Distal Left Circumflex Research Articles

Intercoronary communication: a rare coronary anomaly.

Intercoronary communication also known as coronary arcade or coronary cascade is a rare coronary artery anomaly with an incidence of only 0.002% in patients undergoing angiography. This case emphasizes the importance of recognizing this rare anomaly and highlights its clinical significance. We report a case of intercoronary communication in a 56-year-old female who presented with acute chest pain and ST-segment depression in the lateral leads. High-sensitivity troponin-T was elevated and transthoracic echocardiography revealed normal left ventricular function with no regional wall motion abnormality. Hence, the diagnosis of acute coronary syndrome - non-st-elevation myocardial infarction was considered. Coronary angiography revealed a 95% focal stenosis in the major obtuse marginal artery (OM). The right coronary artery (RCA) angiogram revealed a single abnormal channel communicating the right posterolateral branch (PLV) and the distal left circumflex artery (LCX) with retrograde opacification of the proximal LCX, left main coronary artery (LMCA) and left aortic sinus. After she underwent revascularization with the drug-eluting stent to the OM. CT-coronary angiography confirmed the presence of intercoronary communication (ICC) between the right posterolateral branch and the distal LCX artery. No active intervention was done for the ICC. Over a year of follow-up, our patient remained asymptomatic. Angiographically and anatomically, collaterals and intercoronary communications should be differentiated. Obstructive coronary artery disease leads to the development of collaterals, which are typically less than 1mm in diameter, multiple and tortuous. However, ICC tends to be single and straight, usually seen without obstructive disease with unidirectional or bidirectional flow. Histologically, collaterals consist of endothelium supported by poorly organized collagen, muscle and elastic fibers. Meanwhile, ICCs resemble epicardial vessels in that they have a well-defined muscular layer. This case emphasizes the importance of recognizing this rare coronary anomaly and distinguishing it from collaterals to help in accurate diagnosis. Although they can provide an efficient blood supply to the jeopardized myocardium and can aid as a channel during coronary interventions, they can also cause myocardial ischemia by coronary steal.

Attempted retrieval of guidewire fragment using the twisting wire technique causes coronary perfusion: Case report.

Guidewire fracture is one of the biggest risks of percutaneous coronary intervention, twisting wire technique is very useful for retrieving the fractured wire, but the potential risks have been inadequately reported. Herein, we present a case of retrieval of guidewire fragments using the twisting wire technique that causes coronary perfusion. A 37-year-old male patient was admitted to our hospital for elective percutaneous coronary intervention of the left circumflex coronary artery. For chronic total occlusion of the distal left circumflex coronary artery, antegrade recanalization by wire escalation, and parallel wire techniques were attempted. However, we shockingly found that the BMW guidewire, anchored in the right coronary artery, spontaneously fractured from the proximal right coronary artery, and a lengthy fragment of the guidewire remained in the coronary. Many attempts were made to retrieve the remnant guidewire including the twisting wire technique, which leads to the perforation of the coronary. Finally, percutaneous retrieving procedures were stopped in favor of surgical extraction via a small coronary arteriotomy. This procedure was successful. To the best of our knowledge, the present case is the first reported spontaneous fracture of the guidewire. Leaving such a lengthy remnant guidewire in the artery, or leaving stenting over the wire, would impose a high risk of coronary thrombosis, perforation, and embolization. Yet, the perforation of the artery that occurred in this case, which could have had life-threatening consequences, resulted from our attempts to retrieve the guidewire using the twisting wire technique.

Heart Dominated by Solitary Coronary: A Case Report

The prevalence of coronary artery anomalies has been detected in 0.6% to 1.5% of coronary angiography. They are found since birth but usually with no significant symptoms and it does not generally manifest as myocardial ischemia however, malignant outcomes have been reported. Single coronary arteries are rare congenital anomalies in which the entire circulation for the heart is supplied by a coronary artery originating from a single ostium. It is challenging to recognize the anomaly of the patient’s coronaries, experiencing percutaneous coronary intervention (PCI) procedure, undergoing coronary artery surgery, or receiving a prosthetic valve replacement. In our case, we document a patient who underwent PCI for multi-vessel coronary lesions and in whom the atypical origin of the single left coronary artery, with the right coronary artery (RCA) emerging from the distal left circumflex artery (LCX), which was previously undetected.

