Circumflex Coronary Artery Research Articles

An Anomalous Right Coronary Artery Draining into the Left Ventricle Through a Fistula

Background: Of the three main epicardial coronary arteries, the right coronary artery, left anterior descending artery, and the left circumflex artery, there are many variables between individuals regarding arterial course, distribution of side branches, and termination points. The term ‘Coronary Artery Anomaly’ (CAA) is reserved for congenital alterations in origin or course of the epicardial arteries that occur in less than 1% of the population. While the majority are asymptomatic, such anomalies can significantly increase the risk of myocardial ischemia and sudden cardiac death. With the increasing use of Coronary Computed Tomography Angiography (CCTA), the rate of detection of anomalous coronary arteries is increasing every year. The concurrent presence of a coronary cameral fistula further escalates clinical complexity requiring a multidisciplinary approach to management. Case Report: A 61-year-old female with a past medical history of hypertension, hypothyroidism, migraine, Non-Sustained Ventricular Tachycardia (NSVT), and Supraventricular Tachycardia (SVT), presented to the emergency department with chest pain and palpitations. Coronary angiography was performed revealing a large Right Coronary Artery (RCA) with a proximal branch giving rise to the Left Circumflex Artery (LCX), with an additional branch supplying the Left Anterior Descending (LAD) territory. The RCA and LCX arteries terminated distally in the left ventricular cavity forming a coronary cameral fistula. No flow-limiting stenosis was observed. Intervention versus medical management was discussed with a multidisciplinary team, and the decision was made to proceed with medical management. The patient’s symptoms improved with the medical management. Conclusion: A thorough diagnostic evaluation and a multidisciplinary approach in managing rare coronary anomalies are critical. Medical management, risk factor modification, and regular follow-up are essential components of long-term care for patients with complex coronary artery anomalies.

Chronic total occlusion percutaneous coronary intervention of anomalous coronary arteries: insights from the PROGRESS CTO registry.

There is limited information about the frequency and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in anomalous coronary arteries (ACA). We examined the clinical and angiographic characteristics and procedural outcomes of CTO PCI in ACA among 14,173 patients who underwent 14,470 CTO PCIs at 46 US and non-US centers between 2012 and 2023. Of 14,470 CTO PCIs, 36 (0.24%) were CTO PCIs in an ACA. ACA patients had similar baseline characteristics as those without an ACA. The type of ACA in which the CTO lesion was found were as follows: anomalous origin of the right coronary artery (ARCA) (17, 48.5%), anomalous origin of left circumflex coronary artery (9, 25.7%), left anterior descending artery and left circumflex artery with separate origins (4, 11.4%), anomalous origin of the left anterior descending artery (2, 5.7%), dual left anterior descending artery (2, 5.7%) and woven coronary artery 1 (2.8%). The Japan CTO score was similar between both groups (2.17 ± 1.32 vs 2.38 ± 1.26, p = 0.30). The target CTO in ACA patients was more likely to have moderate/severe tortuosity (44% vs 28%, p = 0.035), required more often use of retrograde approach (27% vs 12%, p = 0.028), and was associated with longer procedure (142.5 min vs 112.00 min [74.0, 164.0], p = 0.028) and fluoroscopy (56 min [40, 79 ml] vs 42 min [25, 67], p = 0.014) time and higher contrast volume (260 ml [190, 450] vs 200 ml [150, 300], p = 0.004) but had similar procedural (91.4% vs 85.6%, p = 0.46) and technical (91.4% vs 87.0%, p = 0.59) success. No major adverse cardiac events (MACE) were seen in ACA patients (0% [0] vs 1.9% [281] in non-ACA patients, p = 1.00). Two coronary perforations were reported in ACA CTO PCI (p = 0.7 vs. non-ACA CTO PCI). CTO PCI of ACA comprise 0.24% of all CTO PCIs performed in the PROGRESS CTO registry and was associated with higher procedural complexity but similar technical and procedural success rates and similar MACE compared with non-ACA CTO PCI.

