Left Coronary Artery System Research Articles

Effect of intramyocardial injection of erytropetin stimulated autologus bone marrow cells on myocardial perfusion using 99mТC-MIBI spect in long-term

Purpose.To evaluate the changes of myocardial perfusion using 99mТс-MIBI single-photon emission computed tomography (SPECT) after the intramyocardial implantation of erythropoietin preconditioned autologous bone marrow cells (ABMC) in laser channels during coronary artery disease (CAD) surgery.Materials and methods.Randomized study of 40 patients (mean age 58.0 ± 6.9, 9 females) with diffuse and (or) distal right coronary artery disease (RCA). Patients of the study group (n= 23) underwent coronary artery bypass grafting (CABG) of the left coronary artery (LCA) system and intramyocardial implantation of erythropoietin preconditioned ABMC in the left ventricular (LV) inferior wall. Patients of the control group (n= 17) underwent CABG of the LCA system only. 99mТс-MIBI SPECT performed 1–2 days before and 12 months after surgery.Results.In study group after 12-month follow-up the summed stress score in a typical RCA supply area (SSSRCA) improved from 7.0 [5.5; 10.5] to 4.0 [1.0; 5.5] (p<0.01), summed rest score (SRSRCA) improved from 3.0 [0.0; 7.0] to 1.0 [0.0; 3.5] (p<0.01), and summed different score (SDSRCA) improved from 3.0 [1.0; 4.0] to 1.0 [0.0; 2.0] (p= 0.03). Control group patients after 12-month follow-up showed significant improvement of SSS RCA only – from 8.0 [6.0; 12.0] to 5.0 [4.0; 7.0] (p<0.01).Conclusion.After 12-month follow-up in patients with diffuse and (or) distal RCA disease, the procedure of intramyocardial implantation of the erythropoietin preconditioned ABMC in laser channels is demonstrated to be safe and induces the improvement of myocardial perfusion.

Hypertrophic Cardiomyopathy (HCM): New insights into Coronary artery remodelling and ischemia from FFRCT

IntroductionAngina, myocardial ischemia, and coronary artery physiology in hypertrophic cardiomyopathy (HCM) are poorly understood. However, coronary computed tomography angiography (CCTA) with fractional flow reserve from CT (FFRCT) analysis offers a non-invasive method for evaluation of coronary artery volume to myocardial mass ratio (V/M) that may provide insight into such mechanisms. Thus, we sought to investigate changes in V/M in HCM. MethodsA retrospective analysis was performed on 37 HCM patients and 37 controls matched for age, sex, and cardiovascular risk factors; CCTA-derived coronary artery lumen volume (V) and myocardial mass (M) were used to determine V/M. FFRCT values were calculated for the left anterior descending (LAD), left circumflex (LCx) and right coronary (RCA) arteries as well as the 3-vessel cumulative FFRCT values. ResultsHCM patients had significantly increased myocardial mass (176 ± 84 vs. 119 ± 27 g, p < 0.0001) and total coronary artery luminal volume (4112 ± 1139 vs. 3290 ± 924 mm3, p < 0.0001) that resulted from increases in segmented luminal volumes of both the left and right coronary artery systems. However, HCM patients had significantly decreased V/M (23.8 ± 5.9 vs. 26.5 ± 5.3 mm3/g; p = 0.026) which was further decreased when restricting V/M analysis to those HCM patients with septal hypertrophy (22.4 mm3/g, p = 0.01) that was mild-moderately predictive of HCM (AUC = 0.68). HCM patients also showed significantly lower nadir FFRCT values in the LCx (0.87 ± 0.06 vs. 0.91 ± 0.06, p = 0.02), and cumulative 3-vessel FFRCT values (2.58 ± 0.18 vs. 2.63 ± 0.14, p = 0.006). ConclusionsHCM patients demonstrate significantly greater coronary volume. Despite this, HCM patients suffer from decreased V/M. Further prospective studies evaluating the relationship between V/M, angina, and heart failure in HCM are needed.

