Inferior Myocardial Infarction Research Articles

Effect of reperfusion time on right ventricular remodeling in inferior ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background: Right ventricle (RV) remodeling and dysfunction are frequent in inferior ST-elevation myocardial infarction (STEMI) patients and possibly implicated to poor outcomes. Objective: The purpose of this study is to investigate the influence of reperfusion time on RV remodeling in patients with inferior STEMI who had primary percutaneous coronary intervention (PPCI).Methods: The subjects were patients with inferior STEMI who had undergone PPCI and met the inclusion and exclusion criteria. From September 2021 to April 2022, samples were taken in the order in which they arrived at the Dr. Sardjito Hospital in Yogyakarta, Indonesia. To investigate the occurrence of RV remodeling, 2D-transthoracic echocardiography was performed before PPCI as baseline and 3-months after PPCI. Confounding factors were investigated using bivariate and multivariate analysis.Results: The RV remodeling was observed in 12 (28.6%) of 42 inferior STEMI patients undergoing PPCI. The RV remodeling group had a longer median reperfusion time (798.5 vs 710 minutes, p=0.568). The baseline RV end-systolic area (RVESA) and RV end-diastolic area (RVEDA) had significant correlations with the occurrence of RV remodeling (p=0.046; p=0.008, respectively). The tricuspid annular plane systolic excursion (TAPSE) rose considerably in both groups during the 3-month follow up. There were significant variations in RVEDA and RV basal diameter in the RV remodeling group, but there was a substantial rise in fractional area change (FAC) and RVESA in the non-RV remodeling group.Conclusion: In patients with inferior STEMI undergoing PPCI, reperfusion time showed no significant effect on RV remodeling.

The Heart Does Not Itch, But it Feels Pain: Three Cases of Kounis Syndrome

Background: Kounis syndrome is defined as the occurrence of acute coronary artery syndrome as a result of activation of inflammatory cells after conditions such as allergy, hypersensitivity, anaphylaxis or anaphylactic reactions. This case reports were presented to provide the latest knowledge on Kounis syndrome, increase awareness of this disease among healthcare providers and researchers, and promote early and appropriate diagnosis and management of this syndrome. Summary of Cases: In the first case, a 45-year-old female patient with no history of coronary artery disease developed anaphylaxis due to a locally applied anesthetic drug. This led to transient coronary artery vasospasm and acute coronary syndrome. In the second case, a 70-year-old male patient with a history of coronary artery disease developed anaphylaxis due to a bee sting. This caused rupture of the coronary artery plaque, resulting in inferior myocardial infarction. In the third case, a 73-year-old male patient with a stent in his coronary artery developed an allergic reaction/anaphylaxis to midazolam, which was administered for sedation before the biopsy procedure. This reaction resulted in restenosis of the old stent and caused an anterior myocardial infarction. Conclusion: Kounis syndrome is a life-threatening condition that requires attention. Ensuring coronary artery patency in the treatment of ischaemia is important to protect cardiomyocyte health and prevent arrhythmias. Ischaemia caused by allergens can be resolved with a combination of antiallergenic treatments. Therefore, for effective management of suspected cases of Kounis syndrome, collaboration between cardiology and allergy-immunology clinics is essential.

Giant Coronary-Pulmonary Artery Fistula Incidentally Detected in a Patient Presenting With Acute Inferior Myocardial Infarction

Giant Coronary-Pulmonary Artery Fistula Incidentally Detected in a Patient Presenting With Acute Inferior Myocardial Infarction

Clinical significance of R-wave amplitude in lead V1 and inferobasal myocardial infarction in patients with inferior wall myocardial infarction.

