Left Main Coronary Artery Obstruction Research Articles

Transesophageal echocardiography: a tool for intraoperative assessment of coronary blood flow

Transesophageal echocardiography (TEE) has become an indispensable part of cardiac surgery, but its potential for assessing coronary anatomy and blood flow remains underutilised. This case report presents a case of acute iatrogenic left main coronary artery obstruction following re-operative aortic valve replacement that was promptly diagnosed by intraoperative TEE and managed successfully by Bentall operation. We also emphasise the technique of TEE for coronary evaluation, its caveats and its clinical application during cardiac surgery.

A Rare Case Report of Ruptured Sinus of Valsalva Aneurysm

<p>主動脈竇動脈瘤是一種罕見的心臟結構病變，因具非特異性表徵及困難診斷，容易導致高死亡風險。本案例是一位53歲男性患者，因急性胸痛入院治療，藉由實驗室檢查發現心肌酵素升高、D-二聚體升高，心電圖檢查為aVR導程ST段上升、於第I、II、V4~6導程出現ST-T波段變化，初步診斷為左冠狀動脈主幹心肌梗塞，立即行冠狀動脈攝影檢查發現無異常。個案出現胸痛合併心因性休克之症狀，從中排除主動脈剝離、肺栓塞、心包填塞等診斷，深入檢視病史紀錄及影像報告，發現心臟超音波、胸部電腦斷層及冠狀動脈血管攝影檢查有由左流向右心室的瘻管分流，最終確診為主動脈竇動脈瘤破裂。患者緊急接受右冠狀竇動脈瘤修補及主動脈瓣置換手術治療後，胸痛、休克狀況改善且左心室功能恢復，術後預後良好。在面對急性胸痛合併血液動力學不穩定的患者時，除了須考慮症狀相關的疾病診斷外，當聽診發現S1及S2連續性心雜音時，建議將主動脈竇動脈瘤破裂列入考慮，以掌握治療處置之重要時機。</p> <p> </p><p>Aneurysm of the sinus of Valsalva is a rare cardiac anomaly due to the nonspecific symptoms and dif-ficult confirmation of diagnosis leading to high mortality. This report describes the case of a 53-year-old man who had suffered from acute chest pain. The electrocardiogram showed the ST segment ele-vation in lead aVR and ST-T wave changes in leads I, II and V4-6. Elevated D-dimer levels and cardi-ac enzymes were also observed. Acute myocardial infarction caused by the left main coronary artery obstruction was initial diagnosed. Coronary angiogram was performed immediately and the result indicated non-obstructive coronary artery. However, cardiogenic shock with persistent chest pain was discovered. Aortic dissection, pulmonary thromboembolism and cardiac tamponade were gradually excluded. Through detailed review and analysis of medical history, physical assessment and image ex-aminations with echocardiography, chest computed tomography and coronary angiogram, a ruptured sinus of Valsalva aneurysm was eventually diagnosed based on image examinations which revealed left-to-right shunt communicating with the right-sided heart chambers. The patient received emergen-cy right coronary sinus aneurysm repairment and aortic valve replacement surgery. Symptoms with chest pain and shock gradually disappeared and left ventricular function was restored postoperatively. The patient demonstrated excellent recovery. In facing relevance diagnostics for patients with acute chest pain and hemodynamic instability, a ruptured sinus of Valsalva aneurysm must be considered to endure best treatment timing if heart auscultation reveals S1 and S2 continuous murmurs.</p> <p> </p>

The Case of Left Main Coronary Stenting in Acute ST Elevation Myocardial Infarction

In the light of present studies, the left main coronary artery (LMCA) lesions more suitable for surgery on stable and planned patients. But invasive tools like OCT, FFR and IVUS usage in this stenting of LMCA lesions gains popularity for procedural optimization in interventional cardiologist era. Although long term results are debatable but short term studies revealed same mortality and morbidity rates between stenting and surgery in acute coronary syndromes. We herein present an acute anterior ST elevation myocardial infarction (MI) with hemodynamic disturbance because of total obstruction of LMCA with no distal flow in left coronary system. After crush stenting of LMCA, patient’s situation was going well and discharged with medical therapy shortly after intervention.