Design, Synthesis, and Preclinical Evaluation of a High-Affinity 18F-Labeled Radioligand for Myocardial Growth Hormone Secretagogue Receptor Before and After Myocardial Infarction.

The peptide hormone ghrelin is produced in cardiomyocytes and acts through the myocardial growth hormone secretagogue receptor (GHSR) to promote cardiomyocyte survival. Administration of ghrelin may have therapeutic effects on post-myocardial infarction (MI) outcomes. Therefore, there is a need to develop molecular imaging probes that can track the dynamics of GHSR in health and disease to better predict the effectiveness of ghrelin-based therapeutics. We designed a high-affinity GHSR ligand labeled with 18F for imaging by PET and characterized its invivo properties in a canine model of MI. Methods: We rationally designed and radiolabeled with 18F a quinazolinone derivative ([18F]LCE470) with subnanomolar binding affinity to GHSR. We determined the sensitivity and invivo and ex vivo specificity of [18F]LCE470 in a canine model of surgically induced MI using PET/MRI, which allowed for anatomic localization of tracer uptake and simultaneous determination of global cardiac function. Uptake of [18F]LCE470 was determined by time-activity curve and SUV analysis in 3 regions of the left ventricle-area of infarct, territory served by the left circumflex coronary artery, and remote myocardium-over a period of 1.5 y. Changes in cardiac perfusion were tracked by [13N]NH3 PET. Results: The receptor binding affinity of LCE470 was measured at 0.33 nM, the highest known receptor binding affinity for a radiolabeled GHSR ligand. In vivo blocking studies in healthy hounds and ex vivo blocking studies in myocardial tissue showed the specificity of [18F]LCE470, and sensitivity was demonstrated by a positive correlation between tracer uptake and GHSR abundance. Post-MI changes in [18F]LCE470 uptake occurred independently of perfusion tracer distributions and changes in global cardiac function. We found that the regional distribution of [18F]LCE470 within the left ventricle diverged significantly within 1 d after MI and remained that way throughout the 1.5-y duration of the study. Conclusion: [18F]LCE470 is a high-affinity PET tracer that can detect changes in the regional distribution of myocardial GHSR after MI. In vivo PET molecular imaging of the global dynamics of GHSR may lead to improved GHSR-based therapeutics in the treatment of post-MI remodeling.

An Atypical Case of Intracardiac Myxoma Fed by Extracardiac Arteries

Myxoma is the most common type of primary benign heart tumor and is usually easily identified by echocardiography. Tumor vascularity is a rare finding in atrial myxomas and reported cases of the right atrial myxomas most frequently involve feeding vessels from the right coronary artery or, less frequently, from both coronary arteries. In this case report, an echocardiographic examination of a 74-year-old male, who was admitted to hospital with chest pain revealed an echogenic solid mass in the right atrium. A coronary angiography showed an arteriocavity fistula connecting the feeding artery to the cardiac chamber. In the computed tomography angiography examination performed, a mass was observed with intense vascularity, containing feeding vessels from the left circumflex artery, the right inferior phrenic artery, and the left hepatic artery; calcifications in the right atrium were also present. The mass was completely and successfully resected. Pathology results of the mass were compatible with cardiac myxoma. This was an atypical case of a right atrial myxoma due to the presence of intense vascularization and the feed from the cardiac and extracardiac arteries.

Coronary Artery Dimensions on Computed Tomography Following the Neonatal Arterial Switch Operation for the Complete Transposition of the Great Arteries.

