Normal Coronary Artery Anatomy Research Articles

The prognostic impact of coronary anatomy in myocardial infarction with nonobstructive coronary artery disease: a seven-year longitudinal follow-up

Abstract Background Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a common condition associated with major adverse events (MAE) that may occur presence of normal or nonobstructive coronary artery anatomy (NCAA and NOCAA, respectively). The prognostic impact presence of NOCAA on long-term outcomes of MINOCA patients remains unclear. Methods This is a retrospective study among consecutive MINOCA patients in a large referral medical center in Israel between the years 2005–2018. Patients with probable alternative cause for myocardial injury, as stress-induced cardiomyopathy and myocarditis, were excluded. Patients were classified according to their coronary angiography diagnosis into NCAA and NOCAA. The primary outcome was MAE, defined as the composite of all-cause mortality and recurrent acute coronary syndrome (ACS). We performed survival analyses using multivariable Cox regression, controlling for potential cofounders. Results Among 36,501 admitted with AMI during the study period, 1,544 patients (4.2%) had MINOCA. Among MINOCA patients, 651 (42%) had NCAA, and 893 (58%) had NOCAA. The mean age was 61.2±12.6 years, and 710 (46.0%) were females. The NOCAA group had more females and were older with higher rates of diabetes, hypertension, dyslipidemia, atrial fibrillation, and chronic renal failure (p<0.05 for all). At a median follow-up of 7 years, MAE occurred in 203 (22.7%) patients and 67 (10.3%) patients in the NOCAA and NCAA groups, respectively (p<0.01). In fully-adjusted multivariable model, NOCAA remained a significant risk factor for long-term MAE [adjusted-hazard-ratio (aHR) 1.67, 95% confidence-interval (95% CI) 1.25–2.23; p<0.001; figure]. Other factors associated with MAE were older age (aHR 1.05, 95% CI 1.03–1.06; p<0.001), left ventricular ejection fraction (LVEF) <40% (aHR 3.04, 95% CI 2.03–4.57; p<0.001) Conclusion Among MINOCA patients, NOCAA was associated with a worse long-term prognosis than NCAA. Other risk factors for long-term MAE were older age and LVEF <40%, while female sex and sinus rhythm at presentation were associated with lower MAE risk. Funding Acknowledgement Type of funding sources: None.

The effect of frequency of sexual intercourse on coronary artery disease

Background: Doubts about the safety of sexual activity are common among cardiac patients and physicians alike, and are often neglected during routine checkups or on discharge from the hospital following a cardiac event or invasive procedure. Although it varies from society to society, it is considered taboo by most patients, so it is reluctant to ask the doctor about sexual activity. Doctors, on the other hand, remain silent due to the lack of clear information about the effect of sexual activity on coronary artery diseases or the presence of doubts. It is ultimately set aside by professionals and their patients. The patient does not ask and the doctor does not answer. This study, it was aimed to investigate the effect of the frequency of sexual intercourse on coronary artery disease. Methods: After applying the exclusion criteria, the remaining 180 patients were included in the study. A self-administered survey was applied to the patients before coronary angiography and patients were assessed according to the presence of additional diseases, their demographic characteristics, and the frequency of sexual intercourse. Two experienced physicians evaluated the angiographic results. Firstly Patients were grouped as 90 patients with normal coronary anatomy and 90 patients with coronary artery disease. After this, Coronary artery disease severity was evaluated according to syntax score. Results: The mean age of the patients was 58 ± 12.5 years. The distribution of age is not reasonable. According to gender, the female/male ratio the proportion of men was higher in patients with coronary artery disease. İncidence of normal coronary anatomy increased as the frequency of sexual intercourse increased. P - value was 0.037 and the result was statistically significant. The frequency of sexual intercourse was found to be 4.2/per month. The relationship between the Syntax score and frequency of sexual intercourse was not statistically significant (p > 0.05). Conclusion: As a result of the study, it was seen that patients with more frequent sexual intercourse had more normal coronary artery anatomy, and those with coronary artery disease had single coronary artery disease than multiple vascular disorders. it was concluded that the incidence of coronary artery disease and coronary artery disease severity decreased as the frequency of sexual intercourse increased. Sexual intercourse might be a preventive factor in the development of coronary artery disease.