Abstract 12522: Non-Ischemic Papillary Muscle Rupture Due to MRSA Myocarditis

Case Presentation: A 46-year-old male with diabetes, ESRD, and recurrent MRSA bacteremia, presented with septic shock and suffered cardiac arrest. Following resuscitation EKG showed inferolateral ischemia. TTE revealed acute mitral valve regurgitation resulting from posteromedial papillary muscle rupture (PMR). An intra-aortic balloon pump was implanted for cardiogenic shock. Coronary angiography revealed right dominant circulation and thrombotic occlusion of a small caliber distal left circumflex artery (LCX). Emergent mitral valve replacement surgery was performed. Pathologic analysis of the excised muscle and leaflet showed marked acute inflammation, bacterial invasion, and myocyte necrosis, confirming non-ischemic rupture due to MRSA myocarditis. Discussion: PMR predominantly occurs after MI, complicating 0.03% of STEMI cases in the reperfusion era. Non-ischemic causes are rare. Coexistence of myocarditis, infective endocarditis (IE), and MI poses a challenge in determining etiology. Establishing causation guides whether to expedite emergent valve surgery or focus on cardiomyocyte salvage by revascularization. The posteromedial papillary muscle is most commonly involved in PMR due to single blood supply from the PDA (most commonly a branch of the RCA, and less commonly the LCX). Coronary angiography, postoperative histopathology, and culture results determined the etiology of PMR was fulminant MRSA bacteremia culminating in myocarditis. Bacterial colonization and resultant inflammation induced physical and mechanical strain leading to complete rupture. The occluded LCX was incidental, and may have been the result of septic embolization, which occurs in up to 65% of left-sided IE. Albeit rare, non-ischemic etiologies must be considered when the anatomic presentation of acute PMR on TTE is incongruent with angiography. Definitive treatment relies on surgical intervention and mechanical circulatory support is often necessary.

Assessment of the Dimensions of Coronary Arteries for the Manifestation of Coronary Artery Disease.

The size of the coronary artery influences the effective outcome of therapeutic measures like coronary artery bypass graft (CABG) surgery, percutaneous coronary interventions (PCI), and diagnosis of coronary artery disease. Patients' age, gender, BMI, anatomical variations, and increased left ventricular size all have an effect on coronary artery parameters. This study aims to compare the average size of the coronary arteries of the Pakistani population in both sexes for manifestation of coronary artery disease. For the analysis of the coronary arteries, 100 patients of both sexes, male and female, were taken. X-ray angiography was performed for two-dimensional images of coronary arteries. For diameter measurement, images were visualized on quantitative coronary angiography (QCA) in different views (caudal and cranial views). The diameters of the left main coronary artery (left main stem/LMS), left anterior descending (LAD), left circumflex (LCx), and right coronary artery (RCA) were measured on angiograms. Data about the dimensions of the coronary artery was gathered through quantitative angiography. Data analysis was done throughSPSS version 26 (IBM Corp., Armonk, NY). There is a notable distinction in the average diameters among the proximal LAD (3.12), mid-LAD (2.40), and distal LAD (1.29). A statistically significant difference is evident among mid-LCx, distal LCx, and proximal LCx (p-value < 0.001). Likewise, the average diameter of the distal RCA (1.89) was smaller when compared to the mid-RCA (3.19) and proximal RCA (3.78). However, there was no significant difference in the average diameter among mid-LMS, distal LMS, and proximal LMS (p-value = 0.09). The average diameter of distal RCA was smaller when compared to mid-RCA and proximal RCA. The average size of proximal LAD and proximal LCx was comparatively larger than mid- and distal LAD and LCx. The findings of current research will be beneficial for the diagnosis and management of coronary artery disease patients.