Coronary events are life-threatening long-term complications of the arterial switch operation for complete transposition of the great arteries. The aim of our study was to assess the dimensions of the reimplanted coronary arteries and their relationship with the various geometric characteristics to gain a better understanding of the involved mechanisms. Coronary computed tomography angiography (CCTA) scans of 78 asymptomatic pediatric patients were performed at the age of 10.7 (6.3-17.8) years. The position of the ostia, the branching angles, and the diameters of the coronary arteries were determined in a subgroup of 51 patients presenting the usual preoperative coronary anatomy. Mean Z-score of the left main coronary artery (LMCA), left anterior descending coronary artery (LAD), left circumflex coronary artery (LCX), and right coronary artery (RCA) diameters were 0.7 ± 1.2, - 0.4 ± 1.1, - 0.3 ± 1.1, and - 0.3 ± 1.1, respectively. The Z-score of the ostial LMCA diameter had a positive correlation with the remoteness from the main pulmonary artery (p < 0.001) and the branching angle (p = 0.001). The ostial diameter Z-score of the LMCA had a negative correlation with the interval between the arterial switch operation and the CCTA (p = 0.004). Even though most of the coronary diameters fell within the accepted range, which suggests normal overall development, acute branching angle and more anterior origin were associated with smaller ostial coronary artery diameter Z-scores. To prove the clinical relevance of the smaller ostial diameter of high-risk left coronary arteries and the decrease of ostial coronary artery Z-scores over time needs further follow-up studies.

Kugel's Artery in Coronary Computed Tomography Angiography in a Patient with Left Main Subtotal Stenosis.

The artery of Kugel is defined as a rare anatomical variant of the coronary arteries. It consists of an anastomotic connection between the branches of the right coronary artery (RCA) and the left circumflex artery (LCx). In patients with coronary artery occlusion, the presence of this connection bypassing the area of the occluded vessel may be a factor that prevents significant necrosis of a specific area of the myocardium. Most cases are detected by invasive coronary angiography. We present images from coronary computed tomography angiography (CCTA), which documented the existence of Kugel's artery in a 67-year-old patient with subtotal stenosis of the left main artery. The presented images clearly indicate that CCTA can visualize the existing rescue collateral circulation in patients with significant coronary artery disease.

Acute atrial infarction: arelatively neglected and under-recognized entity in clinical practice.

Electrocardiograms (ECGs) and angiographic features indicative of acute atrial infarction (AAI) often go unnoticed and are under-recognized in clinical practice. In this retrospective observational study, we analyzed the data of 3981 out of 9803 patients (40.61%) who were referred to our hospital for angiography and/or percutaneous coronary intervention due to acute coronary syndrome (ACS). These patients were diagnosed with acute ST segment elevation myocardial infarction (AMI) affecting the inferior, posterior, and/or right ventricular regions. Of the 3981 patients, 270 (6.78%) had involvement of the main coronary atrial branch meeting the angiographic criteria for AAI. Among the 270 patients identified, the right coronary artery was diagnosed as the infarct-related artery (IRA) in 187 patients (groupR), while the left circumflex artery was the IRA in 83patients (groupL). The incidence of PR-segment deviation was similar between the two groups (65.2% in groupR vs.66.3% in groupL, p = 0.870), as was occurrence of atrial tachyarrhythmia (67.4% vs.55.4%, p = 0.059). The prevalence of P wave morphology abnormalities (29.9% vs.49.4%, p = 0.005) and sinus bradycardia or arrest (25.1% vs.66.3%, p < 0.001) was significantly lower in GroupR than in GroupL. Acute atrial infarction represents adistinct yet frequently overlooked clinical entity. Clinicians should consider the potential for atrial arrhythmias, thromboembolism, hemodynamic instability, and atrial rupture when diagnosing AAI.

