Left Coronary Ostium Research Articles

Sudden death from acute thromboembolic occlusion of the left coronary ostium

The patient was a 55-year-old woman who experienced anterior chest pain after drinking a cup of coffee. The patient had no risk factor for cardiac disease other than mild non- insulin-dependent diabetes mellitus. The patient did have a history of asthma and was on a steroid taper, taking 20 mg of prednisone daily. The patient's physical examination results were within normal limits. Her laboratory data were normal, except for a glucose level of 499 mg/dl and a urinalysis revealing more than 4+ glucose with large ketones. Venous blood gas pH was 7.36, and troponin I, creatinine kinase-MB, electrocardiogram, and chest film were normal. The patient was admitted to rule out acute coronary syndrome. During the placement into an inpatient bed, the patient sustained a cardiac arrest with a narrow complex ventricular rhythm without pulse, from which she could not be resuscitated. The postmortem examination of the lungs revealed no evidence of thromboemboli. The coronary arteries revealed mild atherosclerosis. Examination of the aortic root revealed complete occlusion of the left coronary ostium by a large premortem nonorganized fresh thromboembolus, which was easily removed by passing a probe retrograde from the left main coronary artery (Fig. 1). Microscopically, there were also small thromboemboli in both the distal right and left coronary intramyocardial vessels. An extensive search of the heart and all major vessels was undertaken to identify the source of the possible thromboemboli, and none could be identified. A Medline search of the literature revealed no other similar case.

Control of Troublesome Bleeding During Repair of Acute Type A Dissection with Use of Modified Rapid Deployment Hemostat (MRDH)

Troublesome bleeding occurred in the posterior portion of the proximal anastomosis in an ascending aorta graft, being performed on a patient with acute type A dissection. The suture line was close to the left coronary ostium, and attempts at suturing and other maneuvers failed to control hemorrhage. Modified rapid deployment hemostat (MRDH) was successful in achieving hemostasis. MRDH is a novel hemostatic agent with invaluable use in troublesome bleeding occurring during heart surgery.

Anatomic Properties of Myocardial Bridge Predisposing to Myocardial Infarction

A myocardial bridge (MB) that partially covers the course of the left anterior descending coronary artery (LAD) sometimes causes myocardial ischemia, primarily because of hemodynamic deterioration, but without atherosclerosis. However, the mechanism of occurrence of myocardial infarction (MI) as a result of an MB in patients with spontaneously developing atherosclerosis is unclear. One hundred consecutive autopsied MI hearts either with MBs [MI(+)MB(+) group; n=46] or without MBs (n=54) were obtained, as were 200 normal hearts, 100 with MBs [MI(-)MB(+) group] and 100 without MBs. By microscopy on LADs that were consecutively cross-sectioned at 5-mm intervals, the extent and distribution of LAD atherosclerosis were investigated histomorphometrically in conjunction with the anatomic properties of the MB, such as its thickness, length, and location and the MB muscle index (MB thickness multiplied by MB length), according to MI and MB status. In the MI(+)MB(+) group, the MB showed a significantly greater thickness and greater MB muscle index (P<0.05) than in the MI(-)MB(+) group. The intima-media ratio (intimal area/medial area) within 1.0 cm of the left coronary ostium was also greater (P<0.05) in the MI(+)MB(+) group than in the other groups. In addition, in the MI(+)MB(+) group, the location of the segment that exhibited the greatest intima-media ratio in the LAD proximal to the MB correlated significantly (P<0.001) with the location of the MB entrance, and furthermore, atherosclerosis progression in the LAD proximal to the MB was largest at 2.0 cm from the MB entrance. In the proximal LAD with an MB, MB muscle index is associated with a shift of coronary disease more proximally, an effect that may increase the risk of MI.