To assess electrocardiogram (ECG) for risk stratification in inferior ST-elevation myocardial infarction (STEMI) patients within 24 h. Three hundred thirty-four patients were divided into four ECG-based groups: Group A: R V1 <0.3 mV with ST-segment elevation (ST↑) V7-V9, Group B: R V1 <0.3 mV without ST↑ V7-V9, Group C: R V1 ≥0.3 mV with ST↑ V7-V9, and Group D: R V1 ≥0.3 mV without ST↑ V7-V9. Group A demonstrated the longest QRS duration, followed by Groups B, C, and D. ECG signs for right ventricle (RV) infarction were more common in Groups A and B (p < .01). ST elevation in V6, indicative of left ventricle (LV) lateral injury, was more higher in Group C than in Group A, while the ∑ST↑ V3R + V4R + V5R, representing RV infarction, showed the opposite trend (p < .05). The estimated LV infarct size from ECG was similar between Groups A and C, yet Group A had higher creatine kinase MB isoform (CK-MB; p < .05). Cardiac troponin I (cTNI) was higher in Groups A and C than in B and D (p < .05 and p = .16, respectively). NT-proBNP decreased across groups (p = .20), with the highest left ventricular ejection fraction (LVEF) observed in Group D (p < .05). Group A notably demonstrated more cardiac dysfunction within 4 h post-onset. For inferior STEMI patients, concurrent R V1 <0.3 mV with ST↑ V7-V9 suggests prolonged ventricular activation and notable myocardial damage. RV infarction's dominance over LV lateral injury might explain these observations.

Limitations of Diagnosis of Ischemic Left Ventricular Dysfunction Using the Values of Strain, Twist and Untwist in Patients With Myocardial Infarction of Various Localization.

To compare capabilities for diagnosing regional and global myocardial dysfunction using the values of longitudinal and circular strain, left ventricular (LV) torsion and untwisting in patients with myocardial infarction (MI) of various locations. Patients included in the study (n=121) were divided into three groups: patients with unstable angina (n=30), patients with anterior MI (n=45), and patients with inferior MI (n=46). Clinical, laboratory and instrumental test were performed, including echocardiography. For a quantitative analysis of LV contractility, the maximum systolic peaks of regional and global longitudinal and circular strain, systolic and diastolic rotation, LV torsion and untwisting were measured. Anterior MI was characterized by injury of the LV apical segments, while inferior MI was characterized by injury of the basal segments. In anterior MI, the longitudinal strain was reduced less than 14.5% and circular strain less than 19.3% in the apical segment of the LV anteroseptal wall (ASW). In akinesia of the LV ASW apical segment, longitudinal and circular strains were reduced less than 10%. The magnitude of the circular strain of the LV ASW apical segment (diagnostic threshold 19.3%, sensitivity (Se) 87%, specificity (Sp) 90%) was superior to that of the longitudinal strain as a diagnostic marker for regional ischemic dysfunction in anterior MI. The magnitude of the circular strain of the basal segment of the LV inferior wall in inferior MI has a greater diagnostic value for identifying regional systolic dysfunction than the value of the longitudinal strain of this LV segment. The diagnostic threshold was 17.3%, Se 79%, Sp 80%. A decrease in the circular strain of the LV ASW less than 19.3% in the LV apical segment is more specific (Sp 90%) for diagnosing regional systolic dysfunction in anterior MI than a decrease in longitudinal strain. A circular strain value of less than 17.3% in the basal segment of the LV inferior wall is more specific (Sp 80%) than the longitudinal strain of this segment for diagnosing regional systolic dysfunction in inferior MI. Predominant injury to the LV apex in anterior MI can cause systolic and diastolic myocardial dysfunction, which is manifested by a decrease in LV circular deformation, torsion and untwisting.