Association between 82Rb positron emission tomography-derived regional myocardial blood flow, severity of angiographic coronary artery stenosis, and mortality in patients with chest pain

Impairment in global myocardial flow reserve (MFR) on rubidium-82 (82Rb) positron emission tomography (PET) stress testing predicts cardiovascular events; however, the relationship between regional coronary artery territory myocardial blood flow (MBF) and invasive coronary angiography is unknown. In this study, patients with acute chest pain who were referred for coronary angiography after abnormal PET stress testing were evaluated. Both global and regional coronary territory stress and rest MBF were derived using 82Rb PET. Coronary artery stenosis severity was assessed using quantitative coronary angiography (QCA) performed within 3 months of PET. A total of 189 patients were followed for a median of 4.1 years. The results showed a weak correlation between regional MFR impairment (&lt;1.7) and stenosis severity in the left descending artery (r = &amp;minus;0.20, P = 0.005), left circumflex artery (r = &amp;minus;0.15, P = 0.042), and right coronary artery (r = &amp;minus;0.26, P &lt; 0.001). In addition, a weak correlation was observed between global MFR and stenosis in any vessel, in both binary and continuous analyses. However, impairment in MFR within any territory was associated with increased all-cause mortality in both unadjusted and adjusted analyses. In conclusion, this is the first large-scale study to examine the relationship between regional coronary territory MBF, coronary artery stenosis severity as assessed using QCA, and mortality. Although coronary territory MFR demonstrated a weak correlation with coronary stenosis severity, impairment in per-territory MFR was significantly associated with increased all-cause mortality, suggesting that mechanisms such as diffuse atherosclerosis and/or microvascular disease may be contributing factors.

The effect of hydrostatic pressure on invasive coronary pressure measurements: Comparison with [15O]H2O-positron emission tomography flow data.

Fractional flow reserve (FFR) has emerged as the invasive gold standard for assessing vessel-specific ischemia. However, FFR measurements are influenced by the hydrostatic effect, which might adversely impact the assessment of ischemia. This study aimed to investigate the impact of hydrostatic pressure on FFR measurements by correcting for the height and comparing FFR with [15O]H2O positron emission tomography (PET)-derived relative flow reserve (RFR). The 206 patients were included in this analysis. Patients underwent coronary computed tomography angiography (CCTA), [15O]H2O PET, and invasive coronary angiography with routine FFR in every epicardial artery. Height differences between the aortic guiding catheter and distal pressure sensor were quantified on CCTA images. An FFR ≤ 0.80 was considered significant. The study found a reclassification in 7% of the coronary arteries. Notably, 11% of left anterior descending (LAD) arteries were reclassified from hemodynamically significant to nonsignificant. Conversely, 6% of left circumflex (Cx) arteries were reclassified from nonsignificant to significant. After correcting for the hydrostatic pressure effect, the correlation between FFR and PET-derived RFR increased significantly from r = 0.720 to r = 0.786 (p = 0.009). The average magnitude of correction was +0.05 FFR units in the LAD, -0.03 in the Cx, and -0.02 in the right coronary artery. Hydrostatic pressure has a small but clinically relevant influence on FFR measurements obtained with a pressure wire. Correcting for this hydrostatic error significantly enhances the correlation between FFR and PET-derived RFR.

Predictive value of CCTA-based pericoronary adipose tissue imaging for major adverse cardiovascular events

To evaluate the ability of the radiomic characteristics of pericoronary adipose tissue (PCAT) as determined by coronary computed tomography angiography (CCTA) to predict the likelihood of major adverse cardiovascular events (MACEs) within the next five years. In this retrospective casecontrol study, the case group consisted of 210 patients with coronary artery disease (CAD) who developed MACEs within five years, and the control group consisted of 210 CAD patients without MACEs who were matched with the case group patients according to baseline characteristics. Both groups were divided into training and testing cohorts at an 8:2 ratio. After data standardization and the exclusion of features with Pearson correlation coefficients of |r| ≥0.9, independent logistic regression models were constructed using selected radiomics features of the proximal PCAT of the left anterior descending (LAD) artery, left circumflex (LCX) artery, and right coronary artery (RCA) via least absolute shrinkage and selection operator (LASSO) techniques. An integrated PCAT radiomics model including all three coronary arteries was also developed. Five models, including individual PCAT radiomics models for the LAD artery, LCX artery, and RCA; an integrated radiomics model; and a fat attenuation index (FAI) model, were assessed for diagnostic accuracy via receiver operating characteristic (ROC) curves, calibration curves, and decision curves. Compared with the FAI model (AUC=0.564 in training, 0.518 in testing),the integrated radiomics model demonstrated superior diagnostic performance (area under the curve [AUC]=0.923 in training, 0.871 in testing). The AUC values of the integrated model were greater than those of the individual coronary radiomics models, with all the models showing goodness of fit (P>0.05). The decision curves indicated greater clinical utility of the radiomics models than the FAI model. PCAT radiomics models derived from CCTA data are highly valuable for predicting future MACE risk and significantly outperform the FAI model.