A systematic review on normal and abnormal anatomy of coronary arteries

Coronary artery (CA) disorders are among the major causes of morbidity and mortality in humans. We attempt to explain CA anatomy and its variations in a simple, concise, and understandable way to help clinicians deal with the various disorders. There are two main arteries: right coronary artery (RCA) and left CA. The left bifurcates into two terminal branches: left anterior descending artery (LAD) and left circumflex artery (LCX). The commonest anatomical variant is trifurcation of left main coronary artery (LMCA) with presence of ramus intermedius artery (RIM), abnormal origin of LCX from RCA or right sinus of Valsalva, abnormal CA origin from unusual aortic sinus in-between aorta and pulmonary trunk, myocardial bridging, CA fistula and aneurysm. The RCA may arise abnormally from the left sinus of Valsalva rather than the usual origin from the right sinus. Furthermore, most cases of abnormal CA fistulas affect the RCA where the artery opens into the right heart chambers, pulmonary trunk, or coronary sinus. Although their incidence is relatively rare, coronary abnormalities are of critical importance in medical practice. Identification of normal and abnormal anatomy of CA is essential because not knowing one of the differences can lead to loss of a person’s life.

Case Analysis of a Unique RIII‐C Single Coronary Artery with Type IV Dual LAD and Right‐Dominant Triple PDA

INTRODUCTIONCoronary artery anomalies (CAAs) are rare congenital variations of normal coronary artery anatomy. Examples of CAAs include a single coronary artery (SCA) (instead of separate, left and right vessels) arising from the aortic trunk to supply the entire myocardium (prevalence = 0.024% to 0.066%), two left anterior descending arteries (LAD) (instead of one) occupying the anterior interventricular sulcus (prevalence = 0.02% to 1%), and three posterior descending arteries (PDA) (instead of one) occupying the posterior interventricular sulcus (prevalence uncertain). Reports of rare CAAs, especially those previously undocumented to occur simultaneously, serve as valuable references for medical education and clinical practice. The present study describes an especially unique CAA discovered in a human cadaveric heart where a SCA gives rise to distinct dual LAD and triple PDA. The study aims to characterize the involved CAAs and investigate the anatomy, histology, and clinical considerations of this unique coronary anatomy.METHODSThe SCA, dual LAD, and triple PDA CAAs were discovered during routine cadaveric dissection in a medical education curriculum. The heart was eviscerated, and the CAAs were carefully cleaned of extraneous tissue, photographed, and measured. The SCA was characterized using Lipton’s classifications, and the dual LAD was classified according to the thirteen variations (“Types”) of dual LAD described in the literature. Masson’s Trichrome histological staining was performed to examine CAA tissue integrity via light microscopy. Courses of the CAAs were superimposed on volume rendered computerized tomographic angiography (CTA) images depicting normal coronary anatomy for comparison.RESULTSThe SCA arose from a solitary coronary ostium in the right coronary sinus and traveled 0.57 cm from the aortic trunk before quadfurcating into the right coronary artery (RCA), long LAD, left main coronary artery (LMCA), and descending septal artery (DSA). The RCA maintained normal anatomic course before terminating in a right‐dominant triple PDA. The long LAD coursed pre‐pulmonic along the anterior interventricular sulcus for 13.89 cm before terminating near the apex of the heart. The LMCA tracked retro‐aortic, between the aorta and the atrial wall, for 5.67 cm before bifurcating into the left circumflex artery (LCX) and short LAD. The short LAD paralleled long LAD within the anterior interventricular sulcus for 10.8 cm before anastomosing with the second PDA near the apex. Additional anastomoses were noted near the apex of the heart between the long LAD, short LAD, second PDA, third PDA, diagonal branches of the short LAD, and left marginal artery. The DSA coursed between the aorta and pulmonary trunk before entering the interventricular septum.CONCLUSIONSThe heart presented in this study was supplied by a unique (Lipton’s) RIII‐C SCA with Type IV dual LAD and right‐dominant triple PDA. Unexpected complications can arise from cardiac procedures involving patients with unknown CAAs such as these. This report may serve as a key reference for cardiothoracic surgeons, interventional cardiologists, coronary angiographers, and medical educators when considering simultaneous occurrence of these rare CAAs.

