Proximal Right Coronary Artery Research Articles

Coronary Artery Bypass Grafting for Refractory Ventricular fibrillation after the Release of the Aortic Cross-Clamp in Patients Undergoing Aortic Valve Replacement: A Case Report

Background: Ventricular fibrillation (VF) is a known complication after the release of the aortic cross-clamp (ACC) during cardiopulmonary bypass (CPB) surgery. Various factors contribute to persistent refractory VF, making its management challenging. This case report describes the successful treatment of postoperative refractory VF by coronary artery bypass grafting (CABG) in a patient undergoing aortic valve replacement (AVR) with ACC release. Case Presentation: A 52-year-old woman with a history of hypertension and ischemic cerebral infarction presented with symptoms of chest tightness, dyspnoea and palpitations. She underwent a modified maze procedure of radiofrequency ablation, mitral repair, left atrial appendage closure and mechanical AVR under a CPB procedure. Following the ACC release, the patient experienced recurrent VF that was unresponsive to standard interventions such as lidocaine, amiodarone and direct current shocks. The suspicion of right coronary artery (RCA) insufficiency led to the decision to perform CABG using the great saphenous vein. After the CABG procedure, the patient's heart rhythm gradually returned to sinus rhythm, and she had an uneventful recovery. Discussion and Conclusions: Refractory VF after the ACC release can pose diagnostic and treatment challenges. In this case, RCA insufficiency was suspected as the cause of refractory VF. The absence of blood flow in the proximal RCA and the presence of distal blood return during cardiac surface exploration supported this suspicion. Coronary artery bypass grafting using the great saphenous vein successfully restored normal sinus rhythm, confirming the diagnosis. This case emphasises the importance of considering coronary artery stenosis or occlusion as a potential cause of refractory VF after the ACC release during CPB, with CABG serving as a viable alternative treatment.

Case report: A case of an anomalous right coronary artery arising from the left coronary cusp.

Abstract
 An anomalous origin of the right coronary artery is usually asymptomatic. It is mostly found incidentally on an invasive diagnostic angiogram. It does lead to an increased risk of sudden cardiac death, especially in younger patients. We present a case of a 41-year-old who had presented to the hospital with complaints of chest pain. The patient was evaluated by cardiology who performed an angiography that identified an anomalous origin of the right coronary artery arising from the left coronary cusp but no evidence of coronary artery disease. Once identified, these anomalous vessels should be corrected surgically, as these conditions increase the risk of sudden cardiac death arrhythmia and ischemic events.
 
 INTRODUCTION
 Anomalous aortic origin of the right coronary artery (AAORCA) is an uncommon congenital malformation with varying clinical presentations ranging from asymptomatic to sudden cardiac death (SCD). Those with symptoms or high-risk lesions are usually managed by unroofing or reimplantation, coronary artery bypass graft (CABG), AAORCA treated with right internal memory artery graft with proximal RCA ligation.
 
 CASE DESCRIPTION
 A 41-year-old female patient with obesity and hypertension presented with a 1-year history of intermittent exertional substernal pressure radiating to left shoulder and back. The pain, which lasted about 10 minutes per episode, had been more frequent and intense over the past week.Upon initial evaluation, she was hypertensive at 150/90 mmHg and heart rate 60 bpm. Blood work was unremarkable, including negative serial troponin levels. Electrocardiography showed sinus bradycardia without ischaemic changes. Anomalous origin of RCA was incidentally discovered from computed tomography (CT) of the chest. Coronary angiography and ascending aortography were then performed, which revealed a patent RCA originating from the left coronary cusp (Fig. 1A). CT heart angiography with reconstruction revealed the RCA ostium in the left coronary cusp with a malignant course between the aorta and pulmonary artery and without an obvious intramural segment
 Discussion:
 