Coronary Artery Pseudoaneurysm with Thrombosis of Distal Left Circumflex Artery: A Case Report

Coronary Artery Pseudoaneurysm with Thrombosis of Distal Left Circumflex Artery: A Case Report

Chronic total occlusion percutaneous coronary intervention (CTO PCI) in an intractable heart failure patient: Is there any benefit?

One of the most difficult procedures in interventional cardiology is the percutaneous coronary intervention (PCI) on a chronic total occlusion (CTO) lesion case. To rate the difficulty of guidewire crossing, several angiographic scoring methods have been developed such as the Japan CTO (J-CTO) score. Here we demonstrate the advantages of revascularization using PCI procedure in a CTO case with intractable heart failure. A 53-year-old man presented to the emergency room of Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia with acute decompensated heart failure. The patient had a history of past PCI with two patent drug eluting stents (DES): one in the left main (LM)-left anterior descending (LAD) artery and one in the distal left circumflex (LCX) artery. The patient had three times rehospitalizations in the last three months. According to single-photon emission computed tomography (SPECT) imaging, the right coronary artery was remained functional; however, the lesion was categorized into very difficult level (J-CTO >3). The PCI was carried out on the right coronary artery and the blood vessel was successfully revascularized after applying multiple techniques. Following the procedure, the heart failure was treated and the 6-minute walking test (6MWT) that performed 12 days after the PCI increased from 220 to 260 meters. The success of this case depended on a comprehensive history taking, adequate imaging methods, and the selection of the proper tools and PCI strategy. In conclusion, despite the challenges, PCI is still an option for patients with persistent complete occlusion. The PCI requires comprehensive preparation and the use of angiographic scoring systems, such as the J-CTO score, to determine the approach and the likelihood of success.

Diverse changes of ramus coronary artery on computed tomography derived fractional flow reserve due to ramus artery in normal coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background The ramus artery contributes to the development of turbulence, which may influence computed tomography (CT) derived fractional flow reserve (FFRCT) even without coronary artery disease. The relationship between ramus-induced turbulence and FFRCT is unclear. Purpose To investigate the effect of the ramus artery on FFRCT in normal coronary arteries. Methods A total of 120 consecutive patients who underwent both CT angiography including FFRCT and invasive coronary angiography, resulting in &amp;lt; 20% coronary artery stenosis were evaluated. The patients were divided into three groups: absent-ramus (n = 72), small-ramus that could not be analysed by FFRCT (n = 18), and large-ramus that could be analysed by FFRCT (n = 30). FFRCT was measured at the proximal and distal segments of the left anterior descending (LAD), left circumflex (LCX), and ramus artery (in absent-ramus group, FFRCT was measured at just above the bifurcation between LAD and LCX) were measured. The proximal FFRCT segment (proximal LAD, yellow circle; proximal Ramus or just above the bifurcation angle, yellow square; proximal LCX, yellow triangle) was measured at the same level of each vessel and the distal segment (distal LAD, white circle; distal ramus, white square; distal LCX, white triangle) was measured at obtained by the FFRCT analysis (Figure 1). Vessel morphology (vessel length, lumen volume, plaque volume), bifurcation angle, and left ventricular mass were assessed. Results In the absent-ramus group, proximal FFRCT showed no significant difference between three vessels (LAD, 0.96 ± 0.02; MID, 0.97 ± 0.02; LCX, 0.97 ± 0.02). However, in small and large-ramus groups, proximal FFRCT was significantly higher in the ramus artery than LAD and LCX (small-ramus: LAD = 0.95 ± 0.03, Ramus = 0.97 ± 0.02, LCX = 0.95 ± 0.03; large-ramus: LAD = 0.95 ± 0.03, ramus = 0.98 ± 0.01; LCX = 0.96 ± 0.03; p &amp;lt; 0.05) (Figure 2). A large ramus was associated with a higher prevalence of a distal FFRCT ≤0.80 (odds ratio 7.0, 95% CI 1.2–40.1. p = 0.03). A proximal ramus diameter predicted distal FFRCT ≤ 0.80 (cut-off 2.1 mm, AUC 0.76, sensitivity 100%, specificity 52%, 95% CI 0.61–0.90). Conclusions The presence of a large-ramus artery may cause an FFRCT decline in normal coronary arteries.

