Intervention Of Right Coronary Artery Research Articles

AN ISOLATED ACUTE RIGHT VENTRICULAR INFARCTION

Abstract Isolated right ventricular infarction occurs only in about 3% of the overall myocardial ischemic episodes. Clinical presentation is often insidious and variable case by case. The correct diagnosis is therefore crucial for a proper management, and a good prognosis in the short and long term. A 72–year–old patient suffering from arterial hypertension went to the emergency room of our hospital for malaise and asthenia for about 12 hours that have increased in 3–4 hours before the arrival. He was sweating, tachypneic with normal value of the oxygen saturation to the finger (SpO2:96%), with arterial hypotension (pressure values = 85/50 mmHg), turgor of the jugular veins in the absence of peripheral edema. Cardiac examination revealed no pathological noises and lung examination revealed clear lung fields. Electrocardiogram showed sinus tachycardia at a rate of 118 bpm, second degree atrioventricular (AV) block 2:1 type and an AV conduction delay with a first–degree AV block (P–Q interval: 320–330 msec). A pulmonary P wave was present and the QRS complex showed predominant R waves in V2–V3 with slight repolarization abnormalities (figure, panel A). An ST–elevation in right precordial leads, V3R and V4R was evident. (figure, panel B). Echocardiographic evaluation showed a hypertrophic left ventricle with normal volume and function, with marked enlarged right sections (figure, panels C–H). Moreover, we can observe the flattening of the interventricular septum with a D shaped left ventricle. Septal flattening occurred only in diastole, expression of RV volume overload (figure, panels F–H). After taking 180 mg of ticagrelor administrated orally and 150 mg of aspirin intravenously, the patient was immediately transferred to the catheterization laboratory for emergency coronary angiography. Coronary angiography highlighting an ostial thrombotic obstruction of a co–dominant right coronary artery (RCA) in the absence of significant stenosis of the left coronary circulation (figure, panels I–M). Primary percutaneous coronary intervention of RCA was performed with STENT implantation with a good postoperative result. (figure, panels L). During the hospital stay, the patient showed a good clinical status without any CV events, with progressively normalization of electrocardiographic abnormalities and persistent sinus rhythm. He was discharged after ten days.

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

Impact of percutaneous coronary intervention in right coronary artery on right ventricular function in patients with acute myocardial infarction.

Background: Right ventricular (RV) dysfunction is a potent predictor of mortality and morbidity following acute myocardial infarction (AMI). Despite the fact that elective percutaneous coronary intervention (PCI) has significantly decreased myocardial damage to the left ventricle, there is a lack of information regarding the effect of PCI on RV function. Aim: This study aimed to examine the effect of right coronary artery (RCA) revascularization on the systolic and diastolic functions of the right ventricle following acute inferior wall myocardial infarction. Methods: Fifty-nine patients diagnosed with acute inferior wall myocardial infarction after RCA revascularization were prospectively investigated between April 2018 and January 2020. The patients underwent 2D echocardiography. RV systolic and diastolic functions were reported before and after the PCI procedure and compared using echocardiographic RV systolic and diastolic parameters. Results: After PCI, echocardiographic RV systolic and diastolic functions significantly improved in the proximal and mid RCA in terms of TAPSE, RVFAC, and E/A. Significant improvement was found in the mid RCA in terms of S' velocity (p=0.008) and in the proximal RCA in terms of E/e' (p=0.021). Overall echocardiographic systolic and diastolic parameters in patients with RV dysfunction following PCI were improved [TAPSE (37.29% vs. 81.82%), S' velocity (37.29% vs. 68.18%), RVFAC (33.90% vs. 90.00%), and E/A (33.90% vs. 75.00%)]. Conclusion: Our findings revealed that patients with RV dysfunction showed remarkable improvement after RCA revascularization. Hence, in future cases, RCA revascularization may become an appropriate treatment alternative for the recovery of patients with RV dysfunction.

