Large Coronary Arteries Research Articles

Transcatheter closure of medium and large congenital coronary artery fistula using wire-maintaining technique

BackgroundFor medium and large coronary artery fistula (CAF), the initially selected device sometimes has to be exchanged by reconstruction of track wire loop due to the complexity of CAF. ObjectivesWe sought to evaluate the feasibility and safety of transcatheter closure of medium and large CAF by using the wire-maintaining technique (WMT). MethodsA total of 18 patients aged 15–56 years with congenital CAF underwent percutaneous transcatheter closure by WMT between April 2006 and October 2012. The immediate and long-term outcomes were evaluated. ResultsOf the 18 patients (11 females), 16 (88%) underwent successful transcatheter closure of fistula using WMT. The CAFs originated from the right coronary artery (67%), the left circumflex coronary artery (28%), and the left anterior descending coronary artery (5%). The drainage sites were the right ventricle (56%), right atrium (22%), left ventricle (11%), and coronary sinus (11%). The mean diameter of fistulas was 9.5±1.71mm and mean size of the devices was 13.6±3.03mm. An angiogram following device deployment showed complete occlusion in 11 patients, mild residual shunt in 2 patients, and trivial residual shunt in 3 patients. One patient had transient ST–T wave changes, and one patient had hemolysis after the procedure. Follow-up ranged from 1 month to 54 months (median 39 months). Echocardiogram showed trivial residual shunt in 3 patients at 6-month follow-up and in 1 patient at 12-month follow-up. Coronary artery thrombosis was observed in 1 patient by multislice computed tomography at 12-month follow-up. ConclusionFor those patients with medium and large complex fistula, transcatheter closure of CAF can be performed by using the wire-maintaining technique.

Different Roles for P2Y2 and P2Y6 Receptors in Large and Smaller Coronary Arteries

A clear understanding of the physiological regulation of the coronary blood flow is important in order to recognize the changes after a pathological incident, such as a heart attack. Extracellular pyrimidines activate P2Y receptors on both smooth muscle cells and endothelial cells in the vasculature, leading to vasoconstriction and relaxation respectively. The aim of the present study was to examine the receptor profiles along the vasculature, particularly in the coronary circulation. We studied this in arteries utilizing stable pyrimidine analogues and P2Y2 and P2Y6 receptor KO mice in a myograph setup and also performed blood pressure measurements. The results show that P2Y6 mediates most of the UTP and UDP induced contraction in the larger coronary arteries (lumen diameter ~150 µm) and that P2Y2 is an endothelia dependent relaxing receptor. In the smaller coronary arteries (lumen diameter ~ 50 µm) the expression is opposite, with P2Y2 being the contractile receptor and P2Y6 the relaxant receptor, although together with P2Y2. We therefore propose that released UTP can act as a vasodilator downstream of its release, after being degraded to UDP, also without affecting the contractile pyrimidine receptors.The obtained results gives a completely new view of the purinergic regulation in the vascular bed and can be used as an explanation of the many differences in the expression of purinergic receptors both between species and in various arteries.Funding: Lundbeck foundation (R167‐2013‐15379) and Lundbeck Grant of excellence

Percutaneous coronary intervention with RACER renal stents in very large diameter coronary arteries

Percutaneous coronary intervention with RACER renal stents in very large diameter coronary arteries

Letter by Mohri Regarding Article, “Clinical Usefulness, Angiographic Characteristics, and Safety Evaluation of Intracoronary Acetylcholine Provocation Testing Among 921 Consecutive White Patients With Unobstructed Coronary Arteries”

Angina caused by spasm of the large epicardial coronary artery has been extensively investigated for >50 years, and its risk factors, diagnostic procedures, treatments, and prognosis are well established. In 1998, we proposed coronary microvascular spasm as a possible pathogenic mechanism of myocardial ischemia in Japanese patients with chest pain and normal epicardial coronary arteries (microvascular angina),1 which was later confirmed by others.2 In the cardiac catheterization laboratory, the occurrence of coronary microvascular spasm is suspected when patient’s symptoms are reproduced in association with ischemic electrocardiographic changes after intracoronary injection of acetylcholine or ergonovine without large epicardial artery hyperconstriction/spasm. Coronary …