Značaj prehospitalnog prepoznavanja ST elevacije u aVR odvodu u akutnom koronarnom sindromu

Introduction/Objective the acute coronary syndrome is a medical condition that Emergency Medical Service physicians deal with daily. An especially prompt reaction is required when an ST elevation in the aVR lead is discovered, as it signifies a critical coronary lesion. The objective of the article is to present how educated the Emergency Medical Service doctors included in the STEMI network are in recognizing and treating the aVR lead elevation, as an atypical ECG finding. Case report Three patients with chest pain lasting from 30 minutes to 2.5 hours are presented. The ECG recording shows significant ST segment depressions >1mm in 6 or more leads (I, II, III, aVL, aVF, V2-V6) coupled with a 3-4mm ST elevation in the aVR lead and similar or slightly less pronounced ST elevation in V1. The strategy for primary PCI had been initialized for all three patients, who were then, after consultation with interventional cardiologists in UHMC Bezanijska kosa, Clinical Hospital Centre Zvezdara and the Military Medical Academy and having taken the initial dose of dual antiplatelet therapy (except for the third patient), transported to the hospital catheterization labs in these three institutions. Conclusion ST segment depression of 1 mm or more in six or more leads (inferolateral depression) coupled with ST segment elevation in aVR and/or V1 points to the threevessel disease (3VD) or left main coronary artery (LMCA) obstruction. The Emergency Medical Service doctors react adequately and promptly and, pending consultation with interventional cardiologists, the patients arrive directly into the catheterization lab. The final decision about reperfusion therapy is made by cardiologists and cardiac surgeons. Early invasive approach and adequate therapy (PCI/CABG) lower the risk of cardiogenic shock development and death.

Left Main Coronary Artery Obstruction by Huge Noncoronary Cusp Calcification After Transcatheter Aortic Valve Replacement

A 92-year-old woman with severe aortic stenosis was referred to our institution for transcatheter aortic valve replacement. Pre-procedural multidetector-row computed tomography showed a bulky calcification in the noncoronary cusp (NCC) and left coronary cusp (LCC) ([Figure 1A][1]). Because there

Diffuse ST segment depression and ST segment elevation in lead aVR and V1 by left circumflex artery occlusion

The current guidelines for resting electrocardiograms of diffuse ST segment depression coupled with ST segment elevation in aVR and/or V1 that are otherwise unremarkable indicate multivessel or left main coronary artery obstruction. However, our case meets the above electrocardiogram changes, but involves left circumflex artery occlusion.

Coronary Artery Occlusion; the Night Mare Post AVR

Iatrogenic intra operative acute coronary artery obstruction is a rare and potentially fatal complication of valve surgery [1]. Sudden coronary spasm, embolization of calcium plaque, and surgical factors can induce acute coronary obstruction after AVR [2]. Initially described in 1967, following aortic valve surgery, it is now recognized that patients who develop myocardial ischemia postoperatively following valve surgery, should be investigated deeply to exclude this rare phenomenon as the cause of myocardial dysfunction [3]. Although most reports highlight the potential for coronary artery stenosis in the months following valve surgery there are few documented cases of intraoperative coronary embolism causing circulatory collapse and requiring prompt treatment [5]. After Ethical Committee approval and after written consent taken from the patient family for publication, we present a case of acute intra operative left main coronary artery obstruction after Aortic Valve Replacement (AVR) and its immediate management.

A case report of acute left main coronary artery obstruction during transcatheter aortic valve implantation procedure

经导管主动脉瓣置换术围手术期出现的急性冠状动脉闭塞是一种极其严重的并发症，患者死亡风险高，尤其是合并左主干闭塞时，死亡风险更高。该文介绍1例患者经股动脉自膨式瓣膜置入术后即刻出现顽固性低血压，造影证实为左主干急性闭塞，立即行介入治疗开通左主干，患者生命体征恢复平稳。术后随访1年，患者病情稳定。.

Periprocedural Cardiopulmonary Bypass or Venoarterial Extracorporeal Membrane Oxygenation During Transcatheter Aortic Valve Replacement: A Systematic Review.

