LAD Dissection Research Articles

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.

"CIRCLE OF VIEUSSENS": A LIFE-SAVING CORONARY ARTERY ANOMALY IN A PATIENT WITH KAWASAKI DISEASE

"CIRCLE OF VIEUSSENS": A LIFE-SAVING CORONARY ARTERY ANOMALY IN A PATIENT WITH KAWASAKI DISEASE

Abstract 17082: Recurrent Multisite Spontaneous Coronary Artery Dissections in a Patient Using Prescription Amphetamine

Introduction: Spontaneous Coronary Artery Dissection (SCAD) is an uncommon condition. In patients taking prescription amphetamine or with methamphetamine abuse, SCAD has been reported in some case reports. We describe a case of a young female patient who had recurrent SCAD on prescription amphetamine with multisite involvement. Case presentation: A 48-year-old woman with history of active tobacco use, hypertension presented with substernal chest pain radiating to both arms. Her home medications included prescription amphetamine (Amphetamine, Dextroamphetamine) for reported history of ADHD (Attention Deficit Hyperactivity Disorder, diagnosed in childhood). The patient’s electrocardiogram showed ST elevations in V2,V3 and V4 and with reciprocal changes in leads II, III and aVF. On emergent cardiac catheterization we noted dominant left system with 99% occlusion with thrombus of mid LAD with radiolucent lumens and contrast dye extravasation into the arterial wall suggesting type 1 SCAD. Otherwise we noted normal RCA, LCx and OM branches. An IVUS was not used during the procedure. This lesion was revascularized with a drug eluding stent with containment of the dissection and achievement of TIMI 3 flow. We noted that the patient presented similarly two separate times in the past 2 years and cardiac catheterizations at that time revealed type 2B SCAD involving OM3, which appeared angiographically normal on current angiogram and 90% distal LAD occlusion from type 1 SCAD. The patient was treated with aspirin and ticagrelor and discharged 2 days post procedure in stable condition. Conclusions: Spontaneous Coronary Artery Dissection (SCAD) has been reported in patients with prescription amphetamine and methamphetamine use, but it is imperative to rule out alternative etiologies and amphetamine related SCAD should be a diagnosis of exclusion. We opted to intervene on the mid LAD dissection and the distal dissections were treated medically.

P978 Acute myocardial infarction in young women without atherosclerotic disease

Abstract INTRODUCTION Spontaneous coronary artery dissection (SCAD) is an established cause of acute myocardial infarction (AMI), with an incidence in young women ranging from 22% to 43%. The increased use of coronary angiography contributed to better recognise this condition. Nonetheless, the presentation remains challenging mainly due to the atypical clinical onset. AIMS AND METHODS A very homogeneous case series of 10 young women (age 36 ± 9 years) admitted at our Institution over a period of 10-years with ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI) were analysed. All women had no congenital, coronary, cardiac and/or atherosclerotic disorders. The clinical and angiographic data were evaluated and correlated to the outcome that lasted 5 ± 5 years. RESULTS The clinical presentation was typical in 70% of cases and 30% of them developed ventricular arrhythmias and cardiogenic shock. An atypical presentation was documented in 30%. STEMI accounted for 70%, NSTEMI for 30%. Among the predisposing factors, pregnancy was related in 20%, connective tissue disorders in 30% and acute emotional stress associated to smoke habit in 50% of cases. On coronary angiogram all women were affected by distinctive pattern of non-atherosclerotic single vessel disease: LAD dissection (50% of cases with proximal localization), first obtuse marginal branch dissection in 3 cases, proximal RCA dissection in 1. Medical therapy was the first choice in 40%, while 60% were treated with PTCA-stent (multiple in 30%). The ejection fraction early after AMI was normal in 70%, mildly reduced in 1 case and moderately reduced (<45%) in 2 cases. Follow-up was negative for events in all cases, 3 underwent pregnancy at distance. CONCLUSION A high proportion of subjects presented with atypical challenging symptoms, while 30% were complicated with ventricular arrhythmias. This might be related to the high prevalence of proximal LAD dissection and anterior AMI in our subjects. An equal distribution of risk factors was recorded. No mortality events and no SCAD-recurrence were documented during follow up. Abstract P978 Figure. Image 1