Study of Third Coronary Artery in Adult Human Cadaveric Hearts

Third coronary artery (TCA) is a direct branch arising from the anterior aortic sinus (right aortic sinus) which supplies right ventricular outflow tract. It is found frequently and may be an important source for collateral coronary blood flow through a vascular anastomotic bridge (circle of Vieussens) between the right and left coronary systems. To evaluate the gross anatomy of third coronary artery in terms of their number, origin, extent and distribution. After an ethical approval, 150 formalin fixed adult human cadaveric hearts were collected from Department of Anatomy, BVDU Medical College and Hospital, Sangli and Pune over the period of six years. The careful dissection was carried out to note details about third coronary artery and data was analysed using SPSS computer software. The TCA was present in 32% of the heart specimens. In 42 hearts (28%) single TCA and in 6 hearts (4%) double TCA were noted. It was found to be variably distributed to conus arteriosus, anterior wall of the right ventricle, interventricular septum and the apex of the heart. TCA was larger than right coronary artery in 8 hearts and later ended at inferior border of heart. Myocardial bridge was noted over large third coronary artery in one specimen. TCA is present frequently. It anastomoses with branches of left anterior descending artery (LADA) and contributes to apical and septal perfusion. Hence role of TCA should always be considered during diagnostic and therapeutic interventions.

Background Factors Associated with the Complications of Coronary Artery Lesions Caused by Kawasaki Disease

Appropriate therapy during the acute phase of Kawasaki disease to prevent large coronary artery lesions (CAL) has not been established. The aim of this retrospective study was to investigate the usefulness of an initial single intravenous immunoglobulin (IVIG) therapy. In this study, I included a total of 200 pediatric patients who had received 2g/kg/day IVIG therapy for Kawasaki disease between 1999 and 2015 at the Department of Pediatrics, Aomori Prefectural Central Hospital. An initial IVIG therapy starting on day 5 was used as first-line therapy when possible. The second-line therapy was additional IVIG therapy, and the third-line therapy was an urinastatin infusion or plasma exchange. All patients received an initial single IVIG therapy with delayed or with concomitant administration of aspirin or flurbiprofen. Initial IVIG therapy resistance occurred in 48 of 200 patients (24%), and 17 patients (9%) received additional IVIG therapy. Four patients received urinastatin and one patient received plasma exchange as the third-line therapy. Before the 30th day, the prevalence of CAL was 5% (10/200); after 30 days, it was 2% (4/200). The maximal internal CAL diameter was 4.8 mm (Z score = 6.3) among all patients. Variable factors including IVIG resistance, responsiveness, and relapse of disease were associated with CAL complications. An initial single IVIG therapy may be useful for the prevention of large CAL caused by different factors of Kawasaki disease.

Asymptomatic diabetes: screening by routine imaging beneficial?

Asymptomatic diabetes: screening by routine imaging beneficial?

Surgical repair of a large saccular left main coronary artery aneurysm.

Surgical repair of a large saccular left main coronary artery aneurysm.

Abstract 12059: High Cardiorespiratory Fitness is Associated With Larger Coronary Artery Diameters

Introduction: Cardiorespiratory fitness is inversely associated with morbidity and mortality even after adjustment for traditional risk factors. The biological mechanism for the protective effect of high fitness is largely unknown. Hypothesis: We hypothesized that high fitness would be associated with larger coronary artery diameters independent of traditional risk factors. Methods: In this study, 500 men with a coronary artery calcium score (CACS) < 10 were evaluated, with 100 from each age-adjusted fitness quintile (very poor, 1-20%; poor, 21-39%; fair, 40-59%; good, 60-79%; and excellent, 80-100%). Each participant had undergone fitness assessment with an exercise treadmill test on the day of CACS. Blinded to the fitness category, one of us measured the proximal diameters of the left main (LM), left anterior descending (LAD), left circumflex (LCx), and the right coronary (RCA) arteries. Spearman correlations were calculated for the diameters of each coronary artery with treadmill time and for the sum of artery diameters with treadmill time. Linear mixed-effects regression was used to estimate the association between fitness and coronary artery diameters while adjusting for potential confounders. Results: Each coronary artery diameter (LM r=0.12, p=0.009; LAD r=0.11, p=0.02; LCx r=0.10, p=0.02; RCA r=0.18, p<0.0001) and the sum of artery diameters (r=0.19, p<0.0001) were positively correlated with fitness after adjusting for body surface area. The RCA diameter and the sum of artery diameters remained positively correlated with fitness after further adjusting for traditional risk factors. In multivariate analyses, men in the highest fitness quintile had significantly larger coronary artery diameters compared to those in the lowest fitness quintile [β=0.85 mm (SE=0.27)]. A positive linear trend was observed across fitness quintiles and the LM (p=0.008), LAD (p=0.05), RCA (p<0.0001) diameters, and the sum of coronary artery diameters (p=0.0003). When examined continuously, each minute increase in treadmill time was associated with larger diameters (β=0.08 mm (SE=0.02) p<0.001). Conclusion: Higher fitness is positively associated with larger coronary artery diameters.