PULMONARY ATRESIA WITH INTACT VENTRICULAR SEPTUM: NOT CLEARED FOR TAKEOFF

TOPIC: Pulmonary Vascular Disease TYPE: Fellow Case Reports INTRODUCTION: In patients with underlying lung disease, pulmonary evaluation is required prior to air travel due to hypoxic conditions in higher altitudes. We present a case of a young man aspiring to become a pilot, found to have a congenital cardiopulmonary defect of pulmonary atresia. CASE PRESENTATION: An 18 year old male with right pulmonary atresia and intact ventricular septum (PA-IVS) presented to the pulmonary clinic seeking medical clearance for flight training school, endorsing fatigue and dyspnea on exertion. Vitals signs and physical examination were benign without cardiac murmurs, peripheral edema, or cyanosis. Chest CT revealed absent right PA (pulmonary artery) with contrast reflux. A subsequent angiogram revealed blood flow from the right internal mammary artery to the right upper PA and from the celiac and inferior diaphragmatic artery to the right lower PA. Left and right cardiac catheterization showed normal pressures in the right atrium, right ventricle, and PA. Mean PA pressure was 14 mmHg, and wedge pressure was 6 mmHg. Left ventricular end diastolic pressure was 6 mmHg, with normal coronary artery and vein anatomy. Oxygen saturations were: SVC 86%, RA 82%, RV 81%, left PA 81%, and femoral artery 96%. Treadmill stress test was inconclusive due to early termination as the patient did not achieve 85% of maximum heart rate. Occupational medicine recommended HAST (high altitude simulation testing) in concordance with FAA regulations. Before HAST was performed, the patient opted out of his dream career of becoming a pilot. DISCUSSION: PA-IVS is a rare congenital heart disease accounting for < 1 % of total heart defects [2]. It is characterized by atresia of the RV outflow tract. The precise cause is unclear, but thought to be related to an insult during embryological development. PA-IVS can be classified into membranous and muscular forms with the former harboring a better long term prognosis. The muscular form is associated with abnormal connections between the RV and coronary artery. In our patient, left heart catheterization did not reveal abnormal coronary anatomy to suggest muscular PA-IVS.HAST is utilized in patients with cardiopulmonary defects to predict physiological response to hypobaric conditions at higher altitudes. The patient is asked to breathe a mixture of gases with an oxygen saturation of 15.1%, and simulates cabin pressures up to 2400 meters. The test is considered abnormal if there is evidence of hypoxemia (pAO2 < 50 mmHg), symptoms, and/or arrhythmias. We believe that our patient would have had an appropriate response to HAST due to a favorable form of PA-IVS and normal cardiopulmonary pressures and saturations. CONCLUSIONS: In adolescents with congenital cardiopulmonary defects a thorough workup including HAST is recommended prior to allowing exposure to a suboptimal environment. REFERENCE #1: Daubeney PE, Sharland GH, Keeton BR, et al. Pulmonary atresia with intact ventricular septum. Circulation 1998 (8(6): 562-566. REFERENCE #2: Ferencz C, Rubin JD, McCarter RJ, Brenner JI, Neill CA, Perry LW, Hepner SI, Downing JW. Congenital heart disease: prevalence at livebirth. The Baltimore-Washington Infant Study. Am J Epidemiol. 1985 Jan;121(1):31-6. DISCLOSURES: No relevant relationships by Moises Cossio, source=Web Response No relevant relationships by Domingo Franco-Palacios, source=Web Response No relevant relationships by Arjun Mahendra, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response

Coronary Artery Vasospasm: A Under-recognized Phenomenon in Orthotopic Heart Transplant