Unstable angina early after aortic valve replacement surgery in a female patient with normal coronary arteries preoperatively – a case report

BackgroundAngina pectoris early after aortic valve replacement surgery in patients with previously normal coronary arteries may be life threatening and has to be assessed immediately.Case report12 weeks after aortic valve replacement surgery, a 60-year-old female patient was referred for evaluation of recent onset of severe chest pain on mild exertion and at rest. Coronary angiography showed severe stenosis nvolving the left coronary ostium and the left main stem. The patient was urgently referred for bypass surgery and had an uneventful postoperative recovery.ConclusionA high degree of suspicion is needed for early recognition and aggressive management of this rare but serious complication.

Supravalvular Arrhythmia

Supravalvar ablation has now been well documented to be the ideal mode for ablating specific forms of ventricular tachycardia, atrial tachycardia, and accessory pathways. A studied appreciation of the anatomy of the supravalvar region is a prerequisite for electrophysiologists to safely and effectively approach these arrhythmias. In addition, the consistent ability to correlate the recorded electrograms with fluoroscopic anatomy and intracardiac ultrasound images enhances the chance of successful elimination of supravalvar arrhythmias.

Coronary flow obstruction in percutaneous aortic valve replacement using self-expandable valved stent: an in vitro study

To study the effects of self-expandable and orthotopically implanted percutaneous aortic valved stent on coronary artery flow in vitro. Self-expandable valved stent was developed with nitinol stent and bovine pericardium. The ascending aorta of Chinese mini swine hearts was cut proximal to the brachiocephalic trunk. The right and left main coronary arteries were dissected. In vitro coronary flow tests were performed. Firstly, baseline coronary flow with the native aortic valve was measured (n = 12). Secondly, the valved stent was deployed orthotopically. The commissures of prosthesis were positioned randomly. Through an endoscope, the effects of valved stent and native valve on coronary ostium were obtained and coronary flow measurements repeated (valve preservation group, n = 12). Then the distance from coronary ostium to native leaflet free edge was measured. Native leaflets were removed before similar valved stent deployment. Coronary flow measurements and endoscopic inspections were repeated post-implantation (valve removal group, n = 12). In valve preservation group, valved stent implantation resulted in a significant decrease in left coronary flow (29.46%, P < 0.05). The obstruction was due to native leaflets sandwiched between the stent and aortic wall. The left ostia were obstructed totally in 3 and partially in 4. The flow of right coronary decreased 7.34% (P > 0.05). The right ostia were obstructed partially in 3. In valve removal group, 6.82% and 5.37% decrement in left and right coronary flow were observed after valved stent placement (P > 0.05). The distances from right coronary ostia to annulus were farther than from left coronary ostia. In two groups, the commissures of prosthesis obstructed partially left coronary ostia in 4 and right coronary ostia in 1. Orthotopic implantation of a percutaneous self-expandable aortic valved stent would obstruct the left coronary ostium with the native valve. Coronary ostium may be obstructed partly by the commissures of prosthesis.

A Prospective, Randomized, 6-Month Comparison of the Coronary Vasomotor Response Associated With a Zotarolimus- Versus a Sirolimus-Eluting Stent: Differential Recovery of Coronary Endothelial Dysfunction

We prospectively compared coronary endothelial dysfunction in patients with zotarolimus-eluting stent (ZES) versus sirolimus-eluting stent (SES) implantation at 6-month follow-up. A ZES has been associated with uniform and rapid healing of the endothelium. Fifty patients were randomly treated with intravascular ultrasound-guided stenting with a single stent to the mid-segment of the left anterior descending artery (20 ZES, 20 SES, and 10 bare-metal stents), and endothelial function was estimated before and after intervention at 6-month follow-up by incremental acetylcholine (Ach) (10, 20, 50, and 100 microg/min) and nitrate (200 microg/min) infusions into the left coronary ostium. The vascular response was quantitatively measured in the 5-mm segments proximal and distal to the stent. In the drug-eluting stent groups, more intense vasoconstriction to incremental doses of Ach was observed at 6-month follow-up compared with the responses before stenting. Endothelial function associated with the ZES was more preserved at 6-month follow-up compared with the SES. Vasoconstriction to Ach was more prominent in the distal segments than the proximal segments in both the ZES and SES groups. Endothelium-independent vasodilation to nitrate did not differ significantly among the study groups. Vasoconstriction in response to Ach in the peri-stent region was less pronounced in the ZES group than the SES group at 6-month follow-up, which suggests that endothelial function associated with ZES can be more preserved than the SES.