BackgroundThere are limited data on the use of venoarterial extracorporeal membrane oxygenation (VA‐ECMO) or cardiopulmonary bypass (CPB) to provide hemodynamic support periprocedurally during transcatheter aortic valve replacement. This study sought to evaluate patients receiving transcatheter aortic valve replacement with concomitant use of CPB/VA‐ECMO.Methods and ResultsWe systematically reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring CPB/VA‐ECMO periprocedurally during transcatheter aortic valve replacement. Studies reporting short‐term and long‐term mortality were included. Given the significant methodological and statistical differences between published studies, meta‐analysis of the association of CPB/VA‐ECMO with mortality was not performed. Of the 537 studies identified, 9 studies representing 5191 patients met our inclusion criteria. Median ages were between 75 and 87 years with 33% to 75% male patients. Where reported, the Edwards SAPIEN™ transcatheter heart valve was the most frequently used. A total of 203 (3.9%) patients received periprocedural hemodynamic support with CPB/VA‐ECMO. Common indications for CPB/VA‐ECMO included left ventricular or aortic annular rupture, rapid hemodynamic deterioration, aortic regurgitation, cardiac arrest, and left main coronary artery obstruction. The use of CPB/VA‐ECMO was predominantly an emergent strategy and was used for durations of 1 to 2 hours. Short‐term mortality (in‐hospital and 30‐day) was 29.8%, and 1‐year mortality was 52.4%. Major complications such as bleeding, vascular injury, tamponade, stroke, and renal failure were noted in 10% to 50% of patients.Conclusions CPB/VA‐ECMO was used in 4% in the early experience of patients undergoing transcatheter aortic valve replacement, most commonly for periprocedural complications. There are limited data on preprocedural planned use of VA‐ECMO, and the characteristics of this population remain poorly defined.

Drug-eluting stents Versus Coronary Artery Bypass Grafting in Multivessel Disease and Left Main Obstruction: Meta-analysis of Randomized Clinical Trials

Background: The choice between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remains controversial. Objective: To conduct a meta-analysis of randomized studies comparing drug-eluting stents (DES) and CABG in multivessel disease or obstruction of the left main coronary artery. Method: Electronic databases were searched systematically to evaluate results of randomized trials comparing PCI with DES versus CABG in multivessel disease and obstruction of the left main coronary artery. Ten studies were identified. Results: In the aggregated results (n = 9268), mortality at 30 days and incidence of stroke favored PCI (0.8% versus 1.5%, p = 0.005; 0.4% versus 1.5%, p < 0.0001, respectively). There was no difference in mortality at 1 year (3.4% versus 3.5%, p = 0.50). The late mortality favored CABG (10.1% versus 8.5%, p = 0.01). In patients with diabetes derived from four studies (n = 3830), late mortality favored CABG (12.5% versus 9.7%, p < 0.0001). In six studies of left main coronary artery obstruction (n = 4700), the incidence of stroke favored PCI (0.3% versus 1.5%, p < 0.001) and there was no difference in mortality at 30 days (0.8% versus 1.3%, p = 0.15), mortality at 1 year, or late mortality (8.1% versus 8.1%). The subgroups with high SYNTAX score and diabetes were those influencing most strongly and adversely the PCI results. Conclusion: When compared with PCI, CABG was superior in regards to late mortality and inferior in regards to 30-day mortality and incidence of stroke. Diabetes and SYNTAX score strongly impacted the results.

Delayed Left Main Coronary Artery Obstruction After Radiofrequency-Induced Coronary Dissection and Spasm: Insights From Optical Frequency-Domain Imaging and Intravascular Ultrasound Imaging

A 70-year-old woman underwent second radiofrequency ablation at the left coronary cusp for recurrent and drug-refractory premature ventricular contractions arising from the left coronary cusp. Pre-procedural coronary angiography showed no stenosis in either coronary artery. Radiofrequency energy

Prediction of Left Main Coronary Artery Occlusion by ST Segment Elevation in Lead aVR Greater than that in Lead V1 in Acute Coronary Syndrome