TCTAP C-099 Bifurcation PCI in a Chronic Spontaneous Long Coronary Dissection

### Patient Initials or Identifier Number LY ### Relevant Clinical History and Physical Exam 63 yrs old male Hypertension, Ex-smoker. Admitted in another hospital for anterolateral STEMI. On diagnostic angiography: severe 99% stenosis of proximal LAD and long spontaneous spiral dissection of

Off-Pump Coronary Artery Bypass (OPCAB) for Acute LMCA - LAD Dissection due to Blunt Chest Trauma: A Case Study

Off-Pump Coronary Artery Bypass (OPCAB) for Acute LMCA - LAD Dissection due to Blunt Chest Trauma: A Case Study

TCTAP C-015 Perioperative ST Elevation Myocardial Infarction Due to Left Main Total Occlusion Complicated with Diffuse LAD and LCX Dissection

TCTAP C-015 Perioperative ST Elevation Myocardial Infarction Due to Left Main Total Occlusion Complicated with Diffuse LAD and LCX Dissection

Spontaneous Coronary Artery Dissection: Efficient Clinical Outcome through Percutaneous Coronary Intervention

A 70 years-old male with a history of diabetes mellitus and hypertension, presented an acute squeezing chest tight of 5 hours duration in precordium after emotional stress. He was admitted to emergency department with blood pressure 171/100 mmHg. Electrocardiogram (ECG) showed frequent ventricular premature contractions and complete left bundle branch block which did not happen before. Laboratory examination showed elevated cardiac Troponin I (0.83 μg/L reference range, 0 to 0.15μg per liter) Creatine Kinase (268 U/L reference range, 30 to 170 IU per liter) and Creatine Kinase isoenzyme MB (31 U/L reference range, 0 to 25 IU per liter). Pharmacological management were included nitrate (Isosorbide mononitrate and glonoin) before primary percutaneous coronary intervention (PCI), His coronary angiogram showed a significant about 15mm lesion, dissection at the proximal left anterior descending artery(LAD) (Figure1) and diffuse severe stenosis in middle part of right coronary artery (RCA). There were no signs of dissection in the left circumflex coronary (LCx). Our strategy was combining pharmacological management and PCI which mean implanting a stent in the dissection of LAD. The procedure of cardiac catheterization was supported by intraaortic balloon pump (IABP) and temporary pacemaker (TPM), considering the patient with frequent ventricular premature and heart failure [ejection fraction 28% detected by transthoracic echocardiogram (TTE)]. Firstly a 40 ml IABP was implanted in aorta with adjusted counterpulsation pressure 110 to 130mmHg. Then TPM was transported in the right ventricular apex with 60 t/min setted. A Stent (4.0×24mm) was successfully implanted after balloon dilated from the LAD near end. Repeat angiography revealed that the LAD dissection noted earlier was resolved and far-end flowing blood improved after 30min observation. The patient continued the therapy by treating dual anti-platelet (oral aspirin 100mg and clopidogrel 75mg), blood pressure controlled (oral perindopri 2mg), and blood sugar controlled. After 1 week observation, we decided to implant two Stents (3.5×30mm 4.0×18mm) in the RCA to improve the far-end flowing (Figure 3). Meanwhile we did a angiography which also showed LAD dissection disappeared and no stenosis caused again (Figure 2). The patient did not complain discomfort through the procedure. He was maintained dual anti-platelet blood pressure and blood sugar controlled after revascularization. TTE showed a nearly normal ejection fraction (48%) after 2 years of following up. Spontaneous coronary artery dissection (SCAD) is a rare myocardial ischemic disease that threatens patients’ life. Various risk factors are associated with SCAD, such as smoking, severe hypertension and psychological reasons. Considering the formation of dissection, SCAD can be divided into intimal tear type or intraluminal hemorrhage type. The clinical presentation of SCAD depends on the extent and severity of progression of dissection and may present as unstable angina, acute myocardial infarction, ventricular arrhythmias or asymptom. Treatment of SCAD usually includes percutaneous coronary intervention (PCI), bypass graft surgery or medical therapy depending on the range of dissection. Herein, we report a 70 years-old male diagnosed with dissection in the left anterior descending artery by coronary arteriography. Despite the patient’s exposure to the ventricular arrhythmias, he had a good prognosis and survived at 2 years of following up. We found PCI treatment is suitable for the patient who had SCAD.