Emergency Percutaneous Coronary Intervention in the Setting of a Single Left Coronary Ostium

A 34-year-old man with no significant cardiac risk factors presented with an anterolateral ST-elevation myocardial infarction and was transferred to our institution for rescue percutaneous coronary intervention after failed thrombolysis. At the time of the procedure, he had ongoing chest pain, and there was persistent ST-segment elevation on the ECG. The right coronary artery (RCA) could not be located with a series of diagnostic catheters. Diagnostic images of the left coronary artery showed the circumflex artery and an aberrant dominant RCA arising from the left main stem but, despite multiple views, the left anterior descending artery could not initially be identified (Figure 1; Videos 1 and 2). An aortogram demonstrated only a single coronary ostium in the left coronary sinus. After re-engaging the left coronary artery for further diagnostic images, the left anterior descending artery was finally identified, which was occluded at its ostium and visible in one view only (Figure 2; video 3). After guide wire passage, flow was restored in the culprit vessel and subsequent intervention was uncomplicated with a single 3-mm bare metal stent deployed (Figure 3; Videos 4 through 6). There was TIMI 3 flow at the end of …

Coronary endothelial dysfunction associated with a depressive mood in patients with atypical angina but angiographically normal coronary artery

Background Depression is a risk factor for the development of coronary heart disease but the relationship between coronary endothelial dysfunction and depression is not yet known. This study investigated whether depressive symptomatology is associated with coronary endothelial dysfunction in patients without coronary artery disease (CAD). Methods and results Incremental acetylcholine (Ach; 20, 50 and 100 µg/min) and nitrate (200 µg/min) were infused into the left coronary ostium of 52 patients (male 30, 51.8 years) with depressive symptoms as indicated by a Beck Depression Inventory (BDI) score of ≥ 10 and a Hamilton Depression Rating Scale (HAM-D17) of ≥ 7 but without overt CAD or any vasoactive medications. Vascular responses to each drug were measured quantitatively at the mid-segments of the left anterior descending artery (LAD) and compared to those of 103 matched control subjects (male 64, 51.3 years) with angiographically normal looking LAD and as estimated by BDI < 10 and HAM-D17 < 7. Patients in the depressive group showed significant vasoconstriction compared with patients in the non-depressive group ( p = 0.017, 0.090, 0.004 respectively). However, endothelium-independent vasodilatation to nitrates did not differ significantly between the two groups ( p = 0.461). No differences in risk factors were found between the two groups. Conclusions Depressive mood is associated with coronary endothelial dysfunction in patients without CAD, suggesting a possible mechanism by which depressive mood may act as a cardiovascular risk factor.

Successful Deployment of a Transcatheter Aortic Valve in Bicuspid Aortic Stenosis

Transcatheter aortic valve replacement (TAVR) has recently emerged as a therapeutic option for patients with severe aortic stenosis who are considered inoperable.1 To avoid potential complications related to this novel procedure (such as coronary artery obstruction or perivalvular leakage), detailed information on the aortic valve anatomy is critically important.1,2 Multislice computed tomography (MSCT) enables a comprehensive 3D assessment of aortic valve anatomy and, particularly, the extent and location of valve calcifications, one of the reasons for inappropriate deployment of the valved stent together with the bicuspid anatomy.3 After TAVR, the positioning and deployment of the valve prosthesis can be evaluated by this imaging technique. This report concerns a 54-year-old woman with symptomatic bicuspid aortic valve stenosis (aortic valve area, 0.9 cm2). Comorbidity included hypertension and hypercholesterolemia. Importantly, 2 years earlier, the patient experienced a cerebrovascular accident with severe consequences that determined a high risk for cardiac surgery. Consequently, the …