Background: The electrocardiogram (ECG) predicting an acute obstruction of the LMCA, which requires immediate aggressive treatment, is very important for early diagnosis. We correlated ST segment elevation in lead aVR greater than that in lead V• with coronary angiographic diagnosis of LMCA occlusion in patients with acute coronary syndrome.Methods: Cross sectional analytical study was conducted in the Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh from August 2011 to July 2012. Total 90 patients were included purposively. Study population was divided into two groups. Group I- Patients with ST segment elevation in aVR greater than ST segment elevation in V• (n=45) and group II- Patients with ST segment elevation in aVR less than that in lead V• (n=45). In hospital outcomes were observed for cardiogenic shock, left ventricular failure, hypotension, arrhythmia and death.Results: Acute LVF was significantly (P&lt;0.05) higher in group I but other complications were not significant (P&gt;0.05) between two groups. LM involvement was significantly higher in group I (91.1% vs. 20.0%, p&lt;0.05). ST segment elevation in aVR greater than ST segment elevation in V• (n=45) for prediction of LM significant disease has got a sensitivity of 82.0%, specificity 90.0%, accuracy 85.6%, positive and negative predictive values were 91.1% and 80.0% respectively.Conclusion: ST segment deviation in lead aVR greater than that in lead V1 is supposed to be a positive predictor of left main coronary artery obstruction with highly sensitivity and accuracy. Precordial leads V1 and V6 can also predict the critical LMCA obstruction in patients with acute coronary syndrome.Cardiovasc. j. 2017; 9(2): 77-82

Value of ST- Segment Depression with T-Wave Inversion in Lateral Leads I, aVL, V4-V6 in Diagnosing the Left Main or Left Main Equivalent Coronary Artery Disease

Background: Critical stenosis in the proximal part of the left anterior descending, severe 3 vessel disease and left main stem stenosis have all been recognized as clinical conditions complicated by a high incidence of large infarction, pump failure, arrhythmias and sudden death in patients with acute coronary syndrome (ACS). As many effective treatment modes are available currently, early recognition of those circumstances is crucial for appropriate management.Methods: this observational study was carried out at the Department of Cardiology, National Institute of Cardiovascular Disease (NICVD), Dhaka. Patients (30 patients) with NSTEACS having ST-segment depression with T-wave inversion maximally in leads I,avL,V4-V6 were considered as cases (Group I) and those (30 patients) with ST-segment depression without T-wave inversion in lateral leads were controls (Group II). Coronary angiogram (CAG) was done during in-hospital stay.Results: In present study, it was evident that among group I patients, 43.3% had stenotic lesion in left main artery (LM) and 26.67% in LM equivalent coronary artery (LME CA), whereas had no stenotic lesion in LM and 3.33% had LME CA lesion in group II patients. Low cost, widely available ECG criteria is supposed to be useful predictor of left main or left main equivalent coronary artery obstruction (Sensitivity=95%, Specificity= 76%, Positive predictive value= 70.0% and Negative predictive value= 97.0%) and high ST–segment changes score (&gt;18 mm (100%) &amp;/or ³10mm (80%) was an additive predictor of LM or LMECA lesion.Conclusion: Maximum ST- segment depression with T-wave inversion in the lateral leads I, aVL, V4-V6 on admission ECG can predict the critical LM or LMECA obstruction in patients with NSTEACS. It can help to provide prompt and appropriate management earlier to reduce the mortality &amp; morbidity.Cardiovasc. j. 2017; 9(2): 135-141

Clinical Cases: Valvular heart disease142A sub-aortic valve mass in a rheumatoid arthritis patient: an unconventional mechanism of aortic regurgitation143Symptomatic severe aortic regurgitation with coronary obstruction due to chronic type a dissection144Mitral valve prolapse and ventricular tachycardia: a long-lasting love story

Clinical Cases: Valvular heart disease142A sub-aortic valve mass in a rheumatoid arthritis patient: an unconventional mechanism of aortic regurgitation143Symptomatic severe aortic regurgitation with coronary obstruction due to chronic type a dissection144Mitral valve prolapse and ventricular tachycardia: a long-lasting love story

Case Report: Post transcatheter aortic valve replacement shock: Value of multimodal imaging