3D-printed models optimize preoperative planning for pediatric cardiac tumor debulking.

This study reports the first known application of 3-dimensional (3D) printing of cardiac tumors to preoperatively plan debulking in infants. 3D-printed cardiac tumor models were used to identify the spacial relationship between the tumors and coronary arteries as well as understand the depth and infiltration of the tumors. Physical 3D cardiac tumor models of two children were obtained using medical imaging, image 3D rendering and modeling, and 3D printing. The hearts were 3D-printed in an opaque material while the tumors were made transparent to allow optimal visualization of the cardiovascular anatomy within the tumor. The surgical team used these models to plan exposure of the tumor, as well as, the extent of debulking. Patient 1 had a cardiac tumor arising from the anterior surface of the right ventricle causing significant right ventricular outflow tract obstruction and involving the right and left coronary artery courses. Patient 2 had a cardiac tumor arising from the left ventricle and extending beyond the left atrium compressing the airway preventing extubation, and surrounding the left coronary artery system. In both patients, 3D-printed models were used to maximize debulking and avoid injury to the coronaries. 3D-printed cardiac tumor and anatomic models were effectively used to preoperatively plan two pediatric tumor debulkings. Both patients had tumors that were integrally involved with the coronary arteries. The 3D models helped devise a safe surgical strategy for maximal tumor debulking while protecting the coronary circulation.

USVAH Study Demonstrates Statistically Significant Improvement in Diagnosis and Care of U.S Veterans Using FMTVDM – FHRWW©℗ “Quantitative” Nuclear Imaging. The Era of Truly Quantitative Stress- First, Stress-Only Imaging has begun!

Background: Myocardial perfusion imaging (MPI) has evolved over the last several decades with improvements in equipment and isotopes. Despite these limitations sensitivity and specificity of this study remains 65%-85% principally due to “qualitative” interpretation of the results. Numerous investigators have recommended changes in protocols and quantification of data to increase the diagnostic accuracy of this non-invasive physiologic test. Initial investigations have demonstrated the ability to “quantitatively” measure isotope redistribution with planar, SPECT and PET using FMTVDM©℗. This study was designed to compare the diagnostic and treatment outcomes of U.S. Veterans undergoing conventional “stress-rest” “qualitative” imaging using Technetium 99m isotopes (Sestamibi and Myoview) compared with FMTVDM©℗ “quantification” isotope redistribution using a single dose of the isotope.Methods: Forty-one U.S. Veterans were studied using pharmacologic and exercise stress approaches with either Sestamibi or Myoview following routine MPI Imaging protocols compared with FMTVDM©℗. The results were compared with coronary angiography.Result: Angiographic coronary artery disease (CAD) was defined using both 50% and 70% diameter narrowing/ stenosis (%DS). Accuracy of a “qualitative” (yes/no) test in the determination of the presence or absence of CAD is measured by the ability of the test to find CAD when present (sensitivity) and to show that CAD is not present (specificity) when absent, based upon the arbitrarily assigned value for %DS. The sensitivity, specificity and accuracy of “qualitative” MPI assessment of 50% DS CAD was 50.0%, 88.2% and 70.7% for the left coronary artery system and 29.2%, 64.7% and 43.9% respectively for the right coronary artery system. These values improved to 59.1%, 89.5% and 73.2% for the left coronary artery system and 64.3%, 85.2% and 78.0% respectively for the right coronary artery system when 70%DS was used as the cutoff for CAD. No differences noted between either of the technetium 99m isotopes or cameras used for either the “qualitative” or “quantitative” (FMTVDM©℗) methods. FMTVDM©℗ provides the First Ever “quantitative” Nuclear Cardiology MPI test, which consequently defines CAD not on a yes/no basis, but “quantitatively.” As such, the accuracy of FMTVDM©℗ must be compared first to a “quantitative” measure which is known; viz. isotope decay using TFM. Results of FMTVDM©℗ is then not simply a yes/no result, but rather a “quantitative” value which places the “extent” of CAD on a measured continuum much as a coronary angiogram would, specifically a quantitative coronary angiogram (QCA). FMTVDM©℗ demonstrated a statistically significant relationship between CAD and %DS (r=0.75, p < 0.001).Conclusion: Modern Nuclear Cameras have relied completely upon “quality” control methods, which do exactly that; they provide for “qualitative” control but not “quantitative” control. The accuracy of the cameras ability to correctly count the resulting scintillations from which “quantitative” analysis and even “qualitative” images are displayed for clinician interpretation are dependent, has never been established or used in either the experimental or clinical areas of Medicine. This study demonstrated the importance of first using TFM from the FMTVDM©℗ for “quantitative” camera calibration and correction prior to conducting MPI. Even with the correction of the “quantitative” errors in the Nuclear Cameras, errors in “qualitative” MPI resulted in a conservative estimate of misdiagnosis of CAD 35% of the time. These errors result in potential life threatening CAD being missed as demonstrated here. This same CAD is accurately measured using the new “quantitative” MPI test (FMTVDM©℗), which accurately “quantify” the extent of CAD. FMTVDM©℗ provides the first “quantitative” Nuclear Cardiology and Medicine test, ushering in the era of “machine learning” and “quantitative” Nuclear Cardiology and Medicine providing accurate, reproducible measurement of CAD in less time and with less radiation than the prior “qualitatively” applied method of “physician interpretation” of CAD, reducing healthcare costs and improving patient throughput and clinical management.

