the SRV in comparison with the systemic left ventricle are multifactorial, including distinct fibromuscular architecture, shape and function, coronary artery supply mismatch, intrinsic abnormalities of the tricuspid valve, intrinsic or acquired conduction abnormalities, and varied SRV adaptation to pressure or volume overload. Management of the SRV remains an ongoing challenge because SRV dysfunction has implications on short- and long-term outcomes for all patients irrespective of underlying cardiac morphology. SRV dysfunction can be subclinical, underscoring the need for tertiary follow-up and timely management of target hemodynamic lesions. Catheter interventions and surgery have an established role in selected patients. Cardiac resynchronization therapy is increasingly used, whereas pharmacological therapy is largely empirical. Mechanical assist device and heart transplantation remain options in end-stage heart failure when other management strategies have been exhausted. The present report focuses on the SRV with its pathological subtypes, pathophysiology, clinical features, current management strategies, and long-term sequelae. Although our article touches on issues applicable to neonates and children, its main focus is on adults with SRV.

A study of incidence of trifurcation of left coronary artery in adult human hearts

The aim of our present study is to determine the incidence of trifurcation of left coronary artery in 75 adult human hearts of Hyderabad, Karnataka region. The incidence of trifurcation of left coronary artery in our present study is 14.5%. Since the left main coronary artery supplies the majority of the left ventricle of the heart and as the diseases of left coronary artery are most common, the management of diseases involving the left coronary artery trifurcation is very challenging. Hence this study done involving trifurcation of left coronary artery will be helpful to the physicians, vascular surgeons and cardiac surgeons of this region.

Atrial Myxoma with a Dual Coronary Artery Supply

Primary cardiac tumours are rare, with myxoma being the most common benign heart tumour. The prevalence of coronary disease or neovascular in patients with atrial myxomas is high, yet angiography is not routinely performed. Echocardiography is preferred for evaluation of myxoma, where coronary angiography clarifies the vascular supply of the tumour and may alter the surgical planning. We here report an interesting and rare case of a left atrial myxoma hyper vascularised by two anomalous arteries, from right coronary artery and circumflex artery demonstrated by preoperative coronary angiography. The mass was successfully excised and the diagnosis of cardiac myxoma was confirmed via histopathology. A review of the value of coronary angiography in detecting myxoma neovascularization is provided. Offering additional valuable information, coronary angiography can alter the surgical approach and may therefore be considered prior to myxoma resection.