The utility of low dose serial computed tomography coronary angiography (CTCA) in the management of spontaneous coronary artery dissection (SCAD)

SCAD is a rare and often fulminant clinical entity. Invasive angiographic diagnosis and surveillance for vessel recanalisation is limited both by high procedural risk and inability to visualise mural thrombosis, thought to play an important pathophysiological role. A 41-year-old woman presented to our institution critically unwell post VF arrest with an anterolateral STEMI due to extensive LAD dissection requiring acute PCI. Recurrent symptoms in the following days settled with medical therapy. Serial CTCA, with low cumulative radiation dose (8.1mSv) and no procedural or contrast related complications, was subsequently performed as depicted in figures 1 to 3 below. Figure 1 (left): Day 14 post-presentation CTCA demonstrating new extension of the LAD dissection into the LMCA with diffuse luminal narrowing and mural thickening consistent with thrombosis. Sub-total distal LAD occlusion. Figure 2 (centre): Day 32 CTCA demonstrating improved luminal diameters in the LMCA/LAD and patent stents with recanalisation of the distal LAD. Figure 3 (right): Day 60 CTCA demonstrating ongoing improvement in luminal calibre of the LMCA/LAD.

A case of a young, healthy woman with spontaneous coronary artery dissection associated with oral contraceptive use: Long-term residual dissection of the coronary artery

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome, typically affecting young, healthy women, particularly during the peripartum period. Oral contraceptive use is also recognized as a risk factor for SCAD. In the present report, we describe a case of a young woman with an anterior wall myocardial infarction caused by SCAD of the left anterior descending artery (LAD). The event was probably associated with the patient's oral contraceptive use. The patient underwent percutaneous coronary intervention, and she did not experience any recurrent chest pain or other cardiac symptoms. Although the coronary angiography revealed good LAD flow and no symptoms after 6 months, cardiac computed tomography and intravascular ultrasound revealed that LAD dissection was still present. We continued to closely follow-up the patient without initiating any additional intervention, and the patient has had no cardiac event for up to 4 years of follow-up.<Learning objective: We aimed to present a case of spontaneous coronary artery dissection, with a long-term residual dissection. Coronary computed tomography aided the diagnosis of the residual dissection, which was not detected by coronary angiography.>

Intraoperative Epicardial Sonography as a Useful Adjunct to Repair of Coronary Artery Dissection

CASE REPORTA 61-year-old man with a past medical history of systemic hyper-tension presented with a 1-month history of exertional chest pain andshortness of breath. A cardiac nuclear stress test showed exercise-induced anteroseptal, apical, and inferoposterior ischemia with a leftventricular ejection fraction of 36%. Coronary arteriography then wasperformed showing triple-vessel coronary artery disease. There werechronic total occlusions of the right coronary artery and the mid-LAD.The obtuse marginal arteries 1 and 2 also were found to have 50% to60% stenosis. No obvious collaterals were shown on the coronaryangiogram. The patient initially refused coronary artery bypass graft(CABG) surgery.The LAD lesion was crossed with a guidewire, but attempts atangioplasty resulted in an iatrogenic LAD dissection (Fig 1). Theprocedure was aborted, and the patient was referred for urgent surgery.He remained hemodynamically stable. Intraoperatively, the transesoph-ageal echocardiogram (TEE) showed 1 mitral regurgitation and in-ferior septal hypokinesis. Upon inspection of the epicardial surface, themidportionoftheLADhadabluishdiscoloration.AnL15-7ioepiaorticprobe (Phillips Medical, Andover, MA) was placed into a sterile sheathand used to evaluate the vessel. A dissection and intramural hematomawere visualized originating in the midportion of the LAD with no flowin the false lumen (Figs 2 and 3). The LAD was stabilized and opened(Fig 4). The layers of the wall at the site of the arteriotomy werereapproximated to eliminate the false lumen. A left internal mammaryartery to LAD anastomosis then was constructed. Repeat ultrasoundevaluation showed excellent laminar flow through the anastomosis andin the distal LAD (Fig 5). The right internal mammary artery then wasanastomosed to the right coronary artery, and vein grafts were placedto the 2 obtuse marginal arteries. The immediate postprocedure TEEshowed no significant change. The patient remained hemodynamicallystable with no postoperative electrocardiographic or enzymatic changesand had an uneventful postoperative recovery. He remains asymptom-atic 3 years after surgery.DISCUSSION