Successful percutaneous coronary intervention for an in-stent chronic total occlusion in a patient with dextrocardia: a case report

Percutaneous coronary interventions of chronic total occlusion represent one of the most challenging issues in interventional cardiology. A Caucasian patient with dextrocardia presented with an in-stent chronic total occluded right coronary artery, a constellation which has not been described previously in the literature. A 69-year-old man with pre-known situs inversus totalis and a long history of coronary artery disease with multiple interventions and stent-implantations presented to our department suffering from episodes of chest pain under exercise. A coronary angiogram showed a completely occluded right coronary artery in the area of a drug-eluting stent which had been implanted eight years before. We found collaterals from the left coronary artery system and signs of calcification, so the lesion was classified as chronic total occlusion and the recanalization using an antegrade wire escalation technique successfully performed. This is the first reported case of an in-stent chronic total occlusion in situs inversus with dextrocardia. Our experience in this case demonstrates the feasibility of recanalization of in-stent chronic total occlusions even in the rare setting of this congenital cardiac malposition combined with severe coronary artery disease.

Sol Koroner Arteriyel Sistemin Tam Spazmından Dolayı Gelişen Akut Kroner Sendrom

Sol Koroner Arteriyel Sistemin Tam Spazmından Dolayı Gelişen Akut Kroner Sendrom

Hemodynamic analysis of sequential graft from right coronary system to left coronary system.

BackgroundSequential and single grafting are two surgical procedures of coronary artery bypass grafting. However, it remains unclear if the sequential graft can be used between the right and left coronary artery system. The purpose of this paper is to clarify the possibility of right coronary artery system anastomosis to left coronary system.MethodsA patient-specific 3D model was first reconstructed based on coronary computed tomography angiography (CCTA) images. Two different grafts, the normal multi-graft (Model 1) and the novel multi-graft (Model 2), were then implemented on this patient-specific model using virtual surgery techniques. In Model 1, the single graft was anastomosed to right coronary artery (RCA) and the sequential graft was adopted to anastomose left anterior descending (LAD) and left circumflex artery (LCX). While in Model 2, the single graft was anastomosed to LAD and the sequential graft was adopted to anastomose RCA and LCX. A zero-dimensional/three-dimensional (0D/3D) coupling method was used to realize the multi-scale simulation of both the pre-operative and two post-operative models.ResultsFlow rates in the coronary artery and grafts were obtained. The hemodynamic parameters were also showed, including wall shear stress (WSS) and oscillatory shear index (OSI). The area of low WSS and OSI in Model 1 was much less than that in Model 2.ConclusionsModel 1 shows optimistic hemodynamic modifications which may enhance the long-term patency of grafts. The anterior segments of sequential graft have better long-term patency than the posterior segments. With rational spatial position of the heart vessels, the last anastomosis of sequential graft should be connected to the main branch.