Transesophageal Echocardiography of a Unicuspid Aortic Valve

Transesophageal Echocardiography of a Unicuspid Aortic Valve

Giant Coronary Artery Aneurysm Complicated With Aortic Regurgitation

We present a rare case of a patient diagnosed with aortic insufficiency grade III and a giant coronary artery aneurysm with a maximum diameter of 12 cm. Surgical intervention revealed an incompetent bicuspid aortic valve and a huge thrombosed aneurysm, which communicated with the aorta through the left coronary ostium. In addition to direct closure of the ostium, a saphenous vein was anastomosed to the left anterior descending artery, and the aortic valve was successfully replaced with a mechanical valve.

Aortic root morphology in patients undergoing percutaneous aortic valve replacement: Evidence of aortic root remodeling

Percutaneous aortic valve replacement is an emerging therapy for selected patients with severe aortic stenosis. Preoperative imaging of the aortic root facilitates sizing and deployment of the percutaneous aortic valve replacement device. We compared morphologic characteristics of the aortic root in patients with aortic stenosis versus elderly gender-matched controls using multidetector computed tomography. Twenty-five consecutive subjects with severe calcific aortic stenosis referred for percutaneous aortic valve replacement and 25 elderly gender-matched controls were scanned on a Siemens Definition Dual Source (Siemens Medical, Forchheim, Germany) multidetector computed tomography scanner. Distances from the valve annulus to the coronary artery ostia and sinotubular junction, dimensions of the aortic root, and characteristics of the valve cusps were determined. Subjects with aortic stenosis had reduced distance from the aortic valve annulus to the inferior margins of the left and right coronary artery ostium and sinotubular junction compared with controls. There were no significant differences in cross-sectional dimensions of the aortic root. The distance from the aortic valve annulus to the coronary artery ostia and sinotubular junction is reduced in patients with aortic stenosis compared with controls. This finding suggests that longitudinal remodeling of the aortic root occurs in calcific aortic stenosis and has implications for the design and deployment of percutaneous aortic valve replacement devices.

Remodelling of the aortic root in severe tricuspid aortic stenosis: implications for transcatheter aortic valve implantation

Detailed knowledge of aortic root geometry is a prerequisite to anticipate complications of transcatheter aortic valve (TAV) implantation. We determined coronary ostial locations and aortic root dimensions in patients with aortic stenosis (AS) and compared these values with normal subjects using computed tomography (CT). One hundred consecutive patients with severe tricuspid AS and 100 consecutive patients without valvular pathology (referred to as the controls) undergoing cardiac dual-source CT were included. Distances from the aortic annulus (AA) to the left coronary ostium (LCO), right coronary ostium (RCO), the height of the left coronary sinus (HLS), right coronary sinus (HRS), and aortic root dimensions [diameters of AA, sinus of Valsalva (SV), and sino-tubular junction (STJ)] were measured. LCO and RCO were 14.9 +/- 3.2 mm (8.2-25.9) and 16.8 +/- 3.6 mm (12.0-25.7) in the controls, 15.5 +/- 2.9 mm (8.8-24.3) and 17.3 +/- 3.6 mm (7.3-26.0) in patients with AS. Controls and patients with AS had similar values for LCO (P = 0.18), RCO (P = 0.33) and HLS (P = 0.88), whereas HRS (P < 0.05) was significantly larger in patients with AS. AA (r = 0.55,P < 0.001), SV (r = 0.54,P < 0.001), and STJ (r = 0.52,P < 0.001) significantly correlated with the body surface area in the controls; whereas no correlation was found in patients with AS. Patients with AS had significantly larger AA (P < 0.01) and STJ (P < 0.01) diameters when compared with the controls. In patients with severe tricuspid AS, coronary ostial locations were similar to the controls, but a transverse remodelling of the aortic root was recognized. Owing to the large distribution of ostial locations and the dilatation of the aortic root, CT is recommended before TAV implantation in each patient.

