Marginal Artery Research Articles

Giant true inferoposterior left ventricular aneurysm presenting with heart failure: insights from multimodality imaging

A 58-year old male patient who had undergone post-infarction ventricular septal defect closure and venous coronary bypass grafting to the obtuse marginal artery 2 years previously, presented with congestive heart failure. Echocardiography, computed tomography and ventriculography revealed a giant inferoposterior left ventricular aneurysm (Fig. 1A–D, Supplementary Video 1). Surgical left ventricular restoration was performed by a direct linear suture (Fig. 1E and F).

Angiographic profile of coronary arteries in Keralite population

Background and aims: The incidence of Coronary Artery Disease (CAD) has reached alarming proportions in India. The pathological hall mark of CAD is myocardial ischemia resulting from the atherosclerotic narrowing of coronary arteries. In this era of advanced interventions and cardiac surgery, a thorough knowledge of normal and variant anatomy of coronary arteries is of prime significance and of great use both to the clinicians and anatomists. Materials and methods: One hundred coronary angiograms of patients free of disease were studied in detail in different profiles. The data obtained was quantified according to their frequencies. The relation between the length of left main coronary artery and coronary artery dominance was statistically analyzed using the ‘Chi Square test for Trend’. Results: This study highlighted some interesting findings such as the origin of Sino- atrial nodal artery from the second segment of right coronary artery in 3% of cases, double right marginal artery in 4% cases. Other variations such as Mouchet’s posterior recurrent interventricular artery, origin of circumflex artery from the right coronary artery and abnormal communication between the terminal parts of right coronary artery and circumflex artery were each noticed in 1 % of cases. Conclusions: Coronary arteries and their branches are prone to variations in their course and morphology. Prior knowledge about this is important for the interpretation of coronary angiograms and surgical myocardial revascularization. The present work on normal and variant pattern of coronary arteries will help in gathering momentum to the already advancing research work in this field.

Surgical Treatment of Complete Anterolateral Papillary Muscle Rupture Following Acute Myocardial Infarction

Papillary muscle rupture is a lethal complication of after acute myocardial infarction. We report the successful surgical management of complete anterolateral papillary muscle rupture associated with cardiogenic shock in an 80-year-old woman. The patient was admitted with the sudden onset of chest pain and dyspnea. After hemodynamics deteriorated rapidly, she was intubated and intra-aortic balloon pump was started immediately. Transthoracic echocardiography revealed severe mitral regurgitation due to complete anterolateral papillary muscle rupture associated with lateral myocardial infarction. Coronary angiography demonstrated complete occlusion of the first obtuse marginal artery. She underwent emergency mitral valve replacement and coronary artery bypass grafting. There were no complications of surgery and she was discharged on postoperative day 35. Rapid preoperative assessment and aggressive surgical management are important to improve the prognosis in this setting.

Incidence, Predictors, Treatment, and Long-Term Prognosis of Patients with Restenosis after Long Drug-Eluting Stent Implantation for Coronary Arteries

Background: Few data on the clinical course and management of patients experiencing restenosis after implantation of long drug-eluting stents treatment for coronary arteries was available. Objectives: The aim of this study was to evaluate the incidence, predictors, and long-term outcomes of patients with in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) with long (33 mm & 38 mm) drug-eluting stents (DES) for long lesions in coronary arteries including left anterior descending artery (LAD), Lt circumflex artery (Lt Cx), right coronary artery (RCA), obtuse marginal artery (OM) & posterior descending artery (PDA). Methods: Between July 2009 and October 2010, 421 long DES had being implanted in 421 consecutive patients with significant coronary artery stenosis, with 371 patients (88%) undergoing routine follow up, clinical follow up done by exercise stress test at 6 & 12 months after stenting for 126 patients (34%), in 124 patients (33.5%) follow up was done by Computed Tomography angiography & 121 patients (32.5%) with clinically driven angiographic follow-up. A major adverse cardiac event was defined as the composite of death, myocardial infarction (MI), or target-lesion revascularization (TLR) within 15 months. Results: All patients who underwent clinical follow up were asymptomatic. The overall incidence of angiographic (CT or conventional) ISR with long (33 mm & 38 mm) DES was 4% (15 out of 371 stents) with 8 (53.3%) focal-type and 7 (46.7%) with diffuse-type ISR. Six patients (40%) under-went repeated PCI, seven (46.7%) underwent bypass surgery, and 2 (13.3%) were treated medically. During long-term follow-up (ranging from 12 - 26 months), there were no deaths, 3 (0.8%) MI, and 13 (3.5%) repeated target-lesion revascularization (PCI or CABG) cases. The incidence of major adverse cardiac event was 5.3% in the medical group, 10.1% in the repeated PCI group, and 21.4% in the bypass surgery group. Multivariate analysis showed that the occurrence of DES-ISR did not affect the risk of death or MI. Conclusions: The incidence of ISR was 4% after long DES stenting for coronary arteries. The long-term clinical prognosis of patients with long DES-ISR associated with coronary artery stenting might be benign, if the patient has optimal treatment.