Characterisation and distribution of human coronary artery innervation.

A detailed understanding of the sympathetic innervation of coronary arteries is relevant to facilitate the development of novel treatment approaches. This study aimed to quantitatively examine periarterial innervation in human epicardial coronary arteries. Coronary arteries with adjacent epicardial adipose tissue were excised along the left main coronary artery (LMCA), left anterior descending artery (LAD), left circumflex artery (LCx), and right coronary artery (RCA) from 28 body donors and examined histologically. Immunofluorescence staining was performed to characterise sympathetic nerve fibres. A total of 42,573 nerve fibres surrounding 100 coronary arteries (LMCA: n=21, LAD: n=27, LCx: n=26, RCA: n=26) were analysed. The nerve fibre diameter decreased along the vessel course (median [interquartile range]): (proximal 46 μm [31-73], middle 38 μm [26-58], distal 31 μm [22-46]; p<0.001), with the largest nerve fibre diameter along the LMCA (50 μm [31-81]), followed by the LAD (42 μm [27-72]; p<0.001). The total nerve fibre density was highest along the RCA (123 nerves/cm² [82-194]). Circumferentially, nerve density was higher in the myocardial tissue area of the coronary arteries (132 nerves/cm² [76-225]) than in the epicardial tissue area (101 nerves/cm² [61-173]; p<0.001). The median lumen-nerve distance was smallest around the LMCA (2.2 mm [1.2-4.1]), followed by the LAD (2.5 mm [1.1-4.5]; p=0.005). Human coronary arteries are highly innervated with sympathetic nerve fibres, with significant variation in the distribution and density. Understanding these patterns informs pathophysiological understanding and, potentially, the development of catheter-based approaches for cardiac autonomic modulation.

Frequency and Pattern of Anomalous Origin of Coronary Artery in Bangladeshi Population: Coronary Angiogram Based Single Center Study

Background: Anomalous origin of coronary artery (AOCA) has been traditionally described by coronary angiography or autopsy. However the actual prevalence of such abnormalities is unknown in general Bangladeshi population. Beside conventional coronary angiogram(CAG), CT CAG and Multi-detector computed tomography (MDCT) offers higher possibility to visualize AOCA non-invasively. The purpose of this study was to report the prevalence AOCA in Bangladeshi population by using conventional CAG. Methodology: This was a single center, cross sectional, observational study, done in department of Cardiology, BSMMU over 1 year period. Sample size was 1167. Samples were taken following inclusion and exclusion criteria. Descriptive statistical analysis was done by using SPSS v29.0 Results: 1.3% population had AOCA. Commonest (0.6%) was ‘absent Left main (LM) with separate origin of Left Anterior Descending (LAD) and Left Circumflex (LCX) artery. Second commonest (0.45%) was ‘Right Coronary Artery (RCA) arising from left sinus’. 0.17% had RCA highup origin, and 0.08% had RCA origin from posterior sinus. Discussion: Among AOCA, RCA origin from left sinus, is potentially dangerious, due to high risk of sudden cardiac death (SCD) and surgical complications. Other varities of AOCA are mostly benign, but it may cause difficulties in cannulation during coronary angiography and coronary artery bypass surgery. Conclusion: Although coronary artery anomalies are rare, they may cause difficulties during coronary interventions or cardiac surgery and may occasionally result in sudden cardiac death. So, optimum precaution to findout the AOCA is needed during conventional CAG, and if suspicion, CT CAG and MDCT should also be used. (Bangladesh Heart Journal 2024; 39(2): 117-120