Large coronary artery aneurysm in a syphilitic woman possibly related to syphilitic disease process

Syphilis is known to affect the cardiovascular system in multiple ways but the occurrence of coronary artery aneurysm secondary to syphilitic disease process has never been previously described. We are presenting an interesting case report of a 54 year old female who presented to us with an evolved anterior wall myocardial infarction and coronary angiogram revealed a large thrombus containing aneurysm in the left anterior descending artery. The blood work up of the patient revealed that her VDRL test was positive which was confirmed by TPHA test. The patient decided for conservative medical management.The absence of evidence of atherosclerotic involvement of the same artery in the vicinity of the aneurysm and the other arteries creates a high likelihood of the aneurysm being related to the syphilitic disease process.Although the occurrence of atherosclerotic aneurysm cannot be ruled out completely, and only excision biopsy performed during surgical correction could have provided definitive association of the aneurysm with the syphilitic disease process but with the patient having opted for conservative management so this could not have been possible.Aneurysmal involvement of the coronary arteries due to syphilis has never been reported previously and could be a potentially life threatening complication of the disease and thereby merits a mention.

AB50. Sex and the heart

Significant proportion of men with erectile dysfunction (ED) has asymptomatic ischemic heart disease (IHD). This is probably because comparatively smaller arteries in the penis (1-2 mm in diameter) become symptomatic before larger coronary arteries (3-4 mm in diameter). Studies have revealed that up to three-quarters of all men with consistent ED can expect to suffer a heart attack or stroke within five years unless their risk factors are modified.Diabetes, high blood pressure, hyperlipidaemia, obesity, sedentary life style, smoking are some of the common risk factors for ED and IHD. The link between the two conditions is endothelial dysfunction and atherosclerosis. In addition, long standing untreated ED, irrespective of its cause can lead to depression which has shown to be a risk factor for IHD.IHD is not a contra indication for sex. Sexual activity is another form of exercise, typical maximum workload with the established partner during sexual intercourse is about 3.3-3.4 MET’s. If the patient can achieve 5-6 MET’s without significant ischemia, arrhythmia or fall in blood pressure they are not at risk during normal sexual activity. Most of the reported deaths during sexual activity have happened in unfamiliar settings with an unfamiliar partner after heavy meals and alcohol.Recognizing the relationship between ED and IHD will improve and save lives. With proper medical management and life style modification risk factors can be corrected to improve erectile function and prevent IHD.

Generalized aneurysmal disease in association with autosomal dominant polycystic disease.

A 78-year-old man with end-stage kidney disease secondary to autosomal dominant polycystic disease (ADPKD) on haemodialysis, presented to our institution following a myocardial infarction. He was known to have cystic involvement of his liver and spleen, significant mitral regurgitation secondary to mitral valve prolapse, and a distant history of abdominal aortic aneurysm repair. There was no family history of ADPKD or history of cerebral aneurysms. Coronary angiogram revealed widespread large coronary artery aneurysms affecting both branches of the left and right coronary artery, as well as significant atherosclerotic disease (Figure 1). During work up for coronary artery bypass surgery and mitral valve replacement, multiple other sites of aneurysmal disease were identified, including a 5 cm thoracic aortic aneurysm and bilateral femoral artery aneurysms (Figure 2). Fig. 1. Aneurysmal involvement of the mid to distal left anterior descending coronary artery (black arrow). Fig. 2. Bilateral femoral artery aneurysms (white arrows) together with large polycystic kidneys. Note incidental finding of calcified cyst in left polycystic kidney (black arrow). Whilst waiting for cardiac surgery the patient developed septic shock secondary to an infected renal cyst, requiring prolonged intensive care admission and extended rehabilitation. Given his age and frailty a decision was made to manage his widespread aneurysmal disease conservatively with regular radiographic surveillance. Previous case series have suggested a high incidence of coronary artery aneurysms in association with ADPKD. Hadimeri et al. [1] observed coronary aneurysms in 4 out of 30 (13%) ADPKD patients. This is markedly higher than the incidence observed in the general population, of ∼1.5% of patients studied by coronary angiography or autopsy [2]. There is less evidence regarding the link between ADPKD and aortic, thoracic and femoral aneurysms. While Bailey et al. [3] studied the association between aortic aneurysms and ADPKD, the study was unable to conclusively link the two conditions. Evidence linking thoracic or femoral aneurysms with ADPKD appears predominantly limited to case studies [4]. Given that the gene responsible for ADPKD has been linked with abnormalities of vascular smooth muscle, myofibroblasts, extracellular matrix and collagen defects [5], it seems reasonable for there to be widespread vascular abnormalities in this patient population, although it seems to be seldom described. In summary, we present a rare case of a patient with ADPKD and associated coronary artery aneurysms as well as aorto/iliac aneurysms.