 An anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly that was first described in 1948 by White and Edwards. After carrying out angiography in 126,595 patients, Yamanaka and Hobbs reported the incidence of anomalous origin of the right and left coronary arteries as 136 (0.107%) and 22 (0.017%), respectively. The prevalence of an anomalous origin of RCA (ARCA) arising from the left coronary cusp with an inter-arterial course varies between 0.026% and 0.25%. An ARCA is more common than the anomalous origin of the left coronary artery (ALCA), but the latter is shown to be responsible for up to 85% of sudden cardiac deaths (SCD) related to the anomalous origins of arteries. Most coronary anomalies are detected incidentally on diagnostic angiography and are clinically insignificant; some, however, have been associated with an increased risk of SCD. It is second only to hypertrophic cardiomyopathy as a leading cause of SCD in young athletes. Mechanical compression of the RCA by the great vessels, which dilate and compress the RCA during periods of increased stroke volume, is the usual explanation for coronary ischemia. Patients usually have no ischemic changes on an electrocardiogram (ECG) at rest; however, multi-detector computed tomography (MDCT) is being used to evaluate the course of anomalous vessels outlying their relative positions to the aorta and the pulmonary artery. It also gives additional information regarding any stenotic lesion in these anomalous vessels. Echocardiography (Echo), magnetic resonance angiography (MRA), MCDT, and cardiac catheterization are all complementary diagnostic tools for evaluating anomalous coronary arteries [10]. While it is agreed that surgical correction is the standard of care for ALCA, when found, the management for right ARCA is more complicated. Treatment options for these patients include observation with medical therapy, percutaneous intervention (stenting), or surgery. Early diagnosis of coronary artery anomalies based on the patients’ symptoms can help decrease the incidence of sudden cardiac deaths, fatal arrhythmias, and ischemic events in the high-risk population.
 
 Conclusions 
 
 Coronary anomalies should be suspected in symptomatic young patients with a normal cardiac workup. Non-invasive imaging modalities such as a CTCA can help establish the diagnosis

Correlation Between Magnitude of ST Segment Elevation and the Proximal Right Coronary Artery Lesion in Acute Inferior Myocardial Infarction

Introduction: The determination of the probable site of occlusion within RCA in acute inferior MI is very important because proximal occlusions are likely to cause greater myocardial damage and an early invasive strategy may be planned in such cases. Furthermore, identification of infarct-related artery and its site in acute inferior myocardial infarction not only guide decision regarding the urgency of revascularization but also guide to avoid therapy that may adversely affect the outcome. Objective: To predict the site of lesion in right coronary artery in acute inferior myocardial infarction by the magnitude of ST segment elevation in inferior leads (II, III and aVF). Methodology: This cross-sectional study was conducted in the Department of Cardiology, Sylhet MAG Osmani Medical College Hospital, from January 2014 to December 2015. A total of 50 consecutive patients with inferior MI who present within 12 hours of symptom onset and received fibrinolytic therapy were selected according to inclusion and exclusion criteria. Using 12-lead ECG, height of ST segment elevation in leads II, III and aVF were measured & coronary angiography(CAG) was performed during index hospital period .CAG which showed culprit lesion in RCA were only taken for the study. The sum of STsegment elevation in inferior leads were then correlated with the proximal lesion in RCA. Results: The age of the patients ranged from 31 to 70 years with the mean age of 51.1 (SD 9.2) years. Majorities (88%) of the patients were male and ratio of male to female was 7.33:1.Out of 50 patients, 26(52%) had the lesion in proximal, 19 (38%) in mid and 05 (10%) in distal RCA. Patients with proximal RCA lesion showed a mean ST segment elevation of 12.5(SD 1.07) mm, with mid RCA lesion 8.5 (SD 0.80) mm and distal RCA lesion 6.5(SD 0.42) mm. There was a positive correlation of sum of ST segment elevation in inferior leads II, III and aVF to the proximal lesion in RCA (r=0.923, P < 0.05). Conclusion: From the study it is concluded that the magnitude of ST segment elevation in inferior leads (II,III, aVF) can predict site of lesion in RCA in acute inferior wall myocardial infarction; the greater the sum of the height of ST segment elevation in inferior leads, the higher is the probability of lying the lesion in proximal right coronary artery. Bangladesh Heart Journal 2024; 39(1): 44-48