Clinical and Angiographic Profile of Non-ST Elevation Myocardial Infarction Patients with Multivessel Disease: A Study in a Tertiary Care Hospital in Bangladesh

Background: Non-ST elevation myocardial infarction (NSTEMI) is a type of acute coronary syndrome without ST-segment elevation on electrocardiography. Many non-ST elevation myocardial infarction patients have multivessel disease, which leads to worse outcomes compared to single-vessel disease. Their clinical and angiographic profiles provide valuable insightf into the nature, severity, and treatment of this common cardiac condition. This study aimed to evaluate the clinical and angiographic profiles of non-ST elevation myocardial infarction patients with multivessel disease. Methods: This prospective study was conducted in the Department of Cardiology, National Heart Foundation Hospital and Research Institute, Dhaka, Bangladesh from September 2022 to August 2023. The study enrolled 270 consecutive patients with NSTEMI. Coronary angiography and electrocardiogram were used in assessing the disease condition. The data were analyzed using SPSS version 23.0. Results: The mean age of total participants was 54.31 ±10.54 years and most of them were male (77.8%). Majority of the patients had hypertension (68.1%), diabetes mellitus (59.3%), and dyslipidemia (58.5%). In the clinical assessment, 89.6% of patients had femoral access, 31.1% had a bifurcation lesion, 8.1% showed calcification, and 22.6% had a left main lesion. Stents were used in 41.9% of cases, with a mean total stent length of 55.8 ±26.9 mm. The mean left ventricular ejection fraction was 49.10 ±7.3%. Among the major culprit vessel involvements identified, 6% involved the left main (LM) artery, 56% involved the left anterior descending (LAD) artery, 34% involved the left circumflex (LCX) artery, and 39% involved the right coronary artery (RCA). Regarding the final angiographic findings among the total participants, double vessel disease (DVD) was observed in 40% of cases, while triple vessel disease was observed in 60% of cases. Conclusion: The increased prevalence of triple vessel disease among non-ST elevation myocardial infarction patients underscores the importance of heightened vigilance among healthcare providers and policymakers. Understanding the clinical and angiographic profiles of these patients is essential for effective management strategies.

Hybrid strategy of drug-eluting stent and drug-coated balloon in the treatment of de novo coronary artery disease: 1-year clinical outcomes.

The hybrid strategy of drug-eluting stent (DES) and drug-coated balloon (DCB) has been increasingly accepted for the treatment of de novo coronary artery disease. However, data regarding the clinical outcome of this practice in a Southeast Asian population are limited. We aimed to investigate the safety and clinical outcome of this hybrid strategy (DES and DCB) in the treatment of de novo coronary artery disease. The primary endpoint was target lesion failure (TLF) in the DES/DCB-treated segment at 12 months. TLF is defined as the composite of cardiac death, target vessel myocardial infarction (TVMI) and ischaemia-driven target lesion revascularisation (ID-TLR) in the DES- and/or DCB-treated segment. A total of 401 patients with 458 lesions were treated with the hybrid strategy at the National Heart Institute (IJN), Kuala Lumpur, Malaysia, from 1 July 2021 to 30 June 2022, were retrospectively enrolled in the study. A total of 38 patients (9.5%) were lost to subsequent follow-up, and the remaining 363 patients (90.5%) were included in the outcome analysis. Clinical outcomes at 1 year were analysed. In all, 219 lesions (47.8%) involved the left anterior descending artery, 146 lesions (31.9%) involved the right coronary artery, and 57 lesions (12.4%) involved the left circumflex artery. In all, 87 lesions (19%) were bifurcation lesions. A total of 8 patients (2.2%) had TLF, of whom 3 patients (0.83%) had TVMI, 3 patients (0.83%) had ID-TLR, and 2 patients (0.6%) experienced cardiac death. Four patients died of a non-cardiac cause at 1-year follow-up. A hybrid strategy of DES and DCB for the treatment of de novo coronary artery lesions appears to be feasible and clinically safe according to the 1-year outcomes.