Beyond greyscale: improved detection of myocardial perfusion defects in spectral CT aortic angiography.

A 27-year-old female presented with acute-onset left-sided radiating chest pain, dizziness, and nausea triggered by recreational cycling and aggravated by exertion. Personal and family medical history was negative for heart disease. Nicotine and cannabis abuse stood out as the only cardiovascular risk factors. ECG showed T-wave inversions in V2 and V3 and cardiac biomarkers were elevated (peak hs-troponine I 17 900 ng/L, creatine kinase 1000 U/L). Thoracoabdominal ECG-gated CT angiography was performed on a second-generation spectral CT scanner (CT 7500, Philips Healthcare, the Netherlands) to rule out aortic dissection. While conventional images (A) appeared inconspicuous, the iodine density map (B) showed markedly reduced iodine uptake of the left anterolateral and inferolateral basal to midventricular myocardium (arrowhead). Emergency coronary angiography (C) confirmed type 2 spontaneous coronary dissection (SCAD) of the mid and distal left circumflex artery and hypokinesia of the lateral wall. SCAD was treated conservatively since coronary blood flow was preserved and the patient exhibited only mild symptoms at that time. In the absence of other risk factors for SCAD such as fibromuscular dysplasia or connective tissue disorders, cannabis use stands out as a possible provoking factor in our patient. This case illustrates the value of spectral CT as it allows for on-demand multi-energy analysis of routine scans without prior selection of a dedicated protocol and can improve the detection of perfusion-related pathologies. The area of reduced iodine uptake closely matched late gadolinium enhancement on follow-up cardiac MRI (D) performed 6 weeks later.

The long-term prognostic value provided by Coronary CT angiography

BackgroundRisk-stratification of patients has a major role in the prevention and treatment of cardiovascular disease. The aim was to find the most informative predictors of cardiovascular events in patients undergoing Coronary CT Angiography. MethodsWe carried out a secondary analysis of a large registry dataset. The included population comprises adults aged 18 or older who underwent Coronary CT Angiography of 64-detector rows or greater. We clustered patients based on their characteristics and compared the risk for poor clinical outcomes between the two clusters. ResultsThere were two clusters of patients having different risks for all-cause death, myocardial infarction, and late revascularization [hazard ratios (95%CI) = 2.28 (2.02, 2.57), 1.63 (1.40, 1.89), and 2.46 (2.1, 2.88), all P < 0.001]. The severity of stenosis in the left main coronary artery adjusted for age and sex was the most significant predictor of the high-risk cluster [adjusted odds ratio (95%CI) = 3.35 (2.98, 3.77), P < 0.001]. The severity of stenosis in the first obtuse marginal branch of the left circumflex, distal left circumflex, distal left anterior descending, posterior descending, the first diagonal branch of the left anterior descending, and proximal right coronary artery were important as well (all adjusted odds ratios ≥ 2.52). Cluster profiling showed a higher performance for CT Angiography features (sensitivity = 97.4%, specificity = 85.7%, C-statistic = 98.7%) than calcium, Framingham, and Duke scores in identifying high-risk patients (C-statistic = 82.1, 77.0, and 88.2%, respectively). ConclusionCoronary CT Angiography can accurately risk-stratify patients concerning poor clinical outcomes.

PULMONARY AND CORONARIES OF THE HEART SHOULD STAY APART: A CASE OF MULTIPLE CORONARY TO PULMONARY ARTERY FISTULAS

PULMONARY AND CORONARIES OF THE HEART SHOULD STAY APART: A CASE OF MULTIPLE CORONARY TO PULMONARY ARTERY FISTULAS

Correlation Analysis Between Required Surgical Indexes and Complications in Patients With Coronary Heart Disease.