Quantitative analysis of right coronary artery morphology by digital subtraction angiography

The right coronary artery (RCA) is a major target for interventional and surgical procedures, but its anatomical variations and normal reference values are not well established. This study aimed to establish the normal distribution values of the length, diameter and angle measurements of the RCA. Angiography images of the RCA of 143 patients were analyzed using digital subtraction angiography techniques. The RCA images of each patient were divided into three sections (Proximal RCA, Middle RCA, Distal RCA) and length and diameter measurements were made separately for each section. In addition, the angles formed between the posterior descending artery (PD) and posterior lateral artery (PL) of the RCA and the lengths and diameters of the PD and PL branches were measured separately. The RCA length-diameter measurements were 1.75-4.7 mm for proximal RCA, 4.75-4.2 mm for middle RCA, and 7.45-3.5 mm for distal RCA. The mean values of the angles formed between RCA-PL, PL-PD (bifurcation angle), and RCA-PD were 144.33±19.22˚, 62.67±18.94˚, 151.40±19.33˚, respectively. Our study provides important epidemiological data on the length-diameter-angle values of the RCA. The presented data will be useful in guiding the success and clinical outcomes of the RCA in both interventional and surgical procedures.

TAPSE, Tissue Doppler Systolic annular velocity(S’) and myocardial performance Index (MPI) as a predictor of proximal RCA occlusion in acute inferior wall myocardial ST elevation infarction

TAPSE, Tissue Doppler Systolic annular velocity(S’) and myocardial performance Index (MPI) as a predictor of proximal RCA occlusion in acute inferior wall myocardial ST elevation infarction

Abstract 14974: Spontaneous Coronary Dissection: A Challenging Case of Young Weightlifter

A 26-year-old weightlifter with no significant past medical history presented with chest pain while performing his routine exercise. ECG showed anterior ST elevation myocardial infarction with subsequent angiography revealing 99% occlusion in the proximal LAD with extensive thrombus burden along with a 100% occluded distal RCA with left to right collaterals present, indicating an RCA subacute/chronic lesion (see image). An intra-aortic balloon pump was inserted, and the patient was transferred to UC Davis Medical Center. Repeat angiography revealed thrombus and dissection in the proximal LAD and RCA, stabilized with heparin drip and Gp2b3a inhibitor. Transthoracic echocardiogram showed a severely reduced ejection fraction of 15%. After heart team discussion, the patient was deemed high risk for surgery, so he underwent percutaneous coronary intervention with balloon angioplasty and deployment of drug eluting stents to the LAD and RCA with resulting TIMI-3 flow. He was initiated on guideline directed medical therapy and discharged home with LifeVest. Unfortunately, he presented with ventricular tachycardia (VT) after LifeVest shock on the following day. Repeat angiogram did not show any in-stent restenosis or thrombus. Implantable cardioverter-defibrillator (ICD) was implanted, and the patient was started on amiodarone. The patient continued to have recurrent VT. Lidocaine was added and MRI was done, which showed a large scar burden. Left ventricular assist device Impella 5.5 was placed, and the patient eventually underwent successful cardiac transplant. This case report highlights weightlifting causing spontaneous coronary dissection. It is rare but has devastating complications with limited options for acute management. Revascularization options have limited success in a patient with such an extensive scar burden and a severely reduced ejection fraction.

Assessment of the Dimensions of Coronary Arteries for the Manifestation of Coronary Artery Disease.