End-tidal CO2 Should not be a Parameter for Ventilatory Adjustment during Low Cardiac Output States Like Off-pump Coronary Artery Bypass Grafting

Background: Capnography is widely used as a non-invasive monitoring technique for intra-operative and postoperative mechanically ventilated patients. Aim: To study whether the EtCO2 values should be used to adjust mechanical ventilation during low cardiac output states such as off pump cardiac bypass surgery (OPCABG). Setting and design: Prospective study in 50 patients undergoing OPCABG. Material and Methods: The values of cardiac index (CI), EtCO2, PaCO2 and P(a-Et)CO2 gradient were compared at two time points during OPCABG: immediately before skin incision and during grafting of obtuse marginal artery, as usually OM grafting is considered to be associated with low cardiac output. Statistics: Data was analysed using student’s t-test. Results: There was a significant decrease in the value of CI from point A to point B (2.33 vs. 1.75 L/min/m2, p<0.001), significant decrease in EtCO2 from 25.28 to 21.88mmHg (p<0.001) and statistically significant increase in P(a-Et)CO2 gradient 4.39 at point A to 9.18 mmHg at point B (p<0.003). Conclusion: The decrease in EtCO2 had a positive correlation with the decrease in cardiac index. So during the low flow periods as found in OPCABG, EtCO2 cannot reliably estimate the adequacy of ventilation.

Primary duodenal adenocarcinoma of the fourth portion diagnosed using double-balloon enteroscopy and surgically resected: A case report

Introduction: Primary duodenal adenocarcinoma is extremely rare. If this carcinoma occurs in fourth portion, it can now be diagnosed by recent developments in enteroscopy. Case Report: We report a rare case of primary duodenal adenocarcinoma of the fourth portion diagnosed by double­balloon enteroscopy and resected surgically. A 57­year­old man was anemic. PET­CT revealed accumulation in the fourth portion of the duodenum. Double­ balloon enteroscope showed circular tumor of the fourth portion of the duodenum, and biopsy disclosed poorly differentiated adenocarcinoma. Partial duodenectomy and partial colonectomy were performed. The marginal artery of the transverse colon was invaded. Histological examination disclosed that the tumor was poorly differentiated adenocarcinoma and two lymph node metastases were seen. Conclusion: Primary duodenal adenocarcinoma of fourth portion can be diagnosed by double­ballon enteroscopy and treated by surgical resection.

Effect of carotenoid β-cryptoxanthin on cellular and humoral immune response in rabbit

Beta-cryptoxanthin (b-Cr) is a pro-vitamin A and one of the major carotenoids that can be commonly found in mammalian serum and tissues. Foods rich in certain fatty acids are known to be effective to gain a healthy immune system. In the present study, we evaluated the effect of b-Cr on rabbit humoral and cellular immune responses to have a better vision about the mechanism of effect of carotenoids on immune system. Twenty rabbits were randomly divided into five groups (4 per group): Groups consisted of: 1) control group (normal saline; 2) b-Cr (control); 3) vaccine control; 4) 5mg/kg b-Cr o.p. + vaccine; 5) 10mg/kg b-Cr o.p. + vaccine. Blood samples were obtained from the marginal ear artery at three time points: days 0, 14 and 21 of the study. Blood CD4+ and CD8+ lymphocytes and Serum Immunoglobulin and Cytokines content were evaluated. Results show that b-Cr administration increased the blood CD4+ lymphocytes count (P > 0.01). Serum IgG, IgM and IgA levels increased (P > 0.05) following b-Cr administration. b-Cr treatment increased serum IL-4 levels (P > 0.05). According to presented results, b-Cr may increase the humoral immunity in mammals. So, it would possible has a potentially beneficial effect on health and on prevention of the immunity related diseases.