Prevalence and Clinical Profile of Right Ventricular Infarction in Patients with Acute Inferior Wall Myocardial Infarction at a Tertiary Care Hospital

Objectives: Coronary artery disease remains a prominent global cause of illness and mortality. A significant proportion of individuals experiencing acute inferior myocardial infarction (IWMI) develop right ventricular infarction (RVI), contributing substantially to clinical and hemodynamic instability. This study aims to assess the prevalence of RV infarction in patients presenting with IWMI. Methodology: Consecutive IWMI patients visiting the Department of Cardiology at the National Institute of Cardiovascular Diseases between February 2021 and August 2021, of any gender and aged between 18 and 80 years, were recruited. Patients underwent a comprehensive assessment, including history, clinical examination, routine investigations, and electrocardiogram (ECG). Right ventricular infarction was evaluated based on a right-sided ECG. Results: A total of 155 patients were included, with a mean age of 56.2±12.4 years; 40 (25.8%) were between 18 to 50 years old. In terms of gender distribution, 105 (67.7%) were male. Comorbid conditions included hypertension in 88 (56.8%) patients, diabetes mellitus in 58 (37.4%), 64 (41.3%) smokers, and 26 (16.8%) with a positive family history. RVI was observed in 41 (26.5%) patients. Notably, the prevalence of RVI differed significantly between diabetic and non-diabetic patients (13.8% vs. 34%, p=0.006) and between those with positive and negative family histories (7.7% vs. 30.2%, p=0.017), respectively. No significant impact of other parameters on RVI was observed. Conclusion: Right ventricular infarction was prevalent in more than a quarter of patients with IWMI. It exhibited a negative association with the presence of diabetes and a positive family history.

Informativeness of echocardiography in inferior myocardial infarction at different stages of observation

Aim. to evaluate the informativeness of echocardiographic parameters in patients with acute inferior wall myocardial infarction of the left ventricle, who have undergone primary percutaneous coronary intervention, at discharge from the hospital and in the long-term period.&#x0D; Material and methods. Echocardiographic data was analyzed using speckle tracking technology in 144 patients with acute inferior myocardial infarction of the left ventricle before discharge and 2 years later. In the post-infarction period, 10 patients underwent magnetic resonance imaging and 15 patients underwent stress echocardiography.&#x0D; Results. Using the tree construction method, critical values of 7 ultrasound parameters were identified (for the left ventricle - ejection fraction, end-systolic volume index, global longitudinal and circular strains, for the right ventricle - tricuspid S', global longitudinal strain, free wall strain), which with a probability of 89.4% predict repeat revascularization.&#x0D; Identification of possible areas of myocardial fibrosis in the remote period by speckle-tracking echocardiography has a sensitivity of 46-57%, specificity of 68-76%, and negative predictive value of 74-87% relative to the gold standard detection of postinfarction scarring by magnetic resonance imaging.&#x0D; According to the results of stress-echocardiography, new zones of local contractility impairment registered after exercise were not accompanied by changes in segmental longitudinal deformation.&#x0D; Conclusion. The results of echocardiographic screening of patients with acute inferior myocardial infarction of the left ventricle using speckle tracking technology have high prognostic significance in assessing the likelihood of repeated revascularization at discharge and diagnostic information for verifying post-infarction fibrous changes in the long-term period.

Myocardial Infarction Seen Tardively Complicated by Ventricular Septal Rupture Extending to the Right Ventricule: A Dilemmatic Scenario

Ventricular septal rupture (VSR) is an uncommon but well-recognized mechanical complication of acute myocardial infarction (MI). Mortality without intervention is 70% in intrahospital at 30 days, and 90% at one year due to cardiogenic shock. Transthoracic echocardiography (TTE) is the choice tool in the diagnosis and evaluation of VSR. We report an original case of a 72-year-old patient diagnosed with myocardial infarction of the inferior wall of the left ventricle, complicated by the rupture of its basal segment aneurysm extending to the right ventricle. After which standard drug treatment was prescribed. Inferior wall myocardial infarction complicated with VSR at its basal segment is a rare mechanical complication of MI and this clinical case shows a rare location of VSR compared to forms described in the literatures. On the third day, the patient died from refractory cardiogenic shock, and neurological complications which could have been prevented by surgery. Treatment of VSR secondary to MI is an emergency based on either an open heart surgery or percutaneous intervention inorder to reduce morbi-mortality rate.