A total of 215 patients with coronary heart disease (CHD) were analyzed with SPSS. Samples of different genders showed significance in the obtuse marginal branch of the left circumflex branch × 1, the diagonal branch D1 × 1, and the ms PV representation. Patients with left circumflex branch occlusion are more male and tend to be younger. Age displayed a positive correlation with left intima-media thickness (IMT) and right IMT. This indicated that as age increases, the values of left IMT and right IMT increase. Samples of different CHD types showed significance in the obtuse marginal branch of the left circumflex branch × 1, the middle part of RCA × 1, and the middle part of the left anterior descending branch × 1.5. For non-ST-segment elevation angina pectoris with acute total vascular occlusion, the left circumflex artery is the most common, followed by the right coronary artery and anterior descending branch. Ultrasound of carotid IMT in patients with CHD can predict changes in left ventricular function, but no specific correlation between left and right common carotid IMT was found. Samples with or without the medical history of ASCVD showed significance in the branch number of coronary vessel lesions. The value of the branch number of coronary vessel lesions in patients with atherosclerotic cardiovascular disease (ASCVD) was higher than in those without ASCVD. The occurrence of complication is significantly relative with the distance of left circumflex branch × 1, the middle segment of left anterior descending branch × 1.5, and the distance of left anterior descending branch × 1. For patients without complications, the values in the distal left circumflex branch × 1, the middle left anterior descending branch × 1.5, and the distal left anterior descending branch × 1 were higher than those for patients with complications. The VTE scores showed a positive correlation with the proximal part of RCA × 1, the branch number of coronary vessel lesions, the posterior descending branch of left circumflex branch × 1, the distal part of left circumflex branch × 1, and the middle part of left anterior descending branch × 1.5.

Anomalous right coronary artery from distal left circumflex coronary artery: a rare case report

Coronary artery anomalies (CAAs) being a group of congenital disorders, present with highly variable manifestations and have diverse pathophysiological manifestations. In middle aged to elderly patients, a coronary anomaly is often an incidental finding. We presented a case of 65-year-old female with history of diabetes for past 9 years who presented to our emergency department with history of exertional chest pain for past 4 weeks. Anomalous origin of right coronary artery (RCA) from distal left circumflex artery (LCX) was observed on coronary angiography. Patient was managed with optimised medical therapy (OMT).

The Average Diameter of Coronary Artery in the Healthy Adult Population of Pakistan: A Cross-Sectional Study

Aim: To determine the average diameters of the coronary arteries in the healthy adult population of Pakistan Study design: A cross-sectional study Place and duration: This study was conducted at Civil Hospital, BMCH Quetta Pakistan from March 2020 to March 2021. Methodology: A total of 120 participants were included in the study. All the patients included in the study were advised coronary angiography, nonetheless, their angiograms were normal. According to the inclusion criteria, the patients included in the study could be of any gender, above the age of 18 years, and have normal angiograms. The segments of the artery were divided as per the 29-segment model. The segments selected for the study were studied by the method of quantitative coronary angiography (QCA) method. Results: A total of 120 participants were considered in the study. The mean age of the included participants was 54.35±12.39 years. The mean of the Body Surface Area (BSA) was 1.78±0.163. The mean of the Body Mass Index (BMI) was 27.96±3.1 kg/m2. Proximal Left Circumflex (PLCx) and proximal left anterior descending (PLAD) were larger in diameter and the left main stem diameter was smaller. The Mid right coronary (MRCA) was greater in diameter, whereas the diameters of the proximal right coronary (PRCA), left main, distal left circumflex (DLCx), mid (MLAD), and distal (DLAD) were smaller. The MLAD, PLAD, PLCx, and DLAD had larger diameters and MRCA as well as the left main stem had smaller diameters. Conclusion: The diameters of the segments of the left stem of the coronary artery were smaller in the present study. Standardized data is needed for an accurate comparison. Keywords: Pakistanis, Comparison, Coronary Artery, Diameter