Konno Ross procedure, coronary artery bypass graft and mitral valve replacement in a 12-year-old girl with homozygous familial hypercholesterolemia

Abstract Background Familial hypercholesterolemia (FH) is a genetic disorder caused by a mutation of the gene for the low density lipoprotein receptor. This mutation can lead to elevated plasma cholesterol levels and subsequently to premature coronary artery disease. Management of patients with FH is complicated and surgery is accompanied by high risk, even in skillful hands. Case presentation A 12-year-old female patient was referred to our department in January 2013 with chest pain and dyspnea. Her history showed that he had documented evidence of homozygous HF (HFH) since 2 years of age and that she underwent a Ross–Konno procedure for valvular aortic stenosis, 3 years ago. Electrocardiography showed ST depression in the inferolateral derivations and ST elevation in aVr. The echocardiography showed LV systolic dysfunction and important mitral regurgitation. Coronary angiography demonstrated stenosis in the distal part of the left main and severe three vessel coronary artery disease. The patient presented critical acute myocardial ischemia immediately after coronary angiography. She was referred for surgery. The left anterior descending artery was bypassed using saphenous vein and both right coronary artery and marginal artery using sequential saphenous vein. The mitral valve was replaced with mechanic prosthesis. The postoperative course was uneventful. She was prescribed atorvastatin accompanied by cholestyramine and diet modulation. Conclusion HFH patients are at increased risk of developing coronary artery disease and also sudden death unless the condition is recognized and treated promptly. Surgery remains the most effective means of prolonging the life of these patients.

Coronary arteries morphometry and their vascular territories

Abstract Our study was performed on a total of 24 angioCT’s by each coronary artery executed on a GE LightSpeed VCT64 Slice CT Scanner. To assess the type of vascularization (coronary dominance) we used also dissection on fresh and formalin preserved hearts, injection of contrast substance followed by radiography and plastic mass injection followed by corrosion. Left coronary artery from origin I found a diameter of between 4.1 to 5.8 mm, the length of the left main coronary artery until its branching (bi or trifurcation) ranging from 3 to 11.8 mm. The diameter of the anterior interventricular artery, was between 1.8 to 3.4 mm, and when the anterior interventricular artery branched off a left marginal artery, it was less voluminous than the case when the marginal artery origin by trifurcation of coronary artery, with 1.8-2.5 mm. Anterior interventricular artery detach left anterior ventricular branches with a diameter of 1.2-2.2 mm. Circumflex artery present a diameter of 2.1 to 4.2 mm at the left aspect of the heart circumflex artery has a diameter of 2.1 to 3.4 mm. On the posterior surface of left ventricle from circumflex artery branches come off with 1.2 to 2.4 mm in diameter. Left marginal artery, when originate from the left coronary artery had a diameter of 2.1 to 2.8 mm. The right coronary artery presents at origin a diameter of 3.1 to 5.4 mm, from the coronary right for the anterior aspect of the right ventricle unhooking the branches with a diameter of 2.2 to 4.2 mm. To the posterior of the right ventricle right coronary artery gave branches with a diameter of 1.6 to 2.6 mm. Right marginal artery had a diameter of 1.6-2.2 mm, and in one case (4.17% from cases) had a diameter of 3.4 mm (when the right coronary origin was 5.4 mm ). From right the coronary atrial branches detaches with a caliber of 0.6-2 mm. Regarding the coronary dominance, we found on a number of 88 hearts that in 29.54% of cases there is predominance of right coronary artery in 25% of cases there is a predominance of the left coronary artery, and in 45.46% of cases there is a balance between the territories of the vascularity of the two coronary arteries.