Cadaveric study of branching pattern of left coronary artery

Abstract Background and aim: The branching pattern of vascular system has been the subject of much discussion and debate since it was first suggested that these systems have fractal architecture. Coronary arteries of human heart and their branching pattern have been the subject of particular attention among researchers. Hence, this study of branching pattern ofleft coronary artery (LCA) has been undertaken to highlight the variations of branches of left coronary arterial system. Material and methods: The study material consisted of 50 heart specimens obtained from the cadavers of Anatomy and Forensic departments which were studied by the conventional dissection method. Results: Left posterior aortic sinus gave origin to left coronary artery in all specimens with 90% ostium being below the level of sinotubular junction (STJ). Nearly 50% specimens were of the length ranging between 6-lOmm.Left coronary artery bifurcated into its two main branches in 62%, trifurcated in 32% and quadfurcated in 6%. Among the 16 trifurcating specimens, in five specimens the diagonal artery was seen at the junction of its two main branches, in 11 specimens the diagonal artery was found arising from the anterior interventricular artery and an additional branch the "Median Artery" was seen at the junction. Conclusion : Recent technical advances in the study of coronary arteries make it necessary for all angiographers and cardiac surgeons to be familiar with the variants of left coronary artery branching pattern.

PP-082 The Trifurcation Lesion Treated with Angioplasty and Stenting Via Three Balloons in the Left Coronary Artery System and Broken and Remained Floppy Wire in the Circumflex Artery

PP-082 The Trifurcation Lesion Treated with Angioplasty and Stenting Via Three Balloons in the Left Coronary Artery System and Broken and Remained Floppy Wire in the Circumflex Artery

Computed tomography coronary angiography diagnosis of single right coronary artery with congenital absence of left coronary artery system equivalents

The present case report is computed tomography (CT) coronary angiographic depiction of an exceedingly rare entity-single right coronary artery arising from the right sinus of Valsalva with the absence of equivalent left coronary artery system branches and associated mitral valve prolapse. Even though a statistical rarity, it is potentially fatal and can cause myocardial ischemia, sudden cardiac death, and warrants immediate clinical attention. Further, the report reveals the decisive role of CT coronary angiogram in the diagnosis of such rare entities, in contrast to catheter angiography, which may be inconclusive.

Coronary anatomy as related to bicuspid aortic valve morphology

ObjectiveVariable coronary anatomy has been described in patients with bicuspid aortic valves (BAVs). This was never specified to BAV morphology, and prognostic relevance of coronary vessel dominance in this patient...

Significance of congenital coronary artery fistulas

Congenital coronary artery fistulas (CAFs) are anomalous terminations of coronary arteries in cardiac chambers or great arteries created by bypassing the myocardial capillary bed. CAFs are the second most common coronary anomaly after coronary artery origin anomalies [1]. CAFs are mostly asymptomatic. However, CAFs may cause myocardial ischemia, angina pectoris, congestive heart failure, arrhythmias and infective endocarditis [2]. Previously, we presented a case of multiple coronarycameral fistulas causing stable angina pectoris [3]. A 65-year-old male patient referred to our outpatient clinic with chest pain and exertional dyspnea. The patient was suffering from retrosternal exertional chest pain for six months which relieved with rest. Previous medical history revealed hypertension and diabetes mellitus. Electrocardiogram showed inferolateral T wave inversion (Figure A) and echocardiography revealed normal left ventricular systolic function without left ventricular hypertrophy or cardiomyopathy. Coronary angiography was performed with an early diagnosis of coronary artery disease. There was not any significant coronary stenosis, however in late phase of contrast injection to the left coronary arteries, left ventricle filling and opacification was seen through extensive multiple microfistulas (Figures B and C). Because of extensive spreading of microfistulas through left ventricle myocardium, the patient was not an appropriate candidate for surgical or transcatheter repair and regular follow-up with medical therapy was planned. Symptomatic relief was provided by medical therapy with acetylsalicylic acid, ramipril, amlodipine, metoprolol and atorvastatin. CAFs mostly originate from the right coronary artery system and drain through the right heart chambers. A total of 25 % CAFs originate from the left coronary artery system [4]. Pulmonary arterial fistulization is 17 % in single CAF, whereas this rate increases to 56% in bilateral CAF [5]. Being mostly asymptomatic, CAFs is usually suspected by hearing a murmur during a physical examination and is diagnosed in further evaluation or incidentally in diagnostic CAG. Hemodynamically significant fistulas can cause symptoms such as angina or dyspnoea. Submitted: 15 June 2016; Accepted: 11 July 2016; Published online: 16 July 2016