Surgical Skill Assessment Based on Dynamic Warping Manipulations

Percutaneous coronary intervention (PCI) has become a popular treatment for coronary artery disease. Highly dexterous skills are necessary to procedure success. However, few effective methods can be applied to PCI skill assessment. In this study, ten interventional cardiologists (four experts and six novices) were recruited. <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">In vivo</i> studies were performed via delivering a medical guidewire into distal left circumflex artery (target vessel I) and obtuse marginal artery (target vessel II) of a porcine model. Regarded as a type of manipulation data, the guidewire motion is simultaneously acquired with an electromagnetic (EM) sensor attached to guidewire tail. To address the deficiency of conventional dynamic time warping (DTW) limited to two-sequence matching, a novel warping algorithm is proposed to match multiple manipulation data. Then the intra-similarity is calculated to evaluate consistencies among each subject’s different manipulations, while the inter-similarity is further analyzed to find skill differences among different subjects. Extensive statistical analysis demonstrates that the proposed algorithm can effectively distinguish between the manipulations made by different skill-level subjects with significant differences on the target vessel I ( <inline-formula xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"> <tex-math notation="LaTeX">$P = 3.25\times 10^{-4}$ </tex-math></inline-formula> ) and II ( <inline-formula xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink"> <tex-math notation="LaTeX">$P = 7.30\times 10^{-3}$ </tex-math></inline-formula> ). These promising results show the proposed technique’s great potential to facilitate skill assessment in clinical practice and skill learning in surgical robotics.

Anomalous Right Coronary Artery Arising From Distal Left Circumflex Artery

Single coronary artery (SCA) is a rare congenital anomaly in which the cardiac myocardium is supplied by a coronary circulation arising from a single ostium off of the aorta. SCAs are commonly classified according to the Lipton classification system, and the incidence appears to range between 0.014% and 0.066%.1,2 Presentations of patients with SCA include detection as an incidental finding on angiography, atypical chest pain, typical chest pain thought to be secondary to spasm or decreased blood flow, and typical chest pain with atherosclerosis requiring percutaneous intervention or bypass grafting.

Coronary atherosclerotic plaque extent in hypertensive patients detected by computed tomographic angiography

Objective To evaluate the extent of coronary artery calcium in hypertensive patients using multislice computed tomography. Background Uncontrolled hypertension is one of the most common determinants for hospital admissions owing to acute coronary events. Computed tomographic (CT) coronary calcium scoring has been established as the best noninvasive predictor of atherosclerotic cardiovascular risk available today. Patients and methods The present study was conducted on 90 patients with recurrent chest pain referred for coronary multislice computed tomography angiography at Kobry El-Kobba Military Hospital. Patients comprised 69 hypertensive patients and 21 normotensive patients. Full history taking, laboratory investigation, coronary CT angiography, coronary plaque distribution, and coronary artery calcium scoring (CACS) were done. Results There was no statistically significant difference between the studied groups regarding mid left anterior descending (LAD) obstruction, distal LAD obstruction, proximal left circumflex (LCX) obstruction and distal LCX obstruction, proximal right coronary artery (RCA) obstruction, mid RCA obstruction, and distal RCA obstruction. However, hypertensive patients had significantly higher rate of 1–49% proximal LAD obstruction (P = 0.015) and mid LCX 1–49% and more than or equal to 50% obstruction (P = 0.034). Moreover, nonhypertensive patients had significantly higher number of patients with nonaffected vessels. Hypertensive patients had significantly higher rate of two-vessel affection. Moreover, hypertensive patients had significantly higher CACS, atheroma burden obstructive score, segment involvement score, and segment stenosis scored syntax I score compared with nonhypertensive patients. Conclusion Hypertension is associated with higher rate of coronary artery stenosis as shown by CT angiography. Hypertension is associated with increasing CACS.

Usefulness of Repeat Angiography to Establish Spontaneous Coronary Artery Dissection in Small Vessels.