Intracoronary 99m Tc-Sestamibi Single Photon Emission Computed Tomography/Computed Tomography for Preoperative Evaluation of At-Risk Myocardium

A 73-year-old man with a history of previous coronary artery bypass surgery (left internal mammary artery [LIMA]–to–first obtuse marginal artery graft, right internal mammary artery–to–left anterior descending artery graft, and venous graft to second obtuse marginal branch) and previously treated melanoma and gastric carcinoma was referred for evaluation of an enlarging lung mass adjacent to a vascular graft on computed tomography (CT). CT coronary angiography confirmed that the suspicious left upper lobe lung mass was encasing the LIMA graft (Figure 1). 18F-fluorodeoxyglucose positron emission tomography/CT study confirmed isolated, intense metabolic activity within the lesion consistent with malignancy (Figure 2). Echocardiography confirmed normal left ventricular systolic function. A decision for surgical resection was made, with the need for further evaluation of the coronary circulation to assess the implications of potential sacrifice of the LIMA graft. At the time of coronary angiography (Figure 3), 76 MBq 99mTc-sestamibi was injected directly into the LIMA graft to establish the area of viable myocardium perfused by this vessel. Single photon emission CT/CT imaging performed 1 hour later (Figure 4) demonstrated that, at most, sacrifice of the LIMA graft would result in only a small infarct of the lateral wall. Subtraction of these images from …

An Unusual Case of Single Coronary Artery

An 81-year-old man with a history of hypertension, dyslipidemia, and diabetes consulted for progressive angina. Ergometry findings indicated a poor prognosis. Coronary angiography showed a severe lesion in the dominant circumflex artery (CX) at the bifurcation with the obtuse marginal artery. A severe calcified lesion was seen in the middle portion of the left anterior descending artery (LAD) at the bifurcation with an anomalous artery that ran anterior to the right ventricular outflow tract and reached the coronary sulcus, where it continued in the normal course of the right coronary artery (RCA) (Figs. 1 and 2). Angiography showed agenesis of the right coronary ostium. Myocardial revascularization surgery was undertaken. Anomalous coronary arteries are seen in 0.3% to 1.3% of coronary angiography studies. Single coronary artery is uncommon (0.0024%-0.066%). Origin of the RCA from the LAD is extremely rare. Only 8 cases of RCA arising from the middle LAD have been described, and this is the first published case in Spain. Single coronary artery does not usually have clinical repercussions, although it can present with angina or sudden death. An association with an increase in arteriosclerotic disease has been hypothesized. Computed tomography angiography is an aid to the diagnosis of coronary anomalies. It is not absolutely necessary if management is clarified by angiography. In patients older than 30 years with ischemic symptoms, the treatment is similar to that used in other patients because of the low risk of sudden death. In young patients with an interarterial course, a more aggressive management is recommended, and surgical treatment can be considered.

Rare Case of “Wandering Artery of Drummond” As a Result of Chronic Triple Mesenteric Vessel Occlusion Treated by Isolated Angioplasty and Stenting of the Inferior Mesenteric Artery

We report a rare clinical scenario of chronic mesenteric ischemia (CMI) patient with obstruction of all the three major gut vessels including celiac, superior mesenteric artery (SMA), and inferior mesenteric artery (IMA) with a sole artery supplying the collaterals through marginal artery of left colon (the "wandering artery of Drummond"). A 70-year-old man was presented to hospital with acute onset of dyspnea, diaphoresis, severe epigastric pain, nausea, and vomiting that started after lunch. Initially, patient was diagnosed and treated for non-ST elevation myocardial infarction (NSTEMI). Furthermore, work-up, including computed tomographic scan of abdomen followed by angiogram, revealed 100% obstruction of celiac and SMA, whereas inferior IMA had 90% ostial lesion with poststenotic dilatation and collaterals supplying to entire colon. Subsequently, IMA ostial lesion was stented through percutaneous intervention and patient noted significantly improved symptoms and quality of life. To conclude, percutaneous endovascular treatments confer favorable strategy for CMI, and it may either be curative or allow nutritional optimization before definitive surgery.