Disorder of Sexual Development and Congenital Heart Defect in 47XYY: Clinical Disorder or Coincidence?

Background. 47XYY syndrome is a rare sex chromosome variation characterized by an additional Y chromosome. Most patients with 47XYY karyotype have normal phenotype. This disorder seems associated with a higher risk of developing behavioral and cognitive problems, tall stature, and infertility in adulthood. Sexual development disorder is a rare finding. We report a first case with an abnormal left coronary artery originating from the pulmonary artery in a 47XYY patient. Case. A one-month-old child was referred for ectopic testis and micropenis. Physical examination revealed facial dysmorphia, micropenis, and curvature of the penis with nonpalpable testis. Laboratory tests showed decreased total testosterone and anti-Mullerian hormone (AMH) levels. Blood karyotyping revealed a 47XYY chromosomal formula. At the age of 3 months, the patient developed dyspnea and tachycardia. Echocardiography revealed an anomalous left coronary artery from pulmonary artery with left ventricular dysfunction requiring surgical revascularization by direct reimplantation of the left coronary artery system. Our second case was a 3-year-old child referred for hypospadias with nonpalpable left testicle. Physical examination showed hypertelorism. Blood karyotyping revealed a 47XYY chromosomal formula. Conclusion. To our knowledge, this is the first case of 47XYY syndrome associated with this congenital heart malformation and a sexual development disorder.

Anomalous origin of the left coronary artery from the pulmonary artery in infants: clinical features and the perioperative treatment strategies

To investigate the clinical features and individualized treatment strategies for infants with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Data of 25 less than 1-year-old infants with ALCAPA who presented at Guangdong Cardiovascular Institute between 2006 and 2013 were retrospectively reviewed. The patients' cardiac function was evaluated with echocardiography during follow-up. Most patients presented with symptoms of heart failure, such as tachypnea, diaphoresis, poor feeding, failure to thrive etc. Electrocardiogram showed abnormal q wave in 23 patients and ST-T segment change in 16 patients.Echocardiography showed dilated left ventricle in 25 patients, endocardial hyperplasia in 5 patients, dilated right coronary artery and extensive collateralization between the right and left coronary artery systems in 11 patients. The left ventricular ejection fraction (LVEF) was (45.5±13.9)% (25%-77%). The left ventricular fractional shortening (LVFS) was (22.0±7.3)% (12%-38%). Twenty one patients underwent cardiovascular CT scan. Left coronary artery originated from left posterior sinus in 9 patients, from right posterior sinus in 1 patient, from lower main pulmonary artery in 5 patients, from the bifurcation of main pulmonary artery in 1 patient.Five patients showed ambiguous left coronary artery origination.Sixteen patients were misdiagnosed in other primary or secondary hospitals in 17 patients who were transferred to our tertiary hospital, only 1 case who underwent angiography was diagnosed correctly. Two patients were misdiagnosed in 8 patients first-presented in our hospital. Their diagnoses were corrected after reexamining with echocardiography and cardiovascular CT scan. The preoperative therapies included using inotropic agents, diuretics and vasodilators according to cardiac function. Two patients underwent left coronary artery orifice ligation. Twenty three patients underwent reimplantation of left coronary artery to reconstruct dual coronary system. Patients of NYHA IV with moderate mitral regurgitation (MR) and NYHA III with severe MR underwent mitral annuloplasty. If LVEF was less than 30% after weaning from cardiopulmonary bypass, blood pressure could not be maintained with medication, or lactates increased progressively, extracorporeal membrane oxygenation (ECMO) was demanded. Two patients showed low cardiac output syndrome immediately after surgical procedures, died from refractory ventricular fibrillation even with ECMO.In survived 23 patients during the early stage after surgeries, duration of ventilation was 7-500 hours, 11 of them were supported with ventilator for less than 60 hours. The mean length of hospital stay was (23.4±13.9) d (8-65 d). The follow-up duration ranged from 1-91 months (median 28.5 months). One case was lost to follow up. The patient died from infection 3 months after discharge. The cardiac functions of the remaining 22 patients were improved. The size of left ventricle of 14 patients recovered to normal. LVEF increased to the normal level in 20 cases. No patient underwent redo procedure. The accurate diagnosis can be made based on history, electrocardiogram, echocardiography and other imaging diagnostic tools.Individualized treatment strategy is helpful for seriously sick infants. Aggressive ECMO support can increase surviving rate for patients with postoperative low cardiac output syndrome.