Prognostic Value of Coronary CTA in Coronary Bypass Patients: A Long-Term Follow-Up Study

The goal of this study was to determine the long-term prognostic value of coronary computed tomography angiography (CTA) in a large coronary artery bypass graft (CABG) population. Coronary CTA has shown prognostic utility in patients without previous revascularization. However, prognostication with coronary CTA in CABG patients has not been fully assessed. Between March 2005 and April 2009, 887 consecutive CABG patients (mean age 66.8 ± 8.4 years) were considered for the inclusion in the study. Patients were classified by the number of unprotected coronary territories (UCTs) and a summary of native vessel disease and graft patency: the coronary artery protection score (CAPS). A primary endpoint (cardiovascular [CV] death, nonfatal myocardial infarction [MI]) and a secondary combined adverse events endpoint (CV death, MI, unstable angina, and late revascularizations) were recorded. Among the 887 evaluated, 166 did not meet the inclusion criteria. The final study population consisted of 721 subjects. Ten patients were excluded for unevaluable coronary CTA images. Of the remaining 711 patients, follow-up (mean 73.5 ± 14 months) was obtained in 698. Three hundred forty-seven events were recorded. By univariable analysis, the strongest coronary CTA predictors of events were UCT 2 and 3 (hazard ratio [HR] for CV death/MI: 7.5 and 10.19, p < 0.0001 and p < 0.0003, respectively) and CAPS 4 (HR for CV death/MI: 24.1, p < 0.0001). A high number of UCTs was also a strong multivariable independent predictor of CV death/MI (HR: 7.78 and 10.18 for UCT 2 and 3, p < 0.0001 and p < 0.0007, respectively). Cumulative survival rates for CV death/MI and composite adverse CV events were 86% and 73% with UCT 0, 84% and 49% with UCT 1, 53% and 3% with UCT 2, and 29% and 0% with UCT 3, respectively. Coronary CTA appears to be a promising tool for long-term risk stratification of CABG patients. The UCT score has significant prognostic value to predict CV deaths/MI.

Obesity and coronary microvascular disease - implications for adipose tissue-mediated remote inflammatory response.

It is believed that obesity has detrimental effects on the coronary circulation. These include immediate changes in coronary arterial vasomotor responsiveness and the development of occlusive large coronary artery disease. Despite its critical role in regulating myocardial perfusion, the altered behavior of coronary resistance arteries, which gives rise to coronary microvascular disease (CMD) is poorly understood in obesity. A chronic, low-grade vascular inflammation has been long considered as one of the main underlying pathology behind CMD. The expanded adipose tissue and the infiltrating macrophages are the major sources of pro-inflammatory mediators that have been implicated in causing inadequate myocardial perfusion and, in a long term, development of heart failure in obese patients. Much less is known the mechanisms regulating the release of these cytokines into the circulation that enable them to exert their remote effects in the coronary microcirculation. This mini review aims to examine recent studies describing alterations in the vasomotor function of coronary resistance arteries and the role of adipose tissue-derived pro-inflammatory cytokines and adipokines in contributing to CMD in obesity. We provide examples of regulatory mechanisms by which adipokines are released from adipose tissue to exert their remote inflammatory effects on coronary microvessels. We identify some of the important challenges and opportunities going forward.