Abstract 9492: Transcatheter Amplatzer Occluder Device Closure of Post-Myocardial Infarct Pseudoaneurysm: A Case Report

Introduction: Left Ventricular Pseudoaneurysm (LVP) is defined as cardiac wall rupture leading to a formation of wall with thrombus, pericardial, or scar tissue functioning as a pouch for blood. A loculated pericardial effusion (LPE), and right ventricular pericardial fistula (RVPF) have never been reported in literature. Here, we report the first case of a 70 year old male who developed a LVP, LPE, and RVPF. Case Description: A 70 year old male with a past medical history of hypertension presented with inferior wall STEMI. Cardiac catheterization demonstrated left anterior descending (LAD) with 80% occlusion and right coronary artery (RCA) with 100% occlusion. Percutaneous intervention of RCA with aspiration thrombectomy and two drug eluting stents was performed. Echocardiogram the following day demonstrated a LVP. A transesophageal echocardiogram (TEE) demonstrated LVP near the mid-inferior interventricular septum draining into the pericardial space, and LPE from the apical inferior left ventricle (LV) extending to the apical cap of the right ventricle (RV). Computed tomography angiography (CTA) demonstrated a multiloculated collection at the inferior septal aspect of LV contained by the pericardial space. Patient was a high risk for surgery. LVP was closed via a 24 mm atrial septal defect (ASD) occluder device. Intraoperative TEE demonstrated an ASD occluder device at the mid inferior septum at the location of the LVP neck with minimal residual flow into the LPE and a fistula connecting the LPE space with RV. RVFP was managed conservatively. LAD was managed medically. Patient was discharged home safely on guideline directed medical therapy. Discussion: LVP rate is 0.0026% following myocardial injury. It is reported that untreated LVP have a rupture risk of about 30% and a mortality rate of 50%. Prompt treatment is required to prevent mortality. Surgical management is the standard of care. A multidisciplinary heart team deemed the patient a high risk. Therefore, transcatheter treatment was sought in the patient above. Conclusions: Surgical treatment is standard of care for LVP, but transcatheter wall closure with an ASD device is a promising technique not only for high-risk surgical candidates such as above, but as a gold standard of treatment for LVP.

Correlation between Right Ventricular Function with Revascularization Time and 30-day Mortality in ST-Elevation Myocardial Infarction Patients Underwent Right Coronary Artery Intervention

Abstracts: Right ventricular (RV) function provides strong prognostic information in patients treated with primary percutaneous coronary intervention (PCI) due to myocardial infarction. Longitudinal RV systolic function can be assessed by the measurement of the tricuspid annular plane systolic excursion (TAPSE). This study aimed to evaluate the correlation between TAPSE and revascularization time with 30-day mortality using TIMI risk score in patients presenting STEMI who underwent revascularization of right coronary artery (RCA). This was a descriptive amd analytical study. Data were collected from iSTEMI Registry database which consisted of 49 STEMI patients undergoing PCI in RCA and TAPSE measurement at Prof. Dr. R. D. Kandou General Hospital from October 3rd, 2018 to July 28th, 2019. Echocardiographic examination was done within 48 hours of hospitalization. A descriptive analysis and bivariate correlation with Spearman’s rho were applied between given variables. P-value of <0.05 was considered to be statistically significant. The results showed that the mean age of the patients was 57.92 10.345 years old and 79.2% were male. The mean TAPSE measurement was 18.51 mm +/- 3.63 mm. The median revascularization time was 357.5 minutes while median TIMI score was 4. Shorter treatment time (p=0.708) and lower TIMI score (p=0.923) were not associated with better right ventricular function measured with TAPSE in patients undergoing RCA intervention. In conclusion, right ventricular function is not associated with revascularization time and thirty days mortality in patients presenting with ST-elevation acute myocardial infarction involving right coronary artery.Keywords: tricuspid annular plane systolic excursion; revascularization time; right coronary artery; ST-elevation myocardial infarction

Large False Lumen Prevailed After Coronary Dissection and Intramural Haematoma Fenestration With Cutting Balloon

A 55-year-old man had undergone percutaneous coronary intervention for right coronary artery (RCA) chronic total occlusion 2 years ago. The 3.0-mm balloon dilatation created coronary dissection and an intramural haematoma (IMH). The intravascular ultrasound revealed a no-reflow phenomenon with a large IMH extending to the distal RCA bifurcation. A stent was implanted to cover the proximal dissection and IMH entry site. The distal IMH was rescued by coronary fenestration with a 3.0-mm cutting balloon (Figure 1A).