Pure NOTES Rectosigmoid Resection: Transgastric Endoscopic IMA Dissection and Transanal Rectal Mobilization in Animal Models

We report a pure natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and the Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) rectosigmoidectomy in animal models using transgastric endoscopic inferior mesenteric artery (IMA) dissection and transanal rectal mobilization. Ten live animals (2 pigs weighing 35-40 kg each and 8 dogs weighing 25-30 kg each) were used. A gastrotomy was made using a needle-knife puncture and the balloon dilatation technique or following the creation of a submucosal tunnel. A circular stapler shaft was transanally inserted up to the sigmoid colon for spatial orientation and traction of the mesocolon. The IMA was endoscopically dissected using a Coagrasper™ (Olympus, Tokyo, Japan) and then clipped. Endoscopic division of the sigmoid mesocolon was conducted laterally toward the marginal artery. Transanal full-thickness circumferential rectal and mesorectal dissections were performed, and a colorectal anastomosis was performed using a circular stapler with a single stapling technique. During the transanal approach, the gastrotomy was closed using four endoscopic clips. Endoscopic dissection of the IMA was successful in all cases, but minor bleedings occurred in 3 cases. The mean time from dissection and clipping to division of the IMA was 36.7 minutes (range, 25-45 minutes). The mean operation time was 180.5 minutes (range, 145-210 minutes). There were no intraoperative complications or hemodynamic instability. The mean length of the resected specimen was 11.2 cm (range, 9-17 cm). A pure NOTES approach to rectosigmoid resection using transgastric endoscopic IMA dissection is technically feasible in animal models.

Partial Papillary Muscle Rupture: A Cause of Acute Mitral Regurgitation

A 56-year-old woman presented to the cardiology clinic with a 7-day history of dyspnea and chest pressure. An echocardiogram showed a flail posterior mitral valve leaflet, and subsequent left heart catheterization showed complete occlusion of the first obtuse marginal coronary artery. Further investigation demonstrated the culprit lesion to be ischemic partial rupture of the posteromedial papillary muscle. Timely recognition of this condition allowed for an optimal clinical outcome. In this Cardiology Grand Rounds, the authors further describe the above presentation of ischemic partial papillary muscle rupture and provide a brief review of the pathophysiology, diagnosis and treatment of this condition.

Refining the target area in diffuse gliomas for radiation oncology based upon the location of cingulate gyrus tumors.

e13051 Background: Glioblastoma is a brain tumor with poor survival. Radiation therapy (RTX) is often not effective and the target volume could be improved. The aim of this study is to determine if the patterns of spread for cingulate region gliomas could be used to make rational decision for safely altering the treatment planning target volume. Methods: 69 pts. with cingulate gliomas were collected from the collaborating institutions and the patterns of spread were analyzed by serial MRI evaluation. Results: Most pts. present with seizures, one ischemic stroke and one acute hemorrhage was noted. Anterior cingulate was involved in 49 pts. The basal frontal lobe (orbitofrontal or gyrus rectus) was involved in 6 pts. and the insula in 1. There were 20 cases of posterior cingulate involvement including 1 case which wrapped posteriorly from the hippocampus to indusium griseum. None of the cases spread between the anterior and posterior cingulate. 4 had bilateral cingulate involvement. Given that the callosal fibers surround but do not enter the cingulate, the postoperative imaging were assessed which showed that often the callosum was thin and edematous, or had tumor herniate through the callosal isthmus (3 cases), rather than true callosal involvement. Additional cases outside of the 69 pts. showed callosal tumors sparing the cingulate and supra-cingulate frontal and parietal tumors which did not invade the cingulate sulcus. Conclusions: For RTX the areas of cingulate tumor spread which should be considered is the adjacent corpus callosum. There appear to be a relative functional border by the cingulate sulcus and also separating the anterior and posterior cingulate at the level of the paracentral lobules, suggesting the potential for dose deescalation, which may also help with avoiding the supra-cingulate supplemental motor area and leg motor fibers. Other areas to include are the opposite cingulate gyrus, head of the caudate nucleus and septum pellucidum. Anterior cingulate lesions near the genu should include the subcallosal (risky for deficit) and ipsilateral frontal basal areas (risks for frontal lobe syndrome). Sparing the major callosal marginal or pericallosal arteries may help to avoid stroke.

A case of giant left ventricular lipoma: unusual presentation

Primary cardiac tumors are rare and usually benign. The incidence of cardiac lipomas is 8 % of benign cardiac tumors [1]. Several surgical options have been reported to obtain an appropriate operative view because of their poor visualization when the tumors are located in the Left Ventricle (LV). We report a rare case of massive left ventricular lipoma occupying pericardial space. A 23-year-old female had back pain since 6 months. She visited a local orthopedician, who ordered for computed tomography scan of chest and back. Computed tomography showed a large epicardial mass located along the anterior surface of the heart, from the diaphragm level through the aortic arch level. The mass showed an attenuation value identical with that of subcutaneous adipose tissue and contained some areas with high density. The mass was not enhanced by contrast media. Percutaneous biopsy was done, histologic examination of the specimen demonstrated mature adipose tissue. An encapsulated adipose mass weighing 865 g, which originated from the left ventricle anteriorolateral surface without any invasion to the pericardium, was near completely excised, except for a small portion which was encasing obtuse marginal artery. Microscopic examination revealed mature adipose tissue with partial necrosis, confirming the diagnosis of lipoma.

