Ostium Of Left Coronary Artery Research Articles

Repeated acute coronary syndrome caused by a mind-bending mural thrombus in ascending aorta: a case report and review of the literature

BackgroundAcute coronary syndrome due to coronary artery embolism in the setting of ascending aortic thrombus is an uncommon condition, even rarer when there is no aortic pathology such as aneurysm, severe atherosclerosis, aortic dissection, or thrombophilia (whether inherited or acquired).Case presentationWe report a case of a 58-year-old male presented with acute chest pain, electrocardiogram showing non-ST-elevation acute coronary syndrome. The computed tomography angiography of coronary artery revealed a mural thrombus in the proximal part of ascending aorta, located above the left coronary artery ostium, without any aortic pathologies. With the exception of hypertension and cigarette smoking, no other risk factors were identified in this patient that may increase the risk of thrombosis. Given the life-threatening risk of interventional therapy and surgery, the patient determinedly opted for anticoagulant and dual antiplatelet therapy. Then he experienced the reoccurrence of chest pain after 6-day treatment, progressed to anterior and inferior ST-segment elevation myocardial infarction. Coronary artery embolism originating from the ascending aortic thrombus was suspected. Considering the hemodynamic instability of the patient, the medical treatment was continued and bridged to warfarin and aspirin after discharge. Follow-up computed tomography angiography at 6 months showed no obstruction in coronary artery and complete resolution of the thrombus. No thromboembolic events occurred henceforward.ConclusionsAcute coronary syndrome could be a manifestation of secondary coronary embolism due to ascending aortic thrombus. Currently, there is no standardized guideline for the treatment of aortic mural thrombus, individualized treatment is recommended. When surgical therapy is not applicable for the patient, anticoagulation and dual antiplatelet treatment are alternative treatments that may successfully lead to the resolution of the aortic thrombus.

The impact of left circumflex coronary artery ostium stenosis on outcomes for patients after percutaneous coronary intervention for unprotected left main disease.

The impact of left circumflex coronary artery (LCX) ostium atherosclerosis in left main coronary artery (LM) bifurcation disease is not well-known. The study aimed to assess whether the involvement of LCX ostium carries prognostic implications in patients undergoing unprotected LM percutaneous coronary intervention (PCI). Consecutive 564 patients with unprotected LM (ULMCA) disease who underwent LM PCI between January 2015 and February 2021, with at least 1 year of available follow-up were included in the study. The first group was composed of 145 patients with ULMCA disease with LCX ostium stenosis, and the second group consisted of 419 patients with ULMCA disease without LCX ostium stenosis. Patients in the group with ULMCA disease with LCX ostium stenosis were significantly older and had more comorbidities. The two-stent technique was used more often in the group with LCX ostium stenosis (62.8% vs. 14.6%; P <0.001). During 7-year follow-up, all-cause mortality did not differ significantly between groups with and without LCX ostium stenosis (P = 0.50). The use of one-stent or two-stent technique also did not impact mortality in patients with LCX ostial lesions (P = 0.75). Long-term mortality subanalysis for three groups of patients: (1) patients with LM plus LCX ostium stenosis; (2) LM plus left anterior descending artery (LAD) ostium stenosis; (3) LM plus LCX ostium plus LAD ostium stenosis also did not differ significantly (P = 0.63). LCX ostium involvement in LM disease PCI is not associated with adverse long-term outcomes, which is highly beneficial for the Heart Team's decision-making process.