TCTAP C-046 Retrograde Chronic Total Occlusion Intervention in Right Coronary Artery

TCTAP C-046 Retrograde Chronic Total Occlusion Intervention in Right Coronary Artery

Anomalous Left Coronary Artery Arising from the Right Coronary Sinus Presenting with Acute Coronary Syndrome

Approximately 80% of the coronary artery anomalies are not malignant and asymptomatic. Abnormal origin of the coronary artery has a variable presentation in the young population such as atypical chest pain or unexpected cardiac death. It is necessary to identify these anomalies, as lethal outcomes can be prevented with appropriate treatment and management. Left coronary artery abnormally arising from the right coronary cusp is rare and can be life-threatening if it follows the track between the aorta and pulmonary artery. The second most common cause of sudden cardiac deaths in the young population especially in athletes is coronary artery anomalies following hypertrophic obstructive cardiomyopathy. The case presented here is about abnormally arising left coronary artery following the course between the right ventricle outflow tract and aorta. The patient presented with the non-ST segment elevation-acute coronary syndrome (NSTEACS) for the first time but after 15 months he again presented with ST segment elevation-acute coronary syndrome (STE -ACS) for which he underwent Primary percutaneous coronary intervention of Right coronary artery and for anomalous left coronary artery he was managed conservatively as per patient request.

Residual Right Coronary Artery Stenosis after Left Main Coronary Artery Intervention Increased the 30-Day Cardiovascular Death and 3-Year Right Coronary Artery Revascularization Rate.

Background The outcomes of patients with concomitant left main coronary artery (LMCA) and right coronary artery (RCA) diseases are reportedly worse than those with only LMCA disease. To date, only few studies have investigated the clinical impact of percutaneous coronary intervention (PCI) on RCA stenosis during the same hospitalization, in which LMCA disease was treated. This study was aimed at comparing the outcomes between patients with and without right coronary artery intervention during the same hospital course for LMCA intervention. Methods and Results From a total of 776 patients who were undergoing PCI to treat LMCA disease, 235 patients with concomitant RCA significant stenosis (more than 70% stenosis) were enrolled. The patients were divided into two groups: 174 patients received concomitant PCI for RCA stenosis during the same hospitalization, in which LMCA disease was treated, and 61 patients did not receive PCI for RCA stenosis. Patients without intervention to the right coronary artery had higher 30-day cardiovascular mortality rates and 3-year RCA revascularization rates compared to those with right coronary artery intervention. Patients without RCA intervention at the same hospitalization did not increase the 30-day total death, 3-year myocardial infarction rate, 3-year cardiovascular death, and 3-year total death. Conclusions In patients with LM disease and concomitant above or equal to 70% RCA stenosis, PCI for RCA lesion during the same hospitalization is recommended to reduce the 30-day cardiovascular death and 3-year RCA revascularization rate.

Aortic dissection or coronary artery perforation?

A 73-year-old woman, diabetic, presented with effort angina of Canadian Cardiological Society (CCS) scale III for the last two months. Coronary angiogram revealed multiple significant stenosis of the left anterior descending artery (LAD) and the right coronary artery (RCA). After she was presented to heart team and refused surgical revascularization we proceeded with PCI. LAD was successfully treated with one drug eluting stent. After that we proceeded with RCA intervention. After first balloon inflation huge contrast extravasation (4x4cm) was noticed in projection of aortic wall. Patient was stable, procedure was temporary interrupted and because of suspicion on aortic dissection urgent echocardiography and CT scan of aorta was performed. Echocardiography did not show fluid accumulation in pericardium while CT scan excluded aortic dissection and showed perforation of ostial RCA with cranial intrapericardial contrast extravasation. After that procedure was continued with implantation of three DE stents in RCA. Final angiogram showed successful sealing of ruptured ostial RCA without any contrast leak. During the following days there was no evidence of fluid in the pericardium, also MSCT coronarography confirmed normal flow in RCA and LAD. After five days patient was safely discharged from hospital.

TCTAP C-094 Successful Percutaneous Coronary Intervention for Right Coronary Artery Chronic Total Occlusion Guided by Non-contrast Enhanced CT

### Patient initials or identifier number N.K. ### Relevant clinical history and physical exam Clinical History: 1992: He underwent PCI for proximal RCA CTO (about 20 years ago), which resulted in failure. 2002: Anteroseptal AMI occurred (about 10 years ago), and he received stent implantation

Paravalvular aortic regurgitation as the reason for second CoreValve bioprosthesis implantation in a patient with native bicuspid valve