LAD dissection following parachute belt trauma during BASE jumping

We present the case of a 35-year-old BASE jumper who suffered a parachute-induced blunt chest trauma resulting in LAD dissection presenting with an acute ST-segment-elevation myocardial infarction (STEMI).

Myotomy After Previous Coronary Artery Bypass Grafting for Treatment of Myocardial Bridging

A 57-year-old man with a long history of frequent chest pain was admitted to our cardiac center. Four years ago, he underwent coronary artery bypass grafting (CABG) with the left internal mammary artery (LIMA) to the distal segment of the left anterior descending coronary artery (LAD) grafting for myocardial bridging (MB) in LAD despite having β-blockers and calcium channel blockers. However, the patient still had recurrent angina within 3 months after the operation. ECG showed negative T wave in leads V1 and V2. On echocardiography, left ventricular ejection fraction was 60% with normal regional wall motion. The repeat coronary angiography showed a MB in the proximal LAD about 3 cm in length with 90% systolic narrowing of the LAD, and the LIMA graft was totally occluded (Figure 1A through 1C). The …

Coronary angiography of pregnancy-associated coronary artery dissection: a high-risk procedure

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome occurring predominantly in young women without any cardiovascular risk factors, especially during the peripartum and early postpartum period. Here, we report a case of a 28-year-old pregnant woman who was found to have an isolated distal SCAD of the left anterior descending artery (LAD). Coronary angiography was complicated by extensive LAD and circumflex arteries dissection, requiring an emergency coronary artery bypass grafting associated with ventricular assist device implantation and underlying the extreme fragility of coronary arteries in pregnant women.

Rare case of blunt chest trauma induced left main and LAD dissection in association with anomalous RCA origin

<h3>Abstract</h3> The rare syndrome of Anosognosia for Hemiplegia (AHP) can provide unique insights into the neurocognitive processes of motor awareness. Yet, prior studies have only explored predominately discreet lesions. Using...

A Case of Coronary Artery Dissection After Aortic Replacement in Acute Type A Aortic Dissection

A 59-year-old woman was transferred to our institution with a diagnosis of acute type A aortic dissection. During aortic replacement surgery, the dissection had not extended to the orifice of the left coronary artery. However, ST segment elevation was observed on an electrocardiogram monitor immediately postoperatively. An emergent coronary angiogram showed almost complete collapse of the lumen of the left coronary artery due to pulsatile compression of the false lumen, which was caused by extension of the aortic dissection. Percutaneous coronary intervention (PCI) was performed with placement of stents in the left anterior descending artery (LAD) and left circumflex artery. Coronary angiography and intravascular ultrasound performed 45-days after PCI showed significant instent restenosis (ISR) at the proximal portion of the LAD and residual coronary artery dissection of the diagonal branch. Repeat balloon angioplasty was performed at the site of the ISR. A follow-up coronary angiogram 8-months after the PCI showed no evidence of ISR.

Postpartum spontaneous coronary artery dissection (SCAD) managed conservatively

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and has been described in young women during the peripartum period. Management of these patients has been controversial. A 35 year old Caucasian female, 11 days postcesarean section delivery presented with acute myocardial infarction. She underwent angiography within a few hours of presentation, which showed dissection of LAD. Repeat angiography six days later showed improvement of dissection. Patient showed clinical improvement on conservative treatment and no recurrence of symptoms over the past two years follow-up. There is no consensus on the treatment and our case is one of the cases managed successfully with conservative treatment.