Introduction Cardiac allograft vasculopathy (CAV) is known as the primary cause of death in the first year after orthotopic heart transplant (OHT). Coronary artery spasm (CAS) in OHT is a rare and under-recognized phenomenon in patients undergoing surveillance. The mechanism of coronary vasospasm in OHT remain largely unknown. The presentation can vary from an incidental finding to severe episodes of symptomatic ventricular arrhythmias, high-degree atrioventricular block, syncope, cardiac arrest, or even myocardial infarction in cases of prolonged ischemia. Case Presentation 65 yo female with history of chronic kidney disease, diabetes mellitus type 2, hypertension, hyperlipidemia, and orthotopic heart transplantation with CMV mismatch in 2016 secondary to apical hypertrophic cardiomyopathy. Prior coronary angiography (CA) done at our institution had shown no evidence of vasculopathy. During one of her follow-up visits in the Clinic, she complained of increasing dyspnea on exertion, prompting urgent referral for CA, as per our surveillance protocols. Prior to the procedure, echocardiography was performed which revealed normal graft function and no valvular abnormalities. She underwent CA which showed a proximal significant diffuse luminal narrowing of the right coronary artery (RCA) (Image 1) and normal left coronary artery anatomy (Image 2). We proceed to repeat CA with intracoronary administration of nitroglycerin (ICN) and measurement of fractional flow reserve (FFR) of RCA (Image 3, 4). Angiography revealed near resolution of the RCA lesion, ultimately suggesting that transient vasospasm had been responsible for the previous angiographic appearance (Image 1). Summary CAS can present in patients with or without vasculopathy. It can produce luminal narrowing and can be difficult to distinguish angiographically from CAV. Misdiagnosis of this entity has led to the incorrect diagnosis of CAV and subsequent unnecessary stenting. ICN use can improve angiographic visualization, and prevent the adverse effects of coronary spasm. In conclusion, CAS is a rare and potential complication post OHT. It is a difficult entity to prognosticate due to scarcity of clinical evidence, as prevalence ranges from 4.9% to 12.1%. Some authors hypothesize that CAS in OHT carries a poor prognosis as it is often an early manifestation of CAV. However, this remains largely hypothetical and further studies are needed to better understand this disease.

Non-electrocardiographic-gated computed tomographic angiography can be used to diagnose coronary artery anomalies in Bulldogs with pulmonary valve stenosis.

Coronary artery anomalies have been reported in Bulldogs and present an increased risk when performing balloon valvuloplasty. Identification of coronary anomalies has been reported using multidetector-row computed tomographic (MDCT) angiography with electrocardiographic gating. However, the utility of non-electrocardiographic-gated 16-row computed tomographic for MDCT for the identification of coronary artery anatomy or anomalies to the authors' knowledge has not been fully investigated. The purpose of this study was to evaluate the feasibility of non-electrocardiographic-gated computed tomographic (CT) angiography to identify coronary anomalies in Bulldogs with pulmonary valve stenosis. In this prospective, observational study, Bulldogs with echocardiographically diagnosed pulmonary valve stenosis, an echocardiographically derived transpulmonic pressure gradient >70mmHg, and a clinician recommendation for balloon valvuloplasty were included. Anesthetized dogs underwent a 16-row MDCT non-electrocardiographic-gated CT angiography. A board-certified veterinary radiologist and board-certified veterinary cardiologist reviewed the CT angiography studies and identified the coronary artery anatomy. When normal coronary artery anatomy was detected on CT angiography, a right ventricular outflow tract fluoroscopic angiogram was performed and evaluated during levophase to confirm normal coronary anatomy prior to balloon valvuloplasty. Dogs with coronary anomalies noted on CT angiography were recovered from anesthesia and balloon valvuloplasty was not performed. All dogs (10/10; 100%) had interpretable images from the non-electrocardiographic-gated CT angiography. Coronary anomalies were identified in six dogs based on non-electrocardiographic-gated CT angiography, five with type R2A anomaly and one had a single left coronary ostium. Four dogs had normal coronary anatomy based on non-electrocardiographic-gated CT angiography. Balloon valvuloplasty was performed without incident in these four dogs. We conclude that non-electrocardiographic-gated CT angiography represents a noninvasive method for diagnosing coronary anomalies in Bulldogs with pulmonary valve stenosis.

Continuous ECG monitoring in hospital: part 2, practical issues

Continuous monitoring of the electrocardiogram (ECG) is a common intervention performed by cardiac nurses. In the first article of this two-part series, we evaluated the principal indications for ECG monitoring; these are the detection of arrhythmias, monitoring for myocardial ischaemia, and measurement of the QT interval. In this second article, the practical issues surrounding ECG monitoring are evaluated. The use of 3- and 5-electrode systems is discussed, and related to ECG theory and normal coronary artery anatomy. Recommendations are made for lead selection, correct electrode placement, and the recording of 12-lead ECGs. The current article concludes with a consideration of safe practice with respect to alarm management, and considers both individual and organisational approaches to reducing inappropriate alarms.