The Impact of Percutaneous Coronary Intervention of Right Coronary Artery on Right Ventricular Function after Acute Inferior Myocardial Infarction

The Impact of Percutaneous Coronary Intervention of Right Coronary Artery on Right Ventricular Function after Acute Inferior Myocardial Infarction

Right Ventricular Infarction in Patients with Inferior Wall Myocardial Infarction and its Association with Various Risk Factors

Background: Right ventricular infarction (RVI) is a significant complication of inferior wall myocardial infarction (IWMI), associated with increased mortality, cardiogenic shock, and ventricular arrhythmias. Despite its clinical importance, the detection and management of RVI remain challenging, underscoring the need for further investigation into its prevalence and associated risk factors. Objective: This study aims to assess the prevalence of RVI among patients with IWMI and to identify the major risk factors contributing to the development of RVI, thereby providing insights into more effective management strategies. Methods: A prospective descriptive study was conducted at a military hospital over a period of one year, involving 114 patients diagnosed with IWMI. Patients were screened for RVI using right-sided precordial leads in electrocardiograms. Data on demographics, risk factors, and clinical outcomes were collected. Statistical analyses, including chi-square and Student's t-tests, were employed to identify significant associations between RVI and potential risk factors. Results: Of the 114 patients with IWMI, 42 (36.8%) were diagnosed with RVI. The mean age of participants was 53.17 ± 9.06 years, with a predominance of males (61.4%). Hypertension was identified as the most significant risk factor for RVI, with 65.2% of hypertensive patients developing RVI compared to 17.6% of non-hypertensive patients (p &lt; 0.001). Other significant associations included smoking (56.7% of smokers had RVI, p = 0.008) and diabetes mellitus (58.3% of diabetics had RVI, p = 0.014), while gender and dyslipidemia were not statistically significant predictors. Conclusion: The study highlights a substantial prevalence of RVI among patients with IWMI, with hypertension emerging as the most critical risk factor. These findings underscore the importance of comprehensive screening and management of hypertension and other modifiable risk factors in patients with IWMI to reduce the incidence of RVI and improve clinical outcomes.

Apical thrombus mimicking ventricular septal rupture.

A 51-year-old man with chest pain was admitted to the emergency department. The patient was taken to the coronary angiography lab with a diagnosis of inferior myocardial infarction.

[Characteristics of Inferior Myocardial Infarction With a Special Electrocardiographic Pattern (Aslanger) in Metabolic Syndrome].

To evaluate the features of ST-segment elevation myocardial infarction with the Aslanger pattern in comparison with traditional forms of inferior myocardial infarction in metabolic syndrome. This study included 30 patients with inferior myocardial infarction in the presence of metabolic syndrome: 9 patients with the Aslanger electrocardiographic pattern (group 1, age 59.7 [58.4; 63.1] years) and the rest with one of the traditional forms (control group, 59.9 [57.2; 63.8] years, matched by all criteria of metabolic syndrome). All patients underwent primary percutaneous intervention with assessment of the angiographic picture. The magnitude of ST-segment elevation was measured in lead III at the J point and following 0.06 seconds, and the optimal threshold value of this indicator was determined for a new picture of myocardial infarction. The infarct-related artery in the Aslanger pattern was more often the circumflex artery (p=0.0099), and coronary thrombosis was characterized by a lower TIMI thrombus grade (p=0.014). SYNTAX values for the Aslanger pattern and for the traditional picture of inferior infarction with ST elevation in lead II≥III were higher than for a similar picture with ST elevation in lead III&gt;II. The level of cTnI at admission (p=0.013) and after 24 hours (p=0.0017), the platelet count (p=0.0011) and mean volume (p=0.0047) in group 1 had smaller values than with traditional inferior infarction. The ST elevation at J point and at J+0.06 s point for lead III with the Aslanger pattern was significantly lower than values of such shift in lead III&gt;II and lead II≥III with traditional inferior infarction (p&lt;0.001). An elevation value ≤1.5 mm at J point +0.06 s was a predictor of infarction with the Aslanger pattern. Constructing the ROC curve made it possible to determine that with the Aslanger pattern, the best cutoff value for this index is 2 mm. Myocardial infarction with the Aslanger pattern as compared with traditional lower infarction in metabolic syndrome is characterized by specific individual angiographic signs, lower ST segment elevation, cTnI level, and thrombotic disorders.