Relation Between Coronary Arterial Dominance and Left Ventricular Ejection Fraction After ST-Segment Elevation Acute Myocardial Infarction in Patients Having Percutaneous Coronary Intervention

The presence of a left dominant coronary artery system is associated with worse outcome after ST-segment elevation myocardial infarction (STEMI) compared with right dominance or a balanced coronary artery system. However, the association between coronary arterial dominance and left ventricular (LV) function at follow-up after STEMI is unclear. The present study aimed at evaluating the relation between coronary arterial dominance and LV ejection fraction (LVEF) shortly after STEMI and at 12-month follow-up. A total of 741 patients with STEMI (mean age 60 ± 11 years and 77% men) were evaluated with 2-dimentional echocardiography within 48 hours of admission (baseline) and at 12-month follow-up after STEMI. Coronary arterial dominance was assessed on the angiographic images obtained during primary percutaneous coronary intervention. A right, left, and balanced dominant coronary artery system was noted in 640 (86%), 58 (8%), and 43 (6%) patients, respectively. At baseline, significant difference in LV function was observed, with slightly lower LVEF in patients with a left dominant coronary artery system (LVEF 45 ± 8% vs 48 ± 9% and 50 ± 9%, for left dominant, right dominant, and balanced coronary artery system respectively, p = 0.03). However, at 12-month follow-up no differences in LV function or volumes were observed among the different coronary arterial dominance groups. In conclusion, patients with a left dominant coronary artery system had lower LVEF early after STEMI. At 12-month follow-up, differences in LVEF were no longer present among the different coronary arterial dominance groups.

Double Right Coronary Artery Arising From Separate Ostia

We present a rare case of double right coronary artery (RCA) arising from separate ostia. A 62 years old male patient was admitted with acute onset retrosternal chest pain. ECG was suggestive of sinus rhythm with intraventicular conduction delay and pathological q waves in D3 and avF derivations without any significant ST segment elevations. In the coronary angiography, we detected double RCA, each had its own ostium arising separately from right aortic sinus with complete occlusion seen in one RCA. Plaques were present in left coronary arterial system. Guidewires could not be passed in the completely occluded right RCA and conservative therapy was recommended. Double RCA is a congenital coronary anomaly with a potential of atherosclerotic coronary artery disease which needs regular monitoring.

Influence of coronary vessel dominance on short- and long-term outcome in patients after ST-segment elevation myocardial infarction.