We present the case of a 70-year-old male patient who was admitted to our centre with severe symptomatic aortic stenosis. His medical history included: hypertension, stroke (1998 and 2013) with subsequent left-sided paraparesis and status after traumatic upper right limb amputation in his youth. Patient’s logistic EuroSCORE was 18.1%, EuroSCORE II 5.7% and the Society of Thoracic Surgeons Score 2.7%. Transthoracic echocardiography showed impaired left ventricular ejection fraction of 27%, mean aortic pressure gradient of 70.5 mm Hg, aortic valve area of 0.6 cm2, and peak velocity of 6.3 m/s. For precise aortic annulus measurement, transoesophageal echocardiography (TEE) and a computed tomography scan were performed and revealed a heavily calcified bicuspid valve with mean annulus diameter of 24 mm. Angiography demonstrated a significant lesion in the 3rd segment of right coronary artery (RCA). Due to the high operative risk, the patient was referred by the Heart Team for percutaneous coronary intervention of RCA and transcatheter aortic valve implantation (TAVI) via the femoral route (considering the absence of atherosclerotic lesions in ilio-femoral arteries). Native valve was predilated with a 22 mm Numed balloon catheteter (Fig. 1A). On the basis of pre-procedural imaging, a 29 mm Medtronic CoreValveTM bioprosthesis was implanted at the annulus level. However, control angio and TEE showed low implantation accompanied by significant paravalvular aortic regurgitation (Fig. 1B). Haemodynamic measurement also confirmed a suboptimal effect with low diastolic aortic pressure (DAP) and high left-ventricular end-diastolic pressure (LVEDP) (Fig. 2A). Therefore, the decision was made to implant a second bioprosthesis — another 29 mm CoreValve was placed and deployed 8–10 mm higher than the first one (Fig. 1C). Implantation of the second valve significantly decreased the magnitude of regurgitation from severe to no or mild, both in angiography and pressure recordings (Figs. 1D and 2A, respectively). It has been shown in several observational and randomised trials that even mild paravalvular regurgitation after TAVI is an independent predictor of long-term mortality. It is therefore of crucial importance to diagnose early and minimise the grade of regurgitation by post-dilatation or second valve deployment. This case demonstrates that apart from imaging modalities, direct pressure measurement is an easy, reliable and reproducible method of paravalvular leak detection. Recently, it has been shown in a non-selected population of TAVI procedures that pressure gradient DDAP-LVEDP is a powerful predictor of mortality.

Longitudinal stent compression of everolimus-eluting stent: A report of 2 cases

Second generation drug eluting stents (DES) have shown better safety and efficacy in comparison to first generation DES, because of thinner struts, nondurable polymers and coating with better anti-proliferative drugs. The newer DES with cobalt alloy base have demonstrated a greater trackability, deliverability, conformability, flexibility and radio-opacity. However, these thin strut stents have a downside of poor longitudinal axial strength, and therefore get easily deformed/compressed at their end with a slight trauma during exchange of various catheters. We hereby report two cases of "longitudinal stent compression (LSC)" of everolimus-eluting stent, which happened during percutaneous coronary intervention of right coronary artery. Both the cases were successfully managed with non-compliant balloon dilatation. Various reasons for LSC and its management are discussed in the article.

Clinical Characteristics of Coronary Drug-Eluting Stent Fracture: Insights from a Two-Center DES Registry

Stent fracture (SF) has been implicated as a risk factor for in-stent restenosis, but its incidence and clinical characteristics are not well established. Therefore we investigated the conditions associated with stent fracture and its clinical presentation and outcome. Between 2004 and 2007, consecutive cases of SF were collected from the Seoul National University Hospital. Clinical characteristics and outcome of patients with fractured stents were compared with a ten-fold cohort of age and gender matched controls (n = 236). A total of 4,845 patients received percutaneous coronary intervention and 3,315 patients (68.4%) underwent angiographic follow-up. Twenty-eight fractured stents were observed in 24 patients. The incidence of SF was 0.89% for sirolimus-eluting stents (SES) and 0.09% for paclitaxel-eluting stents. Chronic kidney disease, stent implantation in the right coronary artery (RCA), and SES use were independent predictors of drug-eluting stent fracture by multivariate analysis. SF was significantly associated with binary restenosis (11.4% vs 41.7%, P < 0.001) and increased risk of target lesion revascularization (8.1% vs 33.3%, P = 0.001). Patients with SF but without significant restenosis showed excellent outcome despite only medical treatment. In conclusion, SF is associated with increased rates of restenosis and repeat revascularization. Significant risk factors include chronic kidney disease, RCA intervention, and SES use.

E0494 Extensive dissection to the coronary sinus of valsalva during percutaneous intervention in right coronary artery–a case report and literature review

Severe retrograde dissection extending into the sinus of Valsalva is a rare complication during percutaneous coronary intervention (PCI), but life threatening. The danger of this event depends on two aspects:...