Clinical and Angiographic Outcomes of Bilateral Internal Thoracic Artery Revascularization: In Situ vs Free Grafts

BackgroundBilateral internal thoracic artery (ITA) grafting is associated with improved long-term outcomes; however, the appropriate graft configuration remains controversial. We compared the long-term outcomes of different graft configurations. MethodsBetween 2009 and 2015, 1171 patients underwent isolated bilateral ITA grafting for left-sided complete revascularization at 4 Japanese cardiac surgery centers: underwent in situ left ITA to the left anterior descending artery plus in situ right ITA to the left circumflex artery (LR group, n = 278), in situ right ITA to the left anterior descending artery plus in situ left ITA to the left circumflex artery (RL group, n = 665), and in situ left ITA to the left anterior descending artery plus free right ITA to the left circumflex artery (free group, n = 228). Major adverse cardiovascular events (MACEs), including mortality, myocardial infarction and revascularization, and ITA patency, were compared. ResultsAmong the 3 groups, the free group showed significantly lower MACEs and overall mortality rates (P < .001). Nonfatal myocardial infarction and revascularization rates showed no marked differences among the groups. A weighted analysis revealed a decreased risk of MACEs and death in the free group. No marked difference was observed in the patency of the ITA anastomosed to the left anterior descending artery. Patency of the ITA grafted to the circumflex artery in the LR group was significantly lower relative to the other groups. Using a free right ITA grafted to the circumflex artery reduced the risk of graft failure. ConclusionsThe free right ITA configuration for left-sided revascularization might have better long-term outcomes and significantly better patency than other grafts.

Atypical Aslanger pattern in inferolateral myocardial infarction – A new variant to look out for?

We report a case of a 53-year-old male with inferolateral myocardial infarction, presenting an atypical Aslanger pattern on electrocardiogram (ECG). The ECG showed ST elevation in leads III, aVR, aVF, and posterior leads, with ST depression in II and V2-V6 with terminal positive T waves. Coronary angiography revealed total occlusion of the left circumflex artery (LCx) with significant stenosis of the left anterior descending (LAD) and right coronary artery (RCA). The LCx was successfully revascularized. This case highlights the importance of recognizing atypical Aslanger patterns, which may indicate multivessel coronary artery disease.

Case report: Woven-like coronary arteries in a patient with polycythemia vera

BackgroundWoven coronary artery (WCA) is a rare and underdiagnosed congenital anomaly that involves multiple thin and tortuous epicardial arterial conduits reassembling distally into a single lumen. Recanalized thrombus may present as woven-like coronary arteries, appearing similar to WCA on angiographic images.Case presentationA 58-year-old female patient with intermittent chest pain for 5 years and polycythaemia vera (PV) for 8 years. The left anterior descending artery was presented like WCA on coronary angiography and finally confirmed as recanalized thrombus by optical coherence tomography(OCT), which might have been caused by PV. Given the patient’s high thrombotic risk of PV and thrombotic changes in the left circumflex artery (LCX), we ultimately chose a conservative treatment without stenting.ConclusionsOCT would be needed for the diagnosis and differential diagnosis of woven-like coronary arteries. And physicians should take an appropriate treatment in a personalized way in patients with PV.