Management of a rare isolated left main coronary artery ostial stenosis in a young patient: a case report

BackgroundIsolated congenital ostial stenosis of the left coronary artery (LCA) is extremely rare, and available literature is limited. Long-term treatment success is key in the choice of treatment strategy due to the mostly young age of the patients. Here, we present a clinical case and shed light on the surgical treatment strategies including their pitfalls.Case presentationWe describe a 20-year-old male who presented to the emergency department with recurrent typical angina pectoris symptoms (CCS class II). Computed tomography and coronary angiography revealed isolated ostial stenosis of the LCA, with prominent collaterals from the right coronary artery. The patient was operated on and intra-operative findings showed a severely narrowed LCA ostium that appeared to be fibrotic, and to originate from a similarly fibrotic left coronary sinus of the aortic root. The LCA was excised from the left coronary sinus, and trimmed until the coronary artery lumen appeared macroscopically normal. The fibrotic left coronary sinus was resected and replaced with a bovine pericardial patch, into which the coronary artery was re-inserted. During weaning from cardiopulmonary bypass, we faced a diminished left ventricular function. We attributed this to insufficient myocardial protection. Isolated antegrade cardioplegia had been used, which, for technical reasons, had to be administered separately to the right and left coronary artery after aortotomy. In the setting of huge collaterals from the right to the left coronary artery, a steal-effect likely occurred. After prolonged reperfusion, the left ventricular function recovered, and the further post-operative course was unremarkable.ConclusionsFor the surgical treatment of congenital ostial stenosis of the LCA, both ostium reconstruction and coronary artery bypass grafting have been described. The advantage of ostium reconstruction as chosen here is to create a physiological flow and supply situation to the affected myocardial areas. Furthermore, in case of other downstream events, such as the development of coronary artery disease, all further therapeutic options are preserved.Special attention should be paid to the administration of cardioplegia in these patients. Combined ante and retrograde cardioplegia administration probably would have achieved more extensive myocardial protection in our case.

Abstract 128: Safety And Efficacy Of Pro-efferocytic Nanoparticles To Treat Atherosclerosis In A Porcine Model

Background and Aims: Within the atherosclerotic plaque, the formation of a necrotic core is, in part, a consequence of impaired macrophage efferocytosis in which apoptotic vascular cells upregulate “don’t-eat-me,” anti-phagocytic ligand CD47. In vivo , translational murine model studies demonstrating off-target effects of anti-CD47 antibody-mediated blockade prompted the development and successful validation of a macrophage-specific nanotherapy loaded with a chemical inhibitor of Src homology 2 domain-containing phosphatase-1 (SHP-1), a small molecule downstream of the CD47-SIRPα signaling axis. We aimed to test the safety and efficacy of this SHP-1 inhibitor nanotherapy in preventing atherosclerosis in a pre-clinical porcine model. Methods and Results: Sixteen LDLR -/- pigs were fed an atherogenic diet and treated with single-walled carbon nanotubes (SWNT) loaded with SHP1 inhibitor (SWNT-SHP1i) (n=8) or with SWNT alone (n=8), dosed weekly for three months. Blood samples were collected at baseline and at monthly intervals. The lipid panel, CMP, and CBC demonstrated no significant difference between the SWNT-SHP1i and control treatment groups at each timepoint. Survey of major arterial beds by histology revealed early-stage fatty streak disease within the left and right coronary artery (RCA) ostium in addition to the abdominal aorta distal to the renal arteries. Pigs underwent PET/CT in the final week of treatment. The SWNT-SHP1i treated cohort displayed a reduced carotid artery uptake of 18F-FDG compared to the controls (p = 0.017). Bulk RNA sequencing analysis of the carotid artery demonstrated multiple differentially expressed pathways related to hemostasis and the immune response. Conclusion: In a porcine model, macrophage-specific SWNT-SHP1i treatment is not significantly associated with anemia, thus circumventing off-target effects of global anti-CD47 blockade. PET/CT reveals evidence of significantly decreased vascular inflammation in the carotid arteries in the SWNT-SHP1i treated cohort. Bulk RNA-seq confirms numerous significant differentially expressed genes. Ongoing blinded, quantitative histological analysis will further compare both plaque burden and plaque M1/M2 macrophage content between the two cohorts.

Coronary Obstruction during Valve-in-Valve Transcatheter Aortic Valve Replacement: Pre-Procedural Risk Evaluation, Intra-Procedural Monitoring, and Follow-Up.