Prominent ST-segment elevation in leads V1–V4 due to isolated right ventricular branch occlusion after primary percutaneous coronary intervention for right coronary artery

Isolated right ventricular myocardial infarction (RVMI) rarely occurs. It accounts for only 3% of all infarctions. In the literature, there are several reported isolated RVMI cases with precordial ST-segment elevation. We describe a 55-year-old man with prominent ST-segment elevation in leads V1-V4 in whom isolated RVMI developed due to occlusion of the right ventricular branch during primary percutaneous coronary intervention to the right coronary artery for acute inferior myocardial infarction.

Simultaneous Right and Left Coronary Occlusion Caused by an Extensive Dissection to the Coronary Sinus of Valsalva During Percutaneous Intervention in Right Coronary Artery

We report a case of simultaneous right and left coronary occlusion during percutaneous coronary intervention in the right coronary artery. An aortocoronary dissection induced by the forceful manipulation extended from the right to left sinus of Valsalva and occluded the ostia of both coronary arteries. The patient suffered cardiogenic shock and ventricular fibrillation. However, after successful rapid stenting to right and left coronary arteries, safe discharge was possible.

Asymptomatic extensive coronary cameral fistulae involving the left ventricle

A patient with extensive coronary cameral fistulae (CCF) involving the left ventricle (LV) found incidentally during an emergency coronary angiogram is presented. A 68-year-old woman with a history of hypertension was brought to the emergency room with accelerated anginal symptoms. She was diagnosed with inferior ST segment elevation myocardial infarction, and underwent a coronary angiogram and successful percutaneous intervention to the right coronary artery (RCA). Other than the mid-RCA occlusion, the coronary angiogram was significant for diffuse CCF involving the circumflex-obtuse marginal system and diagonal branches emptying into the LV (Figure 1), delineating the endocardial border very well (Figure 2). After the RCA intervention, the patient remained asymptomatic and was discharged home in stable condition at her excellent baseline functional status. Figure 1) Coronary angiograms demonstrating extensive coronary cameral fistulae (arrowheads) involving the diagonal branches (A) and circumflexobtuse marginal system (B) Figure 2) Coronary angiogram demonstrating extensive coronary cameral fistulae emptying into the left ventricle, delineating the endocardial border (arrowheads) A coronary artery fistula is an abnormal communication between an epicardial coronary artery and a cardiac chamber (CCF) or a major vessel (venae cavae, pulmonary artery or veins, or coronary sinus). CCF are seen in 0.1% of patients undergoing coronary angiograms. Over 90% of the CCF drain into the venous circulation, and most fistulae are single communications. Although most CCF are asymptomatic, sudden or gradual progression of symptoms has also been reported (1). Surgical repair or transcatheter ablations of the fistulae are recommended for symptomatic patients and for asymptomatic patients who are at risk for future complications such as coronary steals, aneurysms and larger shunts. Our case is very rare because of the asymptomatic clinical course and the presence of multiple LV communications.

Silent and Huge Left Ventricular Pseudoaneurysm with Left Atrial Compression: Dedicated Spatial Resolution and Geometry by 3-Dimensional Echocardiography

An 83-year-old man with acute inferior wall myocardial infarction underwent successful percutaneous coronary intervention for right coronary artery. Subsequent echocardiography 3 days later showed an incidental huge cardiac chamber compressing left atrium. The chamber was found to have a narrow neck connecting with left ventricle, suggestive of a pseudoaneurysm. Real-time 3-dimensional echocardiography could clearly demonstrate the spatial relationship between pseudoaneurysm and corresponding cardiac chambers, and its precise location and the orifice of pseudoaneurysm. A myocardial break-out point resembling a bird beak with a flap could also be clearly seen and quantified by real-time 3-dimensional echocardiography. This patient underwent surgical resection and the serial follow-up remained uneventful.

Successful nitinol stent implantation in a large coronary aneurysm: post-interventional patency assessment by magnetic resonance imaging

Nitinol stents are thought to exhibit reduced occurrence of artifacts and may be suitable for magnetic resonance imaging (MRI) evaluation of stent localization and in-stent patency even in coronary-sized stent grafts. A 54-year-old male patient presented with a large coronary post-stenotic aneurysm of the right coronary artery (RCA) beside significant stenoses of the left circumflex coronary artery (LCX) and the left anterior descending coronary artery (LAD) with aneurysm formation. After implantation of stent grafts to the LAD and LCX, two polymermembrane-covered nitinol stent grafts were placed into the RCA. A control MR examination 7 days following the RCA intervention showed successful occlusion of the former aneurysm, no post-interventional endoleak, and bright signal within the stent indicating stent patency. Thus, coronary MRI after nitinol stent implantation in coronary aneurysms is feasible for post-interventional early imaging control at least as far as the exclusion of possible endoleaks is concerned.