Complications resulting from the delayed clinical presentation of a left main coronary artery obstruction can be catastrophic. This case report presents a 73-year-old woman with severe aortic stenosis who underwent transcatheter aortic valve replacement with a core valve who, approximately 20 minutes after heparin reversal with protamine, became hypotensive and was unresponsive to vasopressor and inotropic therapy. Transesophageal echocardiography demonstrated global hypokinesis, which was highly consistent with the occlusion of the left main coronary artery. Angiography confirmed this diagnosis and demonstrated that valve positioning had not changed compared to post-placement examination. Here we report the partial covering of the ostium of the left main coronary artery by a core valve skirt that converted into a total occlusion following the initiation of heparin reversal with protamine and the value of multimodal imaging in the management of this case.

Cardiac Arrest in Early Pregnancy Due to Left Main Coronary Artery Obstruction; Emergency Percutaneous Coronary Intervention with Subsequent Successful Term Delivery

Cardiac Arrest in Early Pregnancy Due to Left Main Coronary Artery Obstruction; Emergency Percutaneous Coronary Intervention with Subsequent Successful Term Delivery

Short left main coronary artery causing dynamic left ventricular outflow tract obstruction and new onset left bundle branch block

Introduction: Left bundle branch block can be seen in conditions like aortic stenosis, extensive coronary artery disease, primary disease of the cardiac electrical conduction system, dilated cardiomyopathy, Lyme disease; it is also associated with short left main coronary artery and dynamic left ventricular outflow tract obstruction. While the former is caused by the shearing force on septal branches of the left anterior descending artery, the latter is related to either Venturi effect in hypertrophic cardiomyopathy or effect of systolic anterior motion caused by abnormal geometric relationship of papillary muscle and the mitral apparatus.

Concomitant Complete Atrioventricular Block and Left Main Coronary Artery Occlusion During Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is now considered a viable alternative therapy to surgery in patients with severe symptomatic aortic stenosis, considered to have a high risk for surgery. Herein, we present a case of severe aortic stenosis treated with transfemoral aortic valve implantation and complicated by complete atrioventrciular block and left main coronary artery obstruction that was successfully managed with permanent pacemaker implantation and left main coronary artery stenting. Although less invasive, TAVI can be associated with major complications. Therefore, extra care is required when performing TAVI in patients with borderline valve to coronary ostia distance.

Circumferential Type A Aortic Dissection and Intimal Intussusception of the Aorta Causing Severe Aortic Regurgitation and Obstruction of the Left Main Coronary Artery

Mini‐AbstractCircumferential dissection of the ascending aorta is a rare subtype of Type A aortic dissection which involves the entire intimal layer of the aorta which can cause a variety of devastating sequelae, given its propensity to involve the aortic valve and coronary arteries. Echocardiography is essential in making the diagnosis and visualize its involvement of the cardiovascular system, as invasive aortography can be limited in visualization of this unusual variant of aortic dissection. We present a patient who suffered a circumferential dissection of the ascending aorta which also caused severe aortic regurgitation and ischemia from left main coronary artery obstruction.

Similar survival 15 years after coronary artery surgery irrespective of left main stem stenosis

Objectives. To evaluate 15-year survival after coronary artery bypass grafting (CABG) in relation to grade left main stenosis (LMS) and right coronary artery (RCA) obstruction. Design. Coronary angiographic findings were prospectively collected in 977 patients who had CABG for stable angina during 1994–1995 and were included in the Swedish Coronary Revascularization – Swedish Council of Technology Assessment study. Results. Significant LMS was present in one fifth of the patients and significant RCA obstruction was found in 61% of those with LMS and in 68% of patients without LMS. The patients were categorized as no LMS (Group I), LMS without RCA obstruction (Group II) or significant LMS with significant right coronary artery (RCA) obstruction (Group III). Early mortality did not differ in the three groups and was 1.2, 1.2% and 0.8% in group I, II and III, respectively. Corresponding survival at 15 years was similar 51%, 47% and 47%, respectively. In multivariable analysis older age, smoking, severe angina, positive stress test, hypertension, diabetes mellitus and ejection fraction < 50% were risk factors for death at 15 years. Conclusions. Death 15 years after CABG correlated to clinical variables but was not predicted from presence of LMS with or without significant associated RCA obstruction.