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is emerging as an effective treatment for patients with symptomatically failing bioprosthetic valves and a high prohibitive surgical risk; a longer life expectancy has led to a higher demand for these valve reinterventions due to the increased possibilities of outliving the bioprosthetic valve's durability. Coronary obstruction is the most feared complication of valve-in-valve (ViV) TAVR; it is a rare but life-threatening complication and occurs most frequently at the left coronary artery ostium. Accurate pre-procedural planning, mainly based on cardiac computed tomography, is crucial to determining the feasibility of a ViV TAVR and to assessing the anticipated risk of a coronary obstruction and the eventual need for coronary protection measures. Intraprocedurally, the aortic root and a selective coronary angiography are useful for evaluating the anatomic relationship between the aortic valve and coronary ostia; transesophageal echocardiographic real-time monitoring of the coronary flow with a color Doppler and pulsed-wave Doppler is a valuable tool that allows for a determination of real-time coronary patency and the detection of asymptomatic coronary obstructions. Because of the risk of developing a delayed coronary obstruction, the close postprocedural monitoring of patients at a high risk of developing coronary obstructions is advisable. CT simulations of ViV TAVR, 3D printing models, and fusion imaging represent the future directions that may help provide a personalized lifetime strategy and tailored approach for each patient, potentially minimizing complications and improving outcomes.

Congenital Absence of Left Coronary Artery Ostium in a Patient Presenting With Anterior ST-Elevation Myocardial Infarction.

A 73-year-old man developed chest pain 12 hours before arriving at our hospital. An electrocardiogram revealed ST-segment elevation in leads V2–V6 (Figure 1A); therefore, an emergent coronary angiography was performed. Several attempts were made to engage the left coronary artery (LCA), but they were unsuccessful. Left coronary cusp angiography and subsequent right coronary angiography demonstrated a single right coronary artery (RCA) with blood flow to the left circumflex coronary artery (LCX) and the congenital absence of the LCA ostium at the left, right, and posterior Valsalva sinuses (Figure 1B, Video 1).

Intramural course of an anomalous left coronary artery is not always associated with a slit-like ostium.

Anomalous aortic origin of the left coronary artery from an incorrect aortic sinus has been reported as the second most common causes of sudden cardiac arrest in young athletes. Intramural course of the proximal left coronary artery is considered a high-risk morphology. It is associated with a slit-like ostium and elliptical shape of the proximal artery. In this case, all pre-operative cardiac images demonstrated a round ostium and round luminal shape of the left coronary artery, which suggested no evidence of intramural course. On intraoperative inspection, although the ostium and proximal left coronary artery appeared round, the patient had a long intramural course of the left coronary artery which our surgeons performed a successful unroofing procedure. The post-operative images showed a patent new ostium from the correct aortic sinus. These findings are very unusual and proved that we should not exclude intramural course even in the absence of a slit-like ostium and elliptical shape of the proximal left coronary artery.

MORPHOMETRIC AND MORPHOLOGICAL ASSESSMENT OF CORONARY ARTERIES WITH INTRAVASCULAR ULTRASOUND

The aim: To perform a morphometric assessment of the coronary arteries ostia by intravascular ultrasound with morphological evaluation among the Ukrainian population. Materials and methods: Intravascular images of the ostia of the right (48%) and left (52%) coronary arteries with the minimum diameter, maximum diameter, mean diameter and lumen area were analyzed. An intravascular ultrasound procedure was performed before percutaneous intervention. Results: A total of 25 IVUS examinations were collected from patients of both sexes and the same ages: 61,27±10,24 for males and females 68±5,83 (p=0.64).The left coronary artery (LCA) ostium assessment was performed in 13 (52%) cases: 8 men and 5 women (32% and 20%, respectively). The right coronary artery (RCA) ostium assessment was performed in 12 (48%) cases: 7 men and 5 women (28% and 20%, respectively). The maximal diameter of the coronary artery ostia was higher in men (5.95±0.66mm) than in women (4.82±0.34mm) (p<0.0001). In men, the maximal diameter of the RCA was higher than in the LCA (6.4±0.40mm and 5.56±0.60mm, respectively). The same differences were found in the mean diameter and lumen area (p<0.05). In women, the minimum diameter, mean diameter, maximum diameter and lumen area of the RCA were higher than LCA but without statistically signi#cant di"erences. The anatomic precondition explains the observed changes in echogenicity. Conclusions: IVUS analysis shows signi#cantly higher parameters of the minimum diameter, mean diameter, maximum diameter and lumen area in men than in women among the Ukrainian population. Therefore, morphological evaluation is crucial in the interpretation of intracoronary images.