Acute myocardial infarction associated with multiple giant coronary artery aneurysms: a management dilemma.

A 77-year-old man presented with an acute inferior ST-segment elevation myocardial infarction.

Diagnostic value of electrocardiographic indices in discriminating the culprit vessel based on the coronary dominancy in inferior acute myocardial infarction

BackgroundIdentifying the culprit during inferior myocardial infarction (MI) is still challenging. We determined the diagnostic effect of electrocardiographic (ECG) indices in identifying the culprit vessel of acute MI and the impact of coronary artery dominance on it. MethodsThis cross-sectional study included patients with acute inferior MI who presented to Imam Khomeini Hospital and Tehran Heart Center and underwent primary PCI within 12 h of the onset of symptoms. A standard 12‑lead ECG was recorded and interpreted by two cardiologists. Based on the coronary angiography, the patients were divided into two groups of LCX or RCA involvement and were compared for general variables and ECG indices. The diagnostic values of the ECG indices for predicting the culprit vessel were then calculated. ResultsWe evaluated 411 patients with inferior STEMI (321 [77.5%] male, age 58.1 ± 11.1 years). RCA was the culprit vessel in 286 patients (69.1%) and LCX in 128 patients (30.9%). 321 patients (77.5%) were right dominant, 40 (9.7%) patients were left dominant, and 53 patients (12.8%), were codominant. Coronary dominance had minimal impact on the ECG indices regarding culprit identification even after adjustment for confounders. STE in lead III > lead II had the highest sensitivity for detecting RCA as the culprit (sensitivity: 89.2% and specificity: 57.8%). STE ≥0.1 mV in V5 or V6 leads had the highest sensitivity for detecting LCX as the culprit (sensitivity: 51.6, specificity: 93.7%). ConclusionIn inferior STEMI, ECG indices can predict the culprit vessel with acceptable sensitivity and specificity independent of coronary artery dominance.

Right ventricular infarction: epidemiological, clinical, and angiographic characteristics and the outcomes through the experience of a Moroccan cardiology department

Background: Acute myocardial infarction (MI) is a major cause of cardiovascular mortality, which is the leading cause of death in the world. Our objective in this study was to evaluate the epidemiological, clinical, and angiographic features of right ventricular infarction (RVI), as well as its complications and its therapeutic approaches. Patients and methods: It is a single-centered retrospective descriptive study conducted over a period of 2 years from November 2018 to October 2020. The authors included 82 patients with RVI hospitalized in the cardiovascular ICU during the initial phase of acute coronary syndrome with persistent ST segment elevation. Patients who were diagnosed with RVI at electrocardiogram and echocardiography were recruited. Results: The authors included 500 patients hospitalized for STEMI, 82 had MI extended to the RV, reflecting a rate of 16.4%. The mean age in our study was 64±12.3 years. Dyslipidemia, diabetes mellitus, and hypertension were the most common cardiovascular risk factors among these patients. RVI co-existed with inferior MI in 62.2 of cases and in 37.8% of anterior MI, while isolated RVI was seen in only one patient. Transthoracic echocardiography showed right ventricular (RV) systolic dysfunction in 24.39% of cases, while RV dilatation was seen in only 10.9% of patients. Therapeutic approach was based essentially on revascularization with thrombolysis and coronary angiography +/- PCI. The percentage of mortality was 2.4%. Conclusion: RVI is relatively rare and is mostly related to an extension of an inferior MI. Early diagnosis, prompt treatment, and appropriate are the keys to improve prognosis, and reduce complications.