Expandable external support device to improve Saphenous Vein Graft Patency after CABG

ObjectivesLow patency rates of saphenous vein grafts remain a major predicament in surgical revascularization. We examined a novel expandable external support device designed to mitigate causative factors for early and late graft failure.MethodsFor this study, fourteen adult sheep underwent cardiac revascularization using two vein grafts for each; one to the LAD and the other to the obtuse marginal artery. One graft was supported with the device while the other served as a control. Target vessel was alternated between consecutive cases. The animals underwent immediate and late angiography and were then sacrificed for histopathologic evaluation.ResultsOf the fourteen animals studied, three died peri-operatively (unrelated to device implanted), and ten survived the follow-up period. Among surviving animals, three grafts were thrombosed and one was occluded, all in the control group (p = 0.043). Quantitative angiographic evaluation revealed no difference between groups in immediate level of graft uniformity, with a coefficient-of-variance (CV%) of 7.39 in control versus 5.07 in the supported grafts, p = 0.082. At 12 weeks, there was a significant non-uniformity in the control grafts versus the supported grafts (CV = 22.12 versus 3.01, p < 0.002). In histopathologic evaluation, mean intimal area of the supported grafts was significantly lower than in the control grafts (11.2 mm^2 versus 23.1 mm^2 p < 0.02).ConclusionsThe expandable SVG external support system was found to be efficacious in reducing SVG’s non-uniform dilatation and neointimal formation in an animal model early after CABG. This novel technology may have the potential to improve SVG patency rates after surgical myocardial revascularization.

Specific morphological characteristics of the coronary arteries

Abstract In 68% of cases, the left coronary ostium is at the free edge of the left sigmoid valve in 22% of cases over the edge of the valve and in 8% of cases under the free edge of the valve. In 56% of cases, the right coronary ostium is at the free edge of the left sigmoid valve in 28% of cases over the edge of the valve and in 16% of cases under the free edge of the valve. We found 5 cases with two right coronary ostium and 2 cases with two left coronary ostium. We found that in 38% of cases, the left coronary artery ends in three branches, such as anterior interventricular, circumflex and left marginal arteries, in rest of the cases, the left coronary artery ending by two branches like the anterior interventricular and circumflex arteries in which case the marginal artery originate from circumflex artery and rarely from anterior interventricular artery, or both, in this last case the left marginal artery being double. We found only 8 cases in which the circumflex artery ends as posterior interventricular artery in rest of the cases being represented by the right coronary artery end. Circumflex artery ends by two branches quite often and rarely with three branches which can sometimes be long, down to near the apex of the heart. In 8% of cases, the circumflex artery was less developed and do not vascularize other than the left side of the posterior surface of the left ventricle, sometimes his terminal ramus being left marginal artery. The right coronary artery frequently ends on diaphragmatic surface of the heart either as a single branch in posterior interventricular groove, by bifurcation or even rarely by trifurcation, when one or two branches are located in the posterior interventricular groove. Sometimes the right coronary artery ends on the posterior surface of the left ventricle, where the posterior interventricular artery occurs as collateral branch of the right coronary artery, the right coronary artery extending their vascularization territory to the posterior surface of the left ventricle, right up to the apex of the heart, the right coronary dominance, the circumflex artery in this case ending on the lateral surface of the heart. The right coronary artery may end up on the posterior surface of the right ventricle in which case posterior interventricular artery is represented by the terminal portion of the circumflex artery. The right coronary artery rarely ended as the posterior interventricular artery can reach the apex of the heart. We have found that the dominant type of a coronary artery can be held not only in the number of collateral, but also by their caliber at their origin from the aorta. We encountered 7 cases in which there is a third coronary artery, in 5 cases the third coronary artery being an anterior right I called her middle coronary artery or right ventricular branch and anterior ventricular artery, and in two cases the third coronary artery represent the circumflex artery. In 6 cases of the 7 cases described the third coronary artery showed no atrial branches