A computational atlas of normal coronary artery anatomy.

The aim of this study was to define the shape variations, including diameters and angles, of the major coronary artery bifurcations. Computed tomographic angiograms from 300 adults with a zero calcium score and no stenoses were segmented for centreline and luminal models. A computational atlas was constructed enabling automatic quantification of 3D angles, diameters and lengths of the coronary tree. The diameter (mean±SD) of the left main coronary was 3.5±0.8 mm and the length 10.5±5.3 mm. The left main bifurcation angle (distal angle or angle B) was 89±21° for cases with, and 75±23° for those without an intermediate artery (p<0.001). Analogous measurements of diameter and angle were tabulated for the other major bifurcations (left anterior descending/diagonal, circumflex/obtuse marginal and right coronary crux). Novel 3D angle definitions are proposed and analysed. A computational atlas of normal coronary artery anatomy provides distributions of diameter, lengths and bifurcation angles as well as more complex shape analysis. These data define normal anatomical variation, facilitating stent design, selection and optimal treatment strategy. These population models are necessary for accurate computational flow dynamics, can be 3D printed for bench testing bifurcation stents and deployment strategies, and can aid in the discussion of different approaches to the treatment of coronary bifurcations.

Prominent coronary artery flow with normal coronary artery anatomy is a rare but ominous harbinger of poor outcome in the fetus

Objectives: “Heart sparing” refers to prominent antegrade fetal coronary artery (CA) blood flow readily visualized by color Doppler and is a harbinger of poor outcome in growth restricted fetus, but little is known of the features and presentation of heart sparing in normally grown fetuses. Our objective was to describe heart sparing effects in normally grown fetuses, and compare the presentation and outcome of heart sparing between fetuses with growth restriction and those who were normally grown.Methods: In a series of fetuses with prominent antegrade CA flow, we assessed Doppler flow profiles in the aortic isthmus, ductus venosus (DV), umbilical vein (UV), umbilical artery (UA) and middle cerebral artery (MCA). We calculated MCA and UA systolic/diastolic ratios and the cerebral placental ratio, and measured fetal biometry. We evaluated cardiac function using the myocardial performance index (MPI) and the cardiovascular profile score (CVPS).Results: Ten fetuses with heart sparing had normal DV flow at 24–36.6 (mean 30.9) weeks of gestation. Five had growth restriction (Group 1); 4/5 had normal MPI and CVPS, and one died. Five were normally grown (Group 2); 5/5 had elevated MPI and decreased CVPS, of these 2 died in utero and one died immediately after birth despite urgent delivery. Coronary arteries were normal after birth or autopsy.Conclusions: Heart sparing confers a poor prognosis in fetal growth restriction and in normally grown fetuses with cardiac dysfunction. We suggest CA flow be assessed in all high-risk fetuses.

Angiographic profile of coronary arteries in Keralite population

Abstract Background and aims: The incidence of Coronary Artery Disease (CAD) has reached alanning 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.

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.

Association of prediabetes with diffuse coronary narrowing and small-vessel disease

BackgroundA significant number of patients may not benefit from conventional techniques of myocardial revascularization due to diffuse coronary artery disease (CAD) or small coronary arterial sizes because of smaller arteries causing anastomotic technical difficulties and poor run-off. Diabetic patients have a more severe and diffuse coronary atherosclerosis with smaller coronary arteries limiting the possibility to perform a successful and complete revascularization, but this has not been examined in prediabetics. ObjectiveTo evaluate whether there is an association between prediabetes and the coronary arterial size. MethodsWe prospectively studied 168 consecutive patients with CAD and 172 patients with normal coronary artery anatomy (NCA). Patients were divided into three groups according to hemoglobin (Hb) A1c levels as “normal,” “prediabetic,” and “diabetic” groups, and the coronary artery sizes and Gensini scores were analyzed. ResultsThere were 78 female patients and 90 male patients in the CAD group, and 87 female patients and 85 male patients in the NCA group. There was a statistically significant difference in distal and proximal total coronary arterial size among the CAD and NCA groups for both genders. There was a positive correlation between the HbA1c subgroups and Gensini score (Spearman's ρ: 0.489, p<0.001 in female group; Spearman's ρ: 0.252 p=0.016 in male group). ConclusionWe found that prediabetic patients have a smaller coronary size and diffuse coronary narrowing for both genders, particularly in distal coronary arterial tree of left anterior descending coronary artery. The early detection of prediabetes in daily cardiology practice may provide more appropriate coronary lesion for percutaneous or surgical revascularization.