278 A CASE OF ACCIDENTAL DIAGNOSIS OF ALCAPA SYNDROME IN ASYMPTOMATIC CHILD

Abstract A 7-year-old (y.o.) boy was referred to our center for a specialist evaluation due to alteration of the ventricular repolarization in the anterior and lateral lead on the electrocardiogram at medical evaluation for physical activity. The child was totally asymptomatic, with normal growth and unremarkable past medical history. The physical examination revealed only S4 and a minimal apical systolic murmur. Transthoracic echocardiogram demonstrated a mildly dilated left ventricle (LV) and normal left ventricular ejection fraction. Strain pattern of basal-medium segments of lateral wall was reduced. Right coronary artery (RCA) appeared dilatated and the left coronary artery (LCA) showed an inverse flow at Doppler evaluation. Findings were suspicious for ALCAPA diagnosis (Anomalous Left Coronary Artery Arising from the Pulmonary Artery); a rare congenital heart disease that, if not treated, leads to death in 90% of cases during first year of life. Adult type of ALCAPA (adolescence-60 y.o) is even more rare and can cause heart failure due to a dilatative cardiomyopathy, chronic cardiac ischemia and, in 80-90% of cases, sudden cardiac death. We performed a coronary angiography that confirmed the anomalous origin of LCA from the pulmonary artery. The RCA was dominant, enlarged and supplied an important collateral flow for LCA. Coronary angiography is indicated not only for diagnosis confirmation, but also for coronary tree demonstration, especially in adult type of ALCAPA, because of the presence of not rare anomalies or “adaptation” of peripheral coronary circulation. All these features are important positive prognostic factors that enable survival beyond infancy. LCA ostium stenosis or bronchial artery collateral vessels are also common but weren't seen in this case. In adult type of ALCAPA surgery is usually indicated at the time of diagnosis, so a coronary button transfer and pulmonary Valsalva sinus reconstruction with autologous pericardial patch were performed. This is the preferred surgical technique in adult patients as it is the most anatomic correction. Since before hospitalization heart failure therapy with betablocker was introduced and after surgery aspirin therapy was started too. Post-surgery transthoracic echocardiogram highlighted a moderate pericardial effusion without haemodynamic impact and a pleural effusion, so an anti-inflammatory therapy with ibuprofen, cortisone and then colchicine was started. After discharge anti-inflammatory therapy was under-titrated until suspension based on gradual reduction of pericardial and pleural effusion. Patient was always free of symptoms and with good performance status. ALCAPA or Bland–White–Garland syndrome is an uncommon congenital heart disease. The presence of adequate collateral circulation between RCA and LCA allows to survive beyond infancy (adult type). We described a case of early diagnosis of adult type of ALCAPA in asymptomatic child thanks to a careful examination of basal electrocardiogram for evaluation of non-competitive sport practice.