Prognostic importance of coronary vessel dominance in patients with ST-elevation myocardial infarction (STEMI) remains uncertain. The aim of this study was to assess influence of coronary vessel dominance on the short- and long-term outcome after STEMI. Coronary angiographic images of consecutive patients presenting with first STEMI were retrospectively reviewed to assess coronary vessel dominance. Patients were followed after STEMI during a median period of 48 (IQR38-61) months for the occurrence of all-cause mortality and the composite of reinfarction and cardiac death. The population comprised 1131 patients of which 971 (86%) patients had a right dominant, 102 (9%) a left dominant, and 58 (5%) a balanced system. After 5 years of follow-up, the cumulative incidence of all-cause mortality was significantly higher in patients with a left dominant system, compared with a right dominant and balanced system (log-rank P = 0.013). Moreover, a left dominant system was an independent predictor for 30-day mortality (OR 2.51, 95% CI 1.11-5.67, P = 0.027) and the composite of reinfarction and cardiac death within 30-days after STEMI (OR 2.25, 95% CI 1.09-4.61, P = 0.028). In patients surviving first 30-days post-STEMI, coronary vessel dominance had no influence on long-term outcome. A left dominant coronary artery system is associated with a significantly increased risk of 30-day mortality and early reinfarction after STEMI. After surviving the first 30-days post-STEMI, coronary vessel dominance had no influence on long-term outcome.

Three Vessel Coronary Cameral Fistulae Associated with New Onset Atrial Fibrillation and Angina Pectoris

Coronary cameral fistulas are abnormal communications between a coronary artery and a heart chamber or a great vessel which are reported in less than 0.1% of patients undergoing diagnostic coronary angiography. All three major coronary arteries are even less frequently involved in fistula formation as it is the case in our patient. A 68-year-old woman was admitted to cardiology clinic with complaints of exertional dyspnea and angina for two years and a new onset palpitation. Standard 12-lead electrocardiogram revealed atrial fibrillation (AF) with a ventricular rate of 114 beat/minute and accompanying T wave abnormalities and minimal ST-depression on lateral derivations. Transthoracic echocardiographic examination was normal except for diastolic dysfunction, minimally mitral regurgitation, and mild to moderate enlargement of the left atrium. Sinus rhythm was achieved by medical cardioversion with amiodarone infusion. Coronary angiography revealed diffuse and multiple coronary-left ventricle fistulas originating from the distal segments of both left and right coronary arterial systems without any stenosis in epicardial coronary arteries. The patient's symptoms resolved almost completely with medical therapy. High volume shunts via coronary artery to left ventricular microfistulas may lead to increased volume overload and subsequent increase in end-diastolic pressure of the left ventricle and may cause left atrial enlargement.

Pencil beam excitation using a 2D spatially selective adiabatic T2-prep for imaging the left coronary arterial system

Background 2D spatially selective radiofrequency (RF) pulses can be used to constrain the location from which an MR signal is obtained. This may lead to more time-efficient data collection by reducing the field of view (FoV) or may improve image quality by suppressing artefacts from outside the area of interest. Meanwhile, T2-Preparation, or T2-Prep, is a magnetization preparation scheme used to improve blood/myocardium contrast. We propose incorporating a “pencil-beam” 2D RF pulse into a T2-Prep module, so as to produce a “2D T2-Prep” that combines T2-weighting with an intrinsic spatial selectivity.

The Survival of an Old Lady with ALCAPA

The coronary artery system is composed of two major systems, the left and right coronary artery system. Both left and right coronary arteries originate from the aortic left and right coronary cusp respectively. The left anterior descending artery (LAD), the main vessel of the left coronary artery system, is considered to be the most important of the coronary artery system. The LAD supplies the left ventricular anterior wall that plays the main role in the left ventricular pumping function. The right coronary artery system is also considered to be the second most important system that mainly supplies the left ventricular inferior wall. The balance of myocardium blood supply demands an adequate coronary artery blood supply from both systems. If the blood supply to some portion of the myocardium is entirely blocked or the energy demand is much higher than the supply, severe myocardium injury or sudden cardiac death may occur. Total blocking of the left main coronary artery (LMA) and proximal LAD vessel is the main cause of death. How does aperson survive with a total absence of arterial blood supply from the left coronary artery system?