A Study of Patients With Normal Coronary Angiogram Over A Period of 14 Months in A Military Hospital

Objectives: The objectives were to study the incidence of the normal coronary artery anatomy, to determine their clinical, electrocardiographic, stress testing, echocardiographic and angiographic characteristics. Methods: This is a retrospective study carried out in cardiac center, Combined Military Hospital, Dhaka, Bangladesh on patients seen during the period from November 2010 to Dec 2011. The coronary artery angiography data was collected by a check list and was revised by the authors. Results: Twelve hundred and two fifty patients who had coronary angiography which showed normal coronary artery or minor coronary artery disease were included in this study. 13% were females. The mean age of the patients was 45.6. 74% patients had one or more coronary risk factors and predominant risk factor was hypertension (31%). More than 50% patients had significant cardiac symptoms and about 40% study subjects were found to have prominent ECG changes which preclude noninvasive tests. Only 38% of study subjects underwent exercise ECG tests, among them 12% had positive ETT. Two hundred and forty nine patients (20%) had normal coronary artery anatomy. Right dominant circulation was found in 79% of the patients. Conclusions: The incidence of normal coronary artery anatomy is similar to those reported in other literatures. Although there are limitations of common noninvasive tests to exclude coronary artery disease, proper clinical evaluation and appropriate use of other noninvasive investigations will definitely reduce the burden of coronary angiogram in patients with angina or suspected ischemic heart disease. DOI: http://dx.doi.org/10.3329/uhj.v8i2.16078 University Heart Journal Vol. 8, No. 2, July 2012

PP-291 UNUSUAL CONCEALED ACCESSORY PATHWAY ABLATION: CASE REPORT

Methods: A 63-year-old-woman was admitted to the emergency department with complaints of palpitation, breathlessness and dizziness. At the admission she was conscious and her systolic blood pressure was 80mmhg. At the ECG there was sustained ventricular tachycardia (Figure 1). In the ED, because of hemodynamic impairment, defibrillation with 30 j was performed and sinus rhythm was restored. After 600mg loading dose of amiodorone, intravenous maintenance therapy was continued. At the same hour two non-sustained ventricular tachycardia attacks happened. Her biochemical parameters demonstrated a potasium concentration of 2.8mmol/L, creatinine 0.8mg/dl (0.72–1.25) and sodium 137mmol/L (136–145). Transthoracic echocardiography was performed and ejection fraction was found 60% and other measurements were normal. 60mEq/L potassium replacement was given to the patient and the control potassium was 3.7mmol/L. The patient had been using amlodipine 10mg, indapamide 1.5mg and acetylsalicylic acid 100mg per day for ten years because of hypertension. The patient was complaining from intermittent chest pain so coronary angiography was performed and normal coronary arterial anatomy was observed. It was thought that VT had occurred because of hypokalemia induced by indapamide so indapamide treatment was stopped. The K was 4.5mmol/L after one week follow up. The patient was followed-up in the coronary care unit and was discharged on the eighth day of admission without any VT attacks. Conclusions: Clinicians should keep in mind that the antihypertensive drug indapamine can cause life threatening ventricular tachycardias because of its hypokalemia side effect. Therefore we emphasize that serum potassium and ECG must be carefully monitored during indapamide therapy.

An Unusual Complication During Bronchoscopy: Hypotension, Global ST Segment Elevation, and Acute Severe Left Ventricular Systolic Dysfunction

Bronchoscopy is widely performed and generally considered safe. Cardiac complications during bronchoscopy are uncommon, and usually occur in elderly patients with coexistent coronary artery disease, hypertension, or severely impaired pulmonary function and resting hypoxemia. We report a patient who developed sudden onset restlessness, chest discomfort, hypotension, global ST elevation in multiple electrocardiogram leads, and acute severe left ventricular systolic dysfunction during a bronchoscopic transbronchial lymph node biopsy. Differential diagnosis included a massive myocardial infarction, apical ballooning (Tako-tsubo syndrome), or coronary vasospasm. The electrocardiogram changes resolved spontaneously, and a coronary angiogram 48 hours later revealed normal coronary artery anatomy and normal LV function. The patient made an uneventful recovery. It is important for physicians to be aware of such unusual complications to be able to appropriately manage these patients in clinical practice.