Detection of left coronary ostial obstruction during transcatheter aortic valve replacement by coronary flow velocity measurement in the left main trunk by intraoperative transesophageal echocardiography

BackgroundCoronary obstruction is a rare but catastrophic complication of transcatheter aortic valve replacement (TAVR) and occurs mostly at the left coronary artery (LCA) ostium. However, some patients do not show any clinical findings, and thus, its detection is sometimes difficult. The peak diastolic flow velocity in left main coronary artery (LM) was reportedly increased in significant stenosis lesions. We evaluated the effectiveness of measuring blood flow velocities in LM by transesophageal echocardiography (TEE) for the detection of LCA ostial obstruction during a TAVR procedure. MethodsA total of 1105 consecutive patients who underwent TAVR in Sendai Kousei Hospital between September 2014 and December 2020 were enrolled. The LM blood flow velocity was measured at pre- and post-valve implantation. ResultsAmong the 1105 patients, 9 had LCA ostial obstruction. The peak LM blood flow velocity at post-TAVR [0.90 (0.39–1.15) vs. 0.37 (0.28–0.50) m/s; p = 0.0046) was significantly higher in 9 patients who had LCA ostial obstruction, compared with the remaining 1096 patients who had not (controls), although no significant difference was observed before the TAVR procedures between the two groups. The post- to pre-TAVR LM flow velocity ratio [2.26 (1.31–3.42) vs. 1.06 (0.82–1.36); p = 0.0030] was also significantly higher in patients with LCA obstruction, compared to the controls. Furthermore, the post- to pre-TAVR LM blood flow velocity ratio was >2.0 in all six hemodynamically stable patients with LCA obstruction, whereas <2.0 in all three patients with LCA obstruction who showed hemodynamic collapse at post-TAVR procedure. ConclusionCoronary blood flow velocity in LM significantly increased in hemodynamically stable LCA obstruction patients. The intraprocedural TEE measurement of the LM flow velocities would be potentially useful to detect asymptomatic and hemodynamically stable LCA ostial obstruction.

TCT-149 Does the Involvement of Left Circumflex Coronary Artery Ostium Affect Prognosis in Patients Undergoing Percutaneous Coronary Intervention for Left Main Disease?

TCT-149 Does the Involvement of Left Circumflex Coronary Artery Ostium Affect Prognosis in Patients Undergoing Percutaneous Coronary Intervention for Left Main Disease?

Percutaneous Patent Foramen Ovale Closure in a Patient With Anomalous Aortic Origin of the Left Coronary Artery

Percutaneous Patent Foramen Ovale Closure in a Patient With Anomalous Aortic Origin of the Left Coronary Artery

P161 INCIDENTAL FINDING OF QUADRICUSPID AORTIC VALVE IN A YOUNG ASYMPTOMATIC PATIENT

Abstract Background Quadricuspid aortic valve (QAV) is a rare congenital heart disease, eventually leading to aortic regurgitation (AR) and heart failure. In up to one–third of patients, QAV is associated with other coexisting cardiac defects, particularly aortic dilation and coronary arteries abnormalities. Case Report A 48–years old man without significant past medical history was referred to the Cardiologist for newly diagnosed arterial hypertension. The patient was asymptomatic and no abnormal findings were noticed on physical examination. Transthoracic echocardiography showed normal end–diastolic volume and diameter of the left ventricle and preserved systolic function. However, a mild dilation of the aortic root (40 mm) and ascending aorta (38 mm) with concomitant moderate–to–severe AR were described. Transoesophageal echocardiogram (TOE) was performed to better visualize the aortic valve anatomy and to define the exact mechanism of the AR. 2D–TOE revealed a QAV with equal–sized cusps (type A according to the Hurwitz–Roberts classification), with a central quadrangular coaptation defect and a moderate AR (vena contracta width: 4 mm) [Fig. 1–2]. The regurgitant jet conditioned a pseudo–prolapse of anterior mitral leaflet with consequent mild–to–moderate mitral regurgitation. 3D–TOE allowed a better characterization of valve morphology and the individuation of the sole left coronary artery ostium. A coronary artery computed tomography was requested to investigate a probable abnormal origin of the right coronary artery. The patients was subsequently addressed to a regular clinic and echocardiographic follow–up for the surveillance of AR and aortic dimensions and a prompt management of an eventual symptoms onset. Discussion We describe a rare case of type A QAV with moderate AR, mild dilation of aortic root and ascending aorta and suspected anomalous origin of the right coronary ostium. The broad diffusion of imaging techniques has recently led to an increase of incidental diagnosis, even in asymptomatic patients. The complex valve anatomy, with many possible morphologies of the supernumerary cusp, and the association with other congenital defects, particularly anomalous coronary ostia location, pose many technical issues in case of valve replacement. A multimodality imaging approach is essential for a clear description of valve morphology and coronary anatomy to avoid intraoperative complications in both surgical and percutaneous valve replacement procedures.