Valve-Sparing Aortic Root Stabilization in Acute Type a Aortic Dissection

Composite replacement is the standard approach for repair of acute type A aortic dissection involving the aortic root. Reimplantation or remodeling procedures have become valve-sparing alternatives. We developed a new and simple technique to stabilize the aortic root. A Dacron graft is attached outside the native aortic cylinder, and incised twice vertically to create openings corresponding to the right and left coronary ostia. Thus the entire graft covers the native aortic root cylinder from the outside, and the native aortic valve and coronary ostia do not need to be reimplanted. From 2002 to 2007, this technique was applied in 14 patients (8 male) with a mean age of 71 years (range, 34-83 years). Four patients died within 30 days; 3 had been hemodynamically unstable with ventilator and inotropic support preoperatively. Echocardiography showed normal function of the preserved aortic valve, without regurgitation, in all patients. This technique is an alternative valve-sparing method for stabilization of the aortic root in patients with acute type A aortic dissection.

Anomalous right coronary artery arising next to the left coronary ostium

Herein we report on the diagnostic potential of multi-detector row computed tomography (MDCT) combined with cardiovascular magnetic resonance (CMR) for the diagnostic workup in an adult patient with a rare coronary anomaly. MDCT unambiguously detected the anomalous right coronary artery (RCA), which originated next to the left coronary ostium and coursed inter-arterially between the ascending aorta and the pulmonary trunk. The intramural proximal intussusception of the ectopic RCA could be clearly appreciated on MDCT images, while multiple mixed plaques were detected in the left anterior descending (LAD), resulting in moderate stenosis of this vessel. CMR during adenosine infusion ruled-out inducible ischemia, yielding normal perfusion patterns both in the RCA and in the LAD coronary territory. Since ischemia was not demonstrated by stress CMR, revascularization was not performed.

Ventricular tachycardia originating from the left coronary aortic sinus

Radiofrequency catheter ablation is an effective and safe treatment of idiopathic ventricular tachycardia (VT) arising from the left coronary aortic sinus (LCAS) when there is a distance of >1 cm between the ablation catheter tip and the left coronary ostium (LCO). A 26-year-old Asiatic woman …

Percutaneous Transluminal Coronary Angioplasty for Postoperative Left Coronary Artery Stenosis Following Surgical Reconstruction of Congenital Atresia of the Left Main Coronary Artery

Congenital atresia of the left main coronary ostium is a rare coronary artery anomaly. A 3-year-old boy who was asymptomatic had a heart murmur because of mitral regurgitation. He underwent reconstruction of the left main coronary artery, but stenosis occurred in the early postoperative period. Although the patient underwent repair of the coronary artery stenosis, the distal portion of the left coronary artery re-stenosed. Percutaneous transluminal coronary angioplasty for the stenosis was performed successfully and there has not been any sign of re-stenosis for 30 months to date.

Valve-Sparing Aortic Root Replacement With the Valsalva Graft

Valve-Sparing Aortic Root Replacement With the Valsalva Graft

Burned out Takayasu aortitis with superimposed atherosclerosis and left subostructive coronary ostium in young woman

Takayasu disease or arteritis (TA) is a chronic, idiopathic, inflammatory disease that that principally affects the aorta and its primary branches. The pathological changes depend on stage of the disease. The late “burned out” stage is marked by fibrous scarring, leading to intimal and advantitial thickening, which may contain dystrophic calcification. Similar histopathological findings are also seen in many other causes of aortitis. We here in report chronic “burned out” TA in 28-year-old woman with superimposed atherosclerosis and left sub obstructive coronary ostium. This patient in addition had Aortic stenosis and calcification of ascending aorta.