Drug-eluting versus bare-metal stents in large coronary arteries of patients with ST-segment elevation myocardial infarction: Findings from the ICAS registry

Background and purposeThere are a few retrospective subgroup analyses or registries of large-vessel (≥3.5mm) stenting. We investigated clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and bare-metal stents (BMS) in large coronary vessels. Methods and subjectsOf 1100 STEMI patients registered in the Ibaraki Cardiovascular Assessment Study (ICAS) multicenter registry from April 2007 to June 2012 who underwent PCI, we enrolled 454 patients (65.8±12.7 years old, 81% male) with ≥3.5-mm stents. We excluded 53 patients with cardiogenic shock or left main trunk lesions. The remaining 401 patients were divided into Group-D, PCI with DES (n=184), and Group-B, PCI with BMS (n=217). Propensity score analysis matched 1:1 according to treatment with DES (n=101) or with BMS (n=101). We evaluated major adverse cardiac and cerebrovascular events (MACCE) and incidence of stent thrombosis (ST). MACCE was defined as all-cause death, myocardial infarction (MI), target-vessel revascularization (TVR), or cerebrovascular accident (CVA). Essential resultsDuring a mean follow-up period of 526 days, all-cause death, MI, CVA, MACCE, and ST were not significantly different in Group-D versus Group-B (all-cause death: 4.35% vs. 4.61%, p=0.90; MI: 0% vs. 0%; CVA: 2.72% vs. 3.23%, p=0.76; MACCE: 15.2% vs. 20.3%, p=0.19; and ST: 0.0% vs. 1.38%, p=0.11). After adjusting for age, insulin use, multivessel disease, intra-aortic balloon pump use, culprit lesions, and estimated glomerular filtration rate <60ml/min/1.73m2, MACCE was not significantly different between the groups (odds ratio: 0.69; 95% CI: 0.40–1.23; p=0.21). However, TVR was significantly lower in Group-D than Group-B in Kaplan–Meier analysis (p=0.048) after propensity score matching. Principal conclusionThere was no advantage to using a DES in large vessels for preventing a hard endpoint, whereas DES use resulted in a significant reduction in TVR in the patients with STEMI in this registry.

Abstract P321: Coronary Artery Remodeling and Subclinical Atherosclerosis: the CARDIA study

Atherosclerosis related inflammation and plaque result in expansive remodeling of the coronary artery, a finding associated with plaque rupture and clinical events. The extent of expansive coronary remodeling in adults prior to the development of clinical disease is largely unknown. We tested the hypothesis that middle-aged adults who have subclinical coronary artery disease also have larger coronary artery diameters. Methods: Submillimeter thin slice, non-contrast cardiac CT images were obtained in 1197 black and white men and women in the Coronary Artery Risk Development in Young Adults (CARDIA) Study during the year 25 examination (2010-2011, mean age 50 years). Average coronary artery diameter(mm) and cross sectional area (mm2) were measured sequentially along the length of each vessel and averaged for the left main (LM) and proximal circumflex (LCX), left anterior descending (LAD), and right coronary (RCA) arteries. Presence/absence of coronary artery calcifications [CAC (0 versus &gt;0 AU)] was measured independently. Multivariable linear regression models were used to examine the association of CAC with artery size. Results: Coronary diameter was larger in blacks compared to whites (p&lt;0.05) and in men compared to women (p&lt;.0001) following adjustment for age and study center. Presence of CAC was associated with larger diameter coronary arteries after adjustment for age, race, sex, education, height, and study center (Table, model 1). These associations remained following additional adjustment for established cardiovascular risk factors, with the exception of the left main segment (Table, model 2), and were similar for vessel area as for vessel diameter (not shown). Conclusion: Coronary arteries are larger in middle-age individuals with vs without CAC, supporting the hypothesis that atherosclerosis leads to expansive coronary remodeling. Coronary remodeling by non-contrast CT is a measure that may provide new information on cardiovascular risk and prediction of clinical cardiovascular events.