Cancer therapy-related cardiac dysfunction after radiation therapy for breast cancer: results from the BACCARAT cohort study

BackgroundRadiation therapy (RT) for breast cancer (BC) can result in subtle cardiac dysfunction that can occur early after treatment. In 2022, the European Society of Cardiology (ESC) published the first guidelines in cardio-oncology with a harmonized definition of cancer therapy-related cardiac dysfunction (CTRCD). The aim of this study was to evaluate CTRCD occurrence over 24 months of follow-up after RT in BC patients and to analyze the association with cardiac radiation exposure.MethodsThe prospective monocentric BACCARAT study included BC patients treated with RT without chemotherapy, aged 40–75 years, with conventional and 2D Speckle tracking echocardiography performed before RT, 6 and 24 months after RT. Based on ESC cardio-oncology guidelines, CTRCD and corresponding severity were defined with left ventricle ejection fraction and global longitudinal strain decrease, occurring at 6 or 24 months after RT. Dosimetry for whole heart, left ventricle (LV) and left coronary artery (left anterior descending and circumflex arteries (CX)) was considered to evaluate the association with CTRCD, based on logistic regressions (Odds Ratio – OR and 95% confidence interval – 95%CI). Youden index based on receiver operating characteristic curve analysis was used to identify the optimal threshold of dose-volume parameters for predicting CTRCD.ResultsThe study included 72 BC patients with a mean age of 58 ± 8.2 years. A total of 32 (44%) patients developed CTRCD during follow-up: 20 (28%) mild CTRCD, 7 (9%) moderate CTRCD, and 5 (7%) severe CTRCD. Cardiac radiation doses were generally higher among patients with CTRCD rather than non-CTRCD. Dose-response relationships were significant for mean CX dose (OR = 2.48, 95%CI (1.12–5.51), p = 0.02) and marginally significant for V2 of LV (OR = 1.03 95%CI (1.00-1.06), p = 0.05). V2 of LV ≥ 36% and mean CX dose ≥ 1.40 Gy thresholds were determined to be optimal for predicting CTRCD.ConclusionFor BC patients treated with RT without chemotherapy, CTRCD can be observed in an important proportion of the population over 24 months after treatment. Left ventricle and circumflex coronary artery exposure were found to be associated with CTRCD and could be used for the prediction of such cardiotoxicity. Further research remains needed to confirm these results.Trial RegistrationClinicalTrials.gov Identifier- NCT02605512.

Anomalous left circumflex artery origin in aortic root surgery

Anomalous left circumflex artery origin in aortic root surgery

The value of CT coronary angiography for a comprehensive assessment of left circumflex artery in Kawasaki disease: 9 years of experience from a tertiary center

Transthoracic echocardiography (TTE) has traditionally been the primary method for coronary imaging in children with Kawasaki disease (KD). We aimed to evaluate coronary artery lesions (CALs) of the left circumflex artery (LCx) in KD on computed tomography coronary angiography (CTCA). Over a 9-year period (November 2013-December 2022), 225 children with KD underwent radiation-optimized CTCA on a 128-slice dual-source platform. TTE was performed on the same day, or a day prior or after CTCA. On CTCA, LCx CALs were seen in 41/225 (18.2%) patients. However, TTE detected CALs in only one third of these patients [15/41 (36.6%)]. CTCA showed 47 LCx CALs in 41 patients-aneurysms in 39 patients (40 fusiform, 2 saccular; 7 giant aneurysms), stenoses in 3, and thrombosis in 2. Thromboses and stenoses were both missed on TTE. Proximal LCx aneurysms were seen in 39 patients-of these, 12 had distal extension. Six patients had distal LCx aneurysms without proximal involvement and 2 non-contiguous multiple aneurysms. Four (9.75%) patients had isolated LCx involvement. Based on CTCA findings, treatment protocols had to be modified in 3/41 (7.3%) patients. This study highlights anatomical findings of LCx involvement in KD. Isolated LCx CALs were noted in 4/41 (9.75%) patients. TTE alone proved inadequate for LCx assessment in children with KD. With abnormalities detected in 18.2% of cases, including those missed by TTE, CTCA emerges as an essential imaging modality. The findings have implications for treatment planning and follow-up strategies in children with KD. None.