Myocardial infarction with huge mural thrombus due to spontaneous coronary artery dissection detected by 64-multidetector computed tomography

A 28-year-old man without medical history of cardiovascular disease came to the clinic to have the cause of his ECG abnormalities and chest discomfort evaluated. Echocardiogram showed regional wall motion abnormality of the anteroseptum and inferoseptum from the upper mid-left ventricle to apex with aneurysm and anterior wall from the mid-left ventricle to apex. It also showed huge and broad mural thrombus (5.2 × 1.4 cm in size) harboring in the left ventricle. Coronary angiography revealed a middle part of left anterior descending coronary artery (LAD) dissection with good distal flow. ECG gated 64-multidetector computed tomography (MDCT) demonstrated the proximal and middle part of LAD dissection. There has been no observation of myocardial infarction with huge mural thrombi complicating a spontaneous coronary artery dissection in which MDCT allowed an accurate and non-invasive diagnosis.

Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy: A Systematic Review of Published Studies

Alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) has emerged as a lesser invasive alternative to surgical myectomy over the past decade. The purpose of this study is to analyze all the published literature on outcomes and complications after ASA. MEDLINE and PubMed were searched for all available published literature on ASA (June 1996-June 2005) using the terms hypertrophic obstructive cardiomyopathy (HOCM), alcohol septal ablation for hypertrophic obstructive cardiomyopathy, alcohol septal ablation for HOCM, alcohol septal ablation (ASA), transcoronary alcohol septal ablation for hypertrophic obstructive cardiomyopathy (TASH), transcoronary alcohol septal ablation for HOCM, nonsurgical septal reduction therapy (NSRT), and percutaneous transcoronary septal myocardial ablation (PTSMA). A total of 42 published studies (2,959 patients) were analyzed. Mean age was 53.5 (35.4-72) years with a mean male to female ratio of 1.17. Mean follow-up was 12.7 +/- 0.3 months (1.5-43.2). Absolute ethanol (3 mL) was injected in 1.2 septal perforator arteries. On average, serum CK peaked at 964 units. At 12 months, there was a sustained decrease in resting and provoked LVOT gradient (65.3-15.8 and 125.4-31.5 mmHg, respectively) accompanied by reduction in basal septal diameter (20.9-13.9 mm), improvement in NYHA Class (2.9-1.2), and increase in exercise capacity (325.3-437.5 seconds). Early mortality (within 30 days) was 1.5% (0.0-5.0%) and late mortality (beyond 30 days) was 0.5% (0.0-9.3%). Other complications include ventricular fibrillation (2.2%), LAD dissection (1.8%), complete heart block requiring permanent pacemaker (10.5%), and pericardial effusion (0.6%). A repeat ASA was performed on 6.6% of patients and 1.9% of patients underwent surgical myomectomy with resolution of symptoms. Literature to date suggests that ASA results in acute and intermediate-term favorable clinical and echocardiographic outcomes. A randomized controlled trial is needed to compare ASA and myomectomy in order to determine which technique provides maximal benefit.

Influence of anastomotic techniques in totally endoscopic coronary artery bypass

Beating heart totally endoscopic coronary artery bypass grafting (TECAB) utilizing a computer-enhanced telemanipulation system is a technically challenging procedure. The objective of our study was to compare two different anastomotic techniques. Ten canine beating heart TECAB procedures were performed using Intuitive's daVinci surgical system. Left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) anastomosis was performed on all subjects. Anastomosis varied between a conventional running suture (8-0 Gore-tex) (group I) and an interrupted nitinol u-clip anastomosis (group II). On-table angiography was then performed to assess graft patency. While internal mammary artery (IMA) mobilization time decreased over the course of the study (p = 0.017), there was no significant difference in ischaemia time, anastomosis time or angiographic assessment between anastomotic techniques. Although operative time in group II was significantly shorter than in group I, this was likely due to the small sample size. There were no differences in anastomotic time or coronary occlusion time. There were also no significant differences in canine weight, IMA mobilization time, lipectomy/pericardiotomy, LAD identification, subxiphoid port placement, stabilizer position, or LAD dissection time between the cases performed with the conventional running suture and the cases performed with u-clips. Interrupted nitinol clip anastomosis or conventional running suture anastomoses are equally favourable in the short term when performing a TECAB procedure.