Cranioselectivity of Sumatriptan Revisited: Pronounced Contractions to Sumatriptan in Small Human Isolated Coronary Artery

Initial concerns about the coronary side-effect potential of the anti-migraine drug sumatriptan and second-generation triptans initiated cranioselectivity studies using proximal human coronary arteries. However, myocardial ischaemia may originate from both large and small human coronary arteries. We investigated the contractions to sumatriptan in proximal (internal diameter 2-3mm), distal (internal diameter 1,000-1,500μm) and small (internal diameter 500-1,000μm) human epicardial coronary arteries and compared these with contractions in the human middle meningeal artery. Concentration response curves to sumatriptan in human coronary arteries were constructed in the absence or presence of the 5-hydroxytryptamine1B (5-HT1B) receptor antagonist SB224289 and the 5-HT1D receptor antagonist BRL15572. The effect of sumatriptan on increased cyclic adenosine monophosphate (cAMP) levels induced by forskolin in proximal and distal coronary artery segments was investigated using a biochemical assay. Western blotting was used to analyse the 5-HT1B receptor density in the human arteries. Contractions in the proximal human coronary artery were significantly smaller than those in the human meningeal artery, as we showed previously. In contrast, contractions to sumatriptan in distal and small human coronary arteries were not different from those in the human meningeal artery. The 5-HT1B receptor antagonist SB224289, but not the 5-HT1D receptor antagonist BRL15572, inhibited the contraction induced by sumatriptan in the coronary arteries. Moreover, in distal, but not in proximal, coronary arteries, sumatriptan inhibited the increase in cAMP levels induced by forskolin. Contrary to our expectations, the 5-HT1B receptor expression was more pronounced in the proximal human coronary artery than in the distal and small human coronary artery. Based on functional experiments in distal and small human coronary arteries, contractions to sumatriptan are not as cranioselective as previously assumed. However, the vast clinical experience with sumatriptan and other triptans has proven that these drugs are cardiovascularly safe when contraindications are taken into account.

Incidental finding of a large right coronary artery aneurysm

Incidental finding of a large right coronary artery aneurysm

Comparison of drug‐eluting and bare metal stents in large coronary arteries

This study sought to evaluate the safety and effectiveness of drug-eluting stents (DES) compared to bare-metal stents (BMS) for patients with large coronary vessels. Randomized trials have demonstrated that DES reduce the risk of target vessel revascularization (TVR) compared to BMS. This benefit is less pronounced as artery diameter increases. Whether DES are superior to BMS for larger coronary arteries in the setting of routine clinical practice is unknown. We analyzed data from 869 patients undergoing de novo lesion PCI with reference vessel diameter greater than or equal to 3.5 mm in the NHLBI Dynamic Registry according to whether they were treated with DES or BMS. Patients were followed for 3 years for the occurrence of cardiovascular events. At 3-year follow-up, rates of TVR at 3 years were similar and low in both groups (4.4% vs. 3.7%, P = 0.62). After adjustment for differences in baseline characteristics, the adjusted hazard ratio for 3-year MI for DES was 1.85 (95% CI 0.93-3.7, P = 0.08), for TVR at 3 years 1.14 (95% CI 0.52-2.49, P = 0.75) and for mortality 0.89 (95%CI 0.49-1.62, P = 0.71). In our study of the unrestricted use of DES for patients with lesions in larger diameter coronary arteries, first generation DES did not reduce 3-year risk of TVR. Our findings do not support the preferred use of DES over BMS for patients with lesions located in arteries >3.5 mm. It is unknown whether secondary generation DES can offer better outcome compared to BMS in large coronary vessels. Further study on this issue is warranted.

Staged Hybrid Treatment for Contained Rupture of a Large Right Coronary Artery Aneurysm

We describe a staged approach to the management of a rare acute condition--contained rupture of a large right coronary artery aneurysm. A covered stent was deployed percutaneously to isolate the aneurysm at presentation followed by planned coronary bypass grafting. Treatment interval was complicated by new-onset pulmonary tuberculosis and subacute thrombosis of the covered stent leading to nonfatal inferior myocardial infarction. Coronary surgery was performed after complete antitubercular treatment and resolution of the acute pericarditis/thrombosis as a consequence of the contained rupture. The advantages of this staged approach included the following: (a) The covered stent prevented both acute myocardial infarction and progressive pseudoaneurysm expansion in the acute phase. (b) Deferred surgery was rendered technically less hazardous while avoiding the undesirable option of having to exclude an extremely calcified dominant right coronary artery. The patient made an excellent postoperative recovery with complete resolution of her symptoms at 6 weeks' follow-up.