An Uncommon Case of Ischemic Heart Disease

<h3>Introduction</h3> Diminutive coronary artery syndrome (DCAS) is rare anomaly, defined as a small luminal diameter of >1 of the major coronary vessels. <h3>Case Report</h3> A previously healthy 5 month old infant presented with acute onset dyspnea. Laboratory and radiographic analysis suggested heart failure and end-organ hypoperfusion. A transthoracic echocardiogram demonstrated a dilated (LVDd z score + 6), and hyper-trabeculated left ventricle (LV) (fig 1) with depressed systolic function (ejection fraction 20-25%). The aortic valve (AV) was bicuspid with normal sized annulus, and without any gradient. Interrogation of the coronary arteries revealed normal origins with hypoplasia of the left main ostium, a short left main segment (fig 2), and turbulence by color doppler. CT angiography revealed near atresia of the left coronary artery (LCA) ostium and the main segment measured <1 mm. Cardiac catheterization confirmed findings and revealed stasis of contrast in the LCA. Patch augmentation of the LCA was performed with ECMO support, and required conversion to Berlin Heart Left Ventricular Assist Device (LVAD). While on LVAD support, recovery of LV function was noted, allowing LVAD explantation and unroofing of the myocardial bridge along the mid- and proximal left anterior descending artery. The patient remains supported on an oral heart failure regimen. <h3>Summary</h3> To our knowledge, our patient is the first reported infant with DCAS presenting with decompensated heart failure, associated with LV non compaction and bicuspid AV. We suggest that DCAS should be evaluated in infants with unexplained cardiomyopathy, as ventricular dysfunction in our patient was likely driven by coronary artery insufficiency.

Cusp Symmetry and Coronary Ostial Eccentricity and its Impact on CoronaryAccess Following TAVR.

The aim of this study was to assess cusp symmetry and coronary ostial eccentricity and its impact on coronary access following transcatheter aortic valve replacement (TAVR) using a patient-specific commissural alignment implantation technique. TAVR implantation techniques to obtain neocommissural alignment have been introduced. The impact of cusp symmetry and coronary ostial eccentricity on coronary access after TAVR remains unknown. Cardiac computed tomographic scans from 200 tricuspid aortic valves (TAVs) and 200 type 1 bicuspid aortic valves (BAVs) were studied. Cusp symmetry and coronary ostial eccentricity were assessed. In addition, the right coronary cusp/left coronary cusp and right coronary artery (RCA)/left coronary artery (LCA) ostia overlap views were calculated and compared. Severe cusp asymmetry (>135°) was more frequent in BAVs (52.5%) than in TAVs (2.5%) (P< 0.001), with the noncoronary cusp being the most common dominant cusp. The RCA ostium was found to be more often eccentric (>20°) than the LCA ostium (28% vs 6%, respectively; P< 0.001). Considering the right/left cusp overlap view, there was<20° deviation between the right coronary cusp-left coronary cusp centered line and the RCA-LCA centered line in 95% of all patients (TAV, 97%; BAV, 93%). The right/left cusp and coronary ostia overlap view differed by<10° and<20° fluoroscopic angulation in 75% and 98% of all cases, respectively. Using the right/left cusp overlap view to obtain commissural alignment in TAVR is also an effective approach to implant one of the transcatheter heart valve commissures in the near center between both coronary ostia in most TAVs and type 1 BAVs. Preprocedural CT assessment remains crucial to assess cusp symmetry and coronary ostial eccentricity.