Background: Spontaneous coronary artery dissection (SCAD) is a rare disease that is often misdiagnosed, except in typical cases. Although intracoronary imaging and multislice coronary computed tomography angiography (CCTA) are useful in establishing dissection, they may not be feasible in all instances, especially in small vessels.Methods and Results: We describe a series of 7 patients with acute coronary syndrome secondary to small vessel SCAD that was detected only upon repeat coronary angiography (CAG). This cohort had a mean (±SD) age of 50±6 years, was predominantly female (n=6; 86%), and had few coronary risk factors. Three patients (43%) had dissection of the distal segment of the right coronary artery, 3 (43%) had distal left circumflex artery dissection, and 1 patient (14%) had a diagonal branch dissection. None of the patients required percutaneous coronary intervention, and received conservative therapy only, because the infarct area was sufficiently small. No definitive diagnosis of SCAD could be established in any of the patients at first admission because CAG alone or CCTA did not reveal the presence of a flap or intraluminal hemorrhage. However, in such patients without a definitive diagnosis, repeat CAG in the chronic stage showed enlargement of vessels, suggesting the healing of an SCAD.Conclusions: Repeat CAG may be useful for suggesting the occurrence of SCAD.

Abstract 15484: Combined Coronary and Carotid Artery Involvement in a Caucasian Patient With Moyamoya Disease

Introduction: Moyamoya disease (MMD) is a rare, progressive steno-occlusive disease of the intracranial carotid arteries. This is primarily a cerebrovascular disease and is mostly seen in young Japanese patients. We report a case of severe stenosis in the distal left circumflex artery (dLCx) in a non-Japanese patient with previously diagnosed MMD. Case presentation: A 33-year-old Caucasian female with history of MMD and 2 CVAs presented with chest pain for 2 days. Her only medication at home was aspirin. There was no history of hypertension, diabetes mellitus, or tobacco use. There was no family history of early CAD. Physical examination was positive for tachycardia but negative for carotid or femoral bruits. Neurologic examination revealed decreased touch sensation and diminished deep tendon reflexes on the left side. ECG demonstrated tachycardia with T wave inversions in leads III and ST depression in lead II. Acute CVA was ruled out with an MRI. Cardiac troponins were minimally elevated with peak of 0.12 ng/dl. An initial diagnosis of NSTEMI was made; patient was loaded with aspirin, clopidogrel and started on a heparin drip. Cardiac catheterization on the following day revealed single vessel CAD in the dLCx, with 80% stenosis and TIMI flow 2. A drug eluting stent was successfully placed in the dLCx. Angiogram post-stent placement showed optimal angiographic result with TIMI 3 flow. The patient was discharged home on dual antiplatelet therapy, statin, beta-blocker and ACE inhibitor. Discussion: MMD is thought to affect the coronary arteries from fibrous intimal thickening and histopathology of these coronary lesions show a homogenous, soft intimal proliferation with minimum lipid deposition and without substantial inflammatory cell infiltration. Although the combined involvement of carotid and coronary artery stenosis is rare, coronary involvement should be considered as one of the causes of ischemic heart disease in young patients with MMD. To the best of our knowledge, this is the first reported case of combined involvement of carotid and coronary artery stenosis in a Caucasian patient with previously diagnosed MMD. It is imperative to educate patients with MMD about possible CAD so that they seek immediate medical attention if cardiac symptoms occur.

Mechanical difference of left ventricle between rabbits of myocardial infarction and hypertrophy

The analysis of cardiac wall stress is of importance to understand the development of heart failure (HF). The aim of the study is to carry out the cardiac mechanics analysis to show the changes of left ventricular (LV) wall stresses after LV hypertrophy (LVH) and myocardial infarction (MI). Here, LVH and MI were generated in rabbit hearts through the transverse aortic constriction (TAC) and the distal left circumflex (LCx) artery ligation operations, respectively. Physiological and CT measurements were carried out at postoperative 2 and 4 weeks, based on which a finite element (FE) model was developed to perform the mechanics computation. We found a gradual increase of end-diastolic myofiber stress in free wall and interventricular septum of LVH and MI (higher stress in the free wall than the septum). In the interventricular septum, the 4-weeks LVH group has the highest ED myofiber stresses (11.378 ± 3.022 kPa), while the 4-weeks MI group has the highest ED myofiber stresses (13.494 ± 2.835 kPa) in the free wall. LVH increased myocardial volume (3.49 ± 0.07 and 4.52 ± 0.26 ml at postoperative 2 and 4 weeks) while MI increased LV volume (from 2.75 ± 0.29 to 4.19 ± 0.27 ml). LVH and MI had different distributions of local myofiber stress.