P 022: Myopericarditis associated with herpes zoster infection presented with STEMI

We describe a case of an 18-year-old male with no known medical illness who presented with a history of fever and skin rash for the previous 2 days. The patient presented with symptoms of acute nausea, vomiting, and chest discomfort. The initial electrocardiogram (ECG) revealed an inferior ST-segment elevation myocardial infarction (STEMI), which prompted the administration of thrombolysis using streptokinase at the district hospital. However, consecutive ECGs showed no change, prompting the patient to be referred to our centre for a rescue percutaneous coronary intervention (PCI). The coronary angiography showed normal coronaries, whereas an echocardiogram showed good LV functions without any regional wall motion abnormalities and with normal valves. Upon further examination, the patient exhibited herpes zoster lesions along the T5–T6 dermatome. Blood investigations revealed elevated levels of thyroid hormones, as well as increased creatinine kinase and troponin I. The cardiac MRI showed the presence of mid-wall enhancement in the septal and lateral myocardium of the left ventricle, sub-epicardium of the right ventricle, and apical region of the left ventricle, which is indicative of myocarditis. The patient was diagnosed with myopericarditis and was treated with IV acyclovir, colchicine, high-dose aspirin, and carbimazole. He subsequently showed significant improvement and was successfully discharged. Although type 1 STEMI remains the prevailing diagnosis, this case emphasises the distinctive differential diagnosis of myopericarditis in patients presenting with chest discomfort and herpes zoster. Clinicians must obtain a thorough medical history and conduct a comprehensive evaluation to identify potential secondary aetiologies.

Successful healing of aneurysmal false lumen using a second-generation drug-eluting stent in spontaneous coronary artery dissection: a case report

BackgroundAccording to 2023 ESC Guideline, conservative medical management is generally recommended for the treatment of spontaneous coronary artery dissection (SCAD) except for patients with signs of ongoing myocardial ischemia. However, in some cases, invasive treatment (coronary artery bypass graft surgery or percutaneous coronary intervention (PCI)) is performed because of the progression of aneurysm in SCAD. Although there is no established strategy for the management of coronary aneurysm in SCAD, we report a case of successful healing of aneurysmal false lumen (AFL) using a second-generation drug-eluting stent (DES) in SCAD.Case presentationA 44-year-old woman without any cardiovascular risk factors was transferred to our hospital due to inferior myocardial infarction. Coronary angiography (CAG) showed multiple SCADs in the coronary artery. We performed PCI to the distal right coronary artery (RCA) because the RCA showed severe stenosis (99%) with bradycardia. Six days after the first PCI, SCAD relapsed in the mid left anterior descending artery (LAD). Furthermore, AFL was observed by intravascular ultrasound imaging. To avoid enlargement of the AFL and progression of the dissection toward the proximal site of the LAD, we performed PCI to the mid LAD to seal the entry tear of the dissection using a second-generation DES. CAG revealed that the AFL in the mid LAD completely diminished at 1 year after PCI.ConclusionsThe implantation of a second-generation DES might be one of therapeutic options for sealing AFL in SCAD patients.

Lipoprotein (a) as a cause of premature coronary artery disease; a case report of a 34-year-old male patient presenting with ST elevation myocardial infarction.