Native valve endocarditis of aortic and mitral valve involving left coronary artery ostium and interventricular septum: Medical and surgical therapy

Infective endocarditis (IE) is an infection of the inner lining of the heart muscle (endocardium) caused by bacteria, fungi, or germs that enter through the bloodstream. Despite improvements in its management, IE remains associated with high mortality and severe complications. The management of IE is multidisciplinary and is comprised of cardiologists, intensive care physicians, and cardiac surgeons. IE involving coronary ostium is very rare and sometimes such cases can cause acute coronary syndrome or sudden cardiac death. In this article, we report the case of a 48-year-old man who developed infective endocarditis involving aortal and mitral valves, as well as interventricular septum and left main coronary ostium as a result of Enterococcus faecalis. The vegetation on the ostium of the left main coronary artery has not caused coronary obstruction, but because of possible embolic events, all vegetation has been cleaned and a more appropriate repairment technique has been applied. Patient treated with vancomycin, rifampicin, and gentamicin before surgical replacement of damaged valves. We have performed aortic valve replacement, and mitral and tricuspidal valve repairment procedures. Beside of that vegetations on the interventricular septum and on the coronary ostium were extracted and damage repaired. The patient has discharged from the hospital on day 5 postoperatively without any signs of IE. Conclusion E. faecalis-associated infective endocarditis should be included in the differential diagnosis of valvular vegetation, especially in patients with a rapidly progressing clinical course. A multidisciplinary approach to IE is critical for improving the life quality of patients by reducing mortality and preventing complications. This case also highlights the importance of collecting blood cultures before initiation of antibiotic treatment.

Measurement of Myocardial Lactate Production for Diagnosis of Coronary Microvascular Spasm.

In about a quarter of patients with angina and non-obstructive coronary arteries, no epicardial spasm is noted on coronary arteriography during an angina attack. Since the pressure-rate product is almost identical at rest and the onset of attack in those patients, the decrease in coronary blood flow rather than increased myocardial oxygen consumption is likely to explain myocardial ischemia, indicating a substantial involvement with coronary microvascular spasm (MVS). Myocardial lactate production, which could be defined as a negative myocardial lactate extraction ratio (ratio of the coronary arterial-venous difference in lactate concentration to arterial concentration), is considered indicative of objective evidence to support the emerging myocardial ischemia. Thus, monitoring of the myocardial lactate production and the emergence of chest pain and ischemic electrocardiographic changes during acetylcholine (ACh) provocation testing is of significant value for detecting the entity of MVS. Practically, 1 min after incremental doses of ACh (20, 50, and 100 μg) are administered into the left coronary artery (LCA), paired samples of 1 mL of blood are collected from the LCA ostium and coronary sinus for measurement of lactate concentration by a calibrated automatic lactate analyzer. Then, the development of MVS could be confirmed by negative myocardial lactate extraction ratio despite the absence of angiographically demonstrable epicardial coronary spasm or before its occurrence throughout ACh provocation testing. In conclusion, assessment of myocardial lactate production is essential and valuable for the diagnosis of MVS.

Surgical Treatment for Occlusion of Left Coronary Artery Ostium by an Aortic Valve Cusp

Surgical Treatment for Occlusion of Left Coronary Artery Ostium by an Aortic Valve Cusp

P25 A Unique Cause of Acute Heart Failure: an Anomalous Left Coronary Artery Ostium Originating From the Left Ventricular Outflow Tract

The aetiology of acute heart failure is important to ascertain, particularly in cases where symptoms are refractory to aggressive medical therapy and thus endanger the patient’s prognosis. We present a rare case of a patient with decompensated heart failure secondary to a stenosed left coronary artery (LCA) ostium originating in the left ventricular outflow tract (LVOT).

A Case of Atresia of Left Coronary Artery Ostium with Rare Myocardial Scintigraphy Findings

A Case of Atresia of Left Coronary Artery Ostium with Rare Myocardial Scintigraphy Findings