Coronary Extramural Haematoma Caused by Perforation during Left Main Coronary Artery Intervention

A year-old male patient with a background of quintuple coronary artery by-pass graft surgery 16 years ago presented to our department with symptoms consistent with unstable angina pectoris. Previous angiography performed in 2001 revealed occluded saphenous vein grafts to the left anterior descending (LAD), right coronary, obtuse The presence of pericardial effusion was immediately ruled out by echocardiography and because of absence of myocardial contrast staining heparin was not reversed. Subsequent intravascular ultrasound (IVUS) examination revealed a minimal lumen area of ≥11.00 mm2 throughout the stented segment despite stent underexpansion at marginal and first diagonal (DA) arteries, and patent left internal mammary artery (LIMA) graft to a second DA. At the same session he underwent percutaneous coronary intervention with bare metal stent implantation for significant mid to distal LAD artery disease. Since then, the patient was stable with Canadian angina class I. During this admission, his echocardiogram revealed an ejection fraction of 40%, akinesia of the inferior wall which was known to be predominantly infarcted and hypokinesia of the basal and mid anterior septum. Coronary angiography (Fig. 1) showed subocclusive calcified and angulated distal left main coronary artery (LMCA) disease, significant ostial LAD artery disease, collateralised occlusion of the distal LAD, left circumflex (LCx) and right coronary arteries, tight proximal disease of a first DA and patent LIMA graft to a second DA. Given these findings we proceeded with stent angioplasty to the LMCA-ostial LAD artery lesion. After a series of predilations with semicompliant balloons, a 4.0 mm × 24 mm drug-eluting stent was the LMCA opposite to the LCx artery ostium and at the LAD artery ostium. Cross-sections of IVUS at the site of perforation revealed an echo-dim pattern suggesting an extramural haematoma and local stent underexpansion with a compression effect by the haematoma whereas the site of blood entry into the adventitia was identified at the distal margin of the haematoma adjacent to a fibrocalcific plaque (Fig. 2). Given the adequate minimal lumen area further stent postdilation was not performed to avoid the risk of frank coronary perforation. The patient was maintained on dual antiplatelet therapy and discharged home after a two-day uneventful hospital course. He remained stable eight months post stenting with Canadian angina class I and no evidence of a cardiovascular event. Extramural haematoma that is accumulation of blood outside the arterial wall in the adventitia tissue is a rare complication of percutaneous coronary intervention and is thought to develop secondary to adventitial dissection implanted from the ostium of the LMCA across the stenosis into the LAD artery at 8 atms. Control angiography after [1–3]. It presents with an echo-dim pattern due to the dilution of the red blood cells and dissemination throughout

Intramural dissecting hemorrhage of the myocardium

A 59-year-old man suffering anterior myocardial infraction 3 months ago with persistent dyspnea. Echocardiography revealed marked hypokinesia of the anterior and septal left ventricular walls with reduced ejection fraction (30%.) as well as turbulent flow at the apical region was noted with suspected apical thrombus formation. Coronary artery angiogram images show total occlusion of the LAD at its proximal and mid segment, tight long 90% stenosis of the first obtuse marginal artery as well as 99% mid segment stenosis of the RCA. Cardiac MRI was done and steady state free precession (SSFP) cine images revealed localized myocardial tearing and a flap appeared at the LV apex with a small tear at the flap containing fresh blood. Delayed-enhancement magnetic resonance imaging (intravenous dosage of 0.2 mmol/kg of Gad-DTPA; inversion recovery delay 260 ms; delayed time 10 min) revealed that the flap was enhanced and deviated toward the LV cavity and scarred enhanced myocardium deviated toward the epicardial border denoting the diagnosis of an intramural dissecting hemorrhage of the myocardium at the LV apical region. This entity accounts for fewer than 10% of cardiac ruptures and may occur after myocardial infarction, chest trauma, or surgery, or even spontaneously. Preoperative diagnosis is difficult, with differential diagnosis including pseudoaneurysm and intracavitary thrombus. Considering the poor prognosis of patients treated medically (less than 10% survival), corrective surgery is usually the treatment of choice.