Acute myocardial infarction with normal coronary artery (MINCA) in a patient with multiple sclerosis

Interestingly, some patients with ST elevation myocardial infarction have normal coronary artery anatomy at cooronary angiography. This situation is called as MINCA (acute myocardial infarction with normal coronary artery). The incidence of MINCA varies between 1.0% and 8.5%. Although some reasons have been propounded, the exact underlying mechanism remains unclear. Nevertheless, thoracic myelitis can be as a possible cause of myocardial infarction. Herein, we report a case of acute myocardial infarction with normal coronary artery in a patient with multiple sclerosis.

Variant anatomy of coronary arteries

Introduction: Wide variations exist in the size, position, and shape of various body organs, finger prints, and proteins in different individuals. Some variations are of considerable clinical importance, such as the coronary arteries. Variations of coronary arteries can cause important clinical manifestation, including sudden death of the individual. Materials and Methods: Coronary arteries were dissected in 10% formalin-fixed cadaveric hearts. The normal and variant anatomy of coronary arteries was studied. Result: In 100% of cases, the right coronary artery (RCA) and main left coronary artery (LCA) were found to arise from anterior aortic sinus and left posterior aortic sinus, respectively. In 8% of cases, the conus was found to have independent origin from the anterior aortic sinus. The RCA was found to be dominant in 90% of cases. In 66.7% of cases, the length of RCA ranged from 4.5 cm to 7 cm. The average length of LCA was found to be 7 mm. In 10% of cases, the circumflex coronary artery was found to be dominant, where the length of the artery ranged 9-11 cm. In 10% of cases, LCA trifurcated, where the obtuse marginal branch was replaced by the ramus intermedius branch. Also, 43.3% of LAD showed myocardial bridging predominantly in the middle 1/3 rd segment, and 6.7% of cases of RCA showed myocardial looping. Discussion: Coronary arteries show immense variation in their origin, termination, branching pattern, myocardial bridging, looping, and dominance pattern. This knowledge is clinically and surgically important to manage coronary artery diseases.

Evaluation of anatomy, variation and anomaly of the coronary arteries with coronary computed tomography angiography

Recent technical advances in computed tomography (CT) have improved image quality, diagnostic performance and accuracy of coronary CT angiography (CCTA). Latest dose-reduction strategies reduce radiation dose to an acceptable level even lower than that from conventional coronary angiography. CCTA is a noninvasive imaging modality which can effectively show complex coronary artery anatomy, variations and congenital anomalies of the coronary arteries. Congenital coronary artery anomalies are rare entities, but sometimes have a potential of producing fatal consequences. CCTA is now the primary imaging modality for the evaluation and diagnosis of coronary artery anomalies. Reporters should, therefore, have knowledge of the normal coronary artery anatomy and variations, and understand the different types of coronary artery anomalies and their respective prognostic implications in order to provide correct diagnosis and to prevent undesirable mistakes during interventional and surgical procedures.

Angioplastía de circunfleja en paciente con doble arteria descendente anterior tipo IV. Propuesta para actualizar la clasificación de Spindola-Franco

The normal anatomy of coronary arteries includes a kind of variants with regard to its origin, distribution and route, which makes that 2 patients do not have coronary arteries exactly alike. Left anterior descending artery could have anatomical variations that do not affect the normal supply of blood to the corresponding myocardial territory. In our 25 years of experience, and more than 11,000 coronary angiographies, we have found only one patient with a type IV dual left anterior descending coronary artery. In this article we show the case of a patient with the described coronary anomaly, presenting a severe stenosis of the circumflex artery which was successfully treated percutaneously. Besides, a proposal for updating the classification of Spindola-Franco is made, where the 4 types previously described were kept invariable, and 7 anatomical variants or subtypes were added.