Background&#x0D; Premature coronary artery disease (PCAD) is considered when coronary artery disease (CAD) occurs in the younger population, less than 45 years old in males. Modifiable risk factors are present in about 80% of patients with PCAD such as smoking, diabetes, high blood pressure and obesity. High serum lipoprotein (a) level has recently emerged as a risk factor for PCAD. However, it is not routinely investigated in young patients presenting with acute coronary syndromes.&#x0D; Case Presentation&#x0D; A 34-year-old African man presented to our hospital with 2 hours of worsening left sided chest pain. He gave a history of long-standing chest pain in the past that was being managed as peptic ulcer disease. He also complained of a slow heart rate. He had no traditional cardiovascular risk factors. The only significant history was a recent recovery from COVID-19 infection two months prior. His physical examination was only significant for a bradycardia, ECG revealed a hyper acute inferior STEMI without right ventricular involvement. Echo showed a normal left ventricle with reduced ejection fraction (EF: 50%), wall motion abnormalities consistent of an inferior MI. He immediately received streptokinase with good clinical and ECG response. His coronary angiogram showed a severe lesion and plaque rupture in the mid-distal segment of a dominant right coronary artery. Percutaneous coronary intervention (PCI) was successfully done, and one drug eluting stent was implanted. He was placed on guideline directed medical therapy for secondary prevention. The only significant possible aetiology found was an elevated Lipoprotein (a) (137mg/dl). Subsequent serum Lipoprotein (a) remained persistently elevated despite therapy with high dose niacin. He was recommended for a PCSK9 receptor blocker, but this medication is not available in the country and the patient could not meet the costs. He remains stable to current medications with no recurrence of chest pain, two years after the index event, the Lipoprotein (a) levels are still high.&#x0D; Conclusions:&#x0D; Lipoprotein (a) appears to be an important overlooked cardiovascular risk factor for premature coronary artery disease especially in the absence of traditional risk factors. It should always be considered in the screening of premature coronary cardiovascular disease. The acute presentation in this patient was probably triggered by SARS COV-2 infection.

Up against the wall - emergency double myocardial rupture repair

BackgroundLeft ventricular free wall rupture (LVFWR) and interventricular septal rupture (VSR) are potentially catastrophic mechanical complications after acute myocardial infarction (AMI). When they occur together, “double myocardial rupture” (DMR), survival is unlikely. DMR is seen in only 0.3% of all AMIs. With or without surgical intervention, the odds are against the patient.Case presentationA 57-year-old male self-referred to the emergency department of a remote hospital 5 days after first experiencing chest pain. Investigations in ED confirmed an inferior ST-segment elevation myocardial infarction (STEMI) complicated by DMR. Coronary angiography revealed a mid-course total occlusion of the right coronary artery (RCA). He was rapidly transferred to our regional cardiac surgical unit, arriving straight into the operating theatre, in cardiogenic shock. He was briefly conscious, before arresting prior to intubation and being massaged onto bypass. Not only did he survive the all-night operation, requiring a mitral valve replacement in the process, but he survived multiple postoperative complications to be eventually transferred on postoperative day 66, neurologically intact, to a peripheral unit to complete his rehabilitation. He was subsequently discharged home 88 days after the operation and was able to ambulate with a walking frame into his first postoperative follow-up clinic appointment.ConclusionsOur patient, against all odds, has survived DMR and multiple postoperative complications. We present the details of his case and the literature surrounding the condition. The patient’s mental fortitude and his supportive family played a significant role, along with excellent multidisciplinary team work, in assuring his survival.

Coronary Cascade Connecting Right Posterior and Left Anterior Descending Arteries: A Rare Coronary Anomaly

“Coronary cascades” or “coronary arcades” are congenital inter-coronary communications allowing uni- or bi-directional blood flow seen in the absence of obstructive coronary lesions. Coronary cascades take up the role of collaterals if atherosclerotic lesions develop. We present the angiogram images of a coronary cascade connecting left anterior and right posterior descending arteries (LAD and RPDA) in the distal interventricular groove in a patient with spontaneous coronary artery dissection and near total occlusion of LAD who presented with inferior wall myocardial infarction secondary to acute thrombotic occlusion of the right coronary artery. The presence of the arcade prevented a massive inferior or anterior wall myocardial infarction in our patient.