The size of the coronary artery influences the effective outcome of therapeutic measures like coronary artery bypass graft (CABG) surgery, percutaneous coronary interventions (PCI), and diagnosis of coronary artery disease. Patients' age, gender, BMI, anatomical variations, and increased left ventricular size all have an effect on coronary artery parameters. This study aims to compare the average size of the coronary arteries of the Pakistani population in both sexes for manifestation of coronary artery disease. For the analysis of the coronary arteries, 100 patients of both sexes, male and female, were taken. X-ray angiography was performed for two-dimensional images of coronary arteries. For diameter measurement, images were visualized on quantitative coronary angiography (QCA) in different views (caudal and cranial views). The diameters of the left main coronary artery (left main stem/LMS), left anterior descending (LAD), left circumflex (LCx), and right coronary artery (RCA) were measured on angiograms. Data about the dimensions of the coronary artery was gathered through quantitative angiography. Data analysis was done throughSPSS version 26 (IBM Corp., Armonk, NY). There is a notable distinction in the average diameters among the proximal LAD (3.12), mid-LAD (2.40), and distal LAD (1.29). A statistically significant difference is evident among mid-LCx, distal LCx, and proximal LCx (p-value < 0.001). Likewise, the average diameter of the distal RCA (1.89) was smaller when compared to the mid-RCA (3.19) and proximal RCA (3.78). However, there was no significant difference in the average diameter among mid-LMS, distal LMS, and proximal LMS (p-value = 0.09). The average diameter of distal RCA was smaller when compared to mid-RCA and proximal RCA. The average size of proximal LAD and proximal LCx was comparatively larger than mid- and distal LAD and LCx. The findings of current research will be beneficial for the diagnosis and management of coronary artery disease patients.

Echocardiographic and Angiographic Assessment of Right Ventricular Function and Right Coronary Artery Stenosis in Acute Inferior Wall Myocardial Infarction.

Cardiovascular diseases (CVDs) are a global concern. CVD remains a primary cause of death despite reduced coronary heart disease death rates. Acute coronary syndrome (ACS) involves myocardial infarction (MI) and unstable angina, sharing mechanisms such as plaque instability. Our study assesses the right ventricular (RV) function's predictive value in acute inferior wall MI (IWMI) to identify high-risk patients with an elevated likelihood of experiencing severe cardiac complications, hemodynamic instability, or a higher mortality risk following an acute IWMI. The research was conductedin the Department of Cardiology at theRajendra Institute of Medical Sciences (RIMS), Ranchi, from July 2021 to June 2022, following the necessary ethical approval. A cohort of 140 patients with IWMI, carefully chosen according to rigorous criteria, clearly understood the study's objectives before providing informed consent. The evaluations were conducted in the following order: clinical assessments, followed by blood testing, then echocardiography, and finally, coronary angiography. Furthermore, the study examined risk factors and utilized statistical methods to elucidate the associations between qualities and results. The study included 140 participants, with 61% being male and 39% female. Among the participants, 14% were aged 30-45, 50% were aged 46-60, and 30% were over 60. Age shows significant proportions in different categories. Diabetes, dyslipidemia, hypertension, and smoking/tobacco addiction did not differ among stenosis groups. Proximal right coronary artery (RCA) stenosis patients had elevated jugular venous pressure (JVP). The echocardiograms were performed within 48 hours of post-percutaneous coronary intervention, and significant differences between groups were observed. Participants with proximal stenosis had lower tricuspid annular plane systolic excursion (TAPSE) and right ventricular fractional area change (RVFAC), which showedcompromised RV systolic function. Proximal stenosis patients had reduced systolic motion velocity (Sm), indicating impaired myocardial contraction. Echocardiographic parameters such as early diastolic velocity (Em), atrial contraction velocity (Am), Em/Am ratio (a marker of diastolic function), isovolumic relaxation time (IVRT), isovolumic contraction time (IVCT), and ejection time (ET) between groups were different, indicating distinct cardiac functions. Proximal stenosis increased the myocardial performance index (MPI), indicating cardiac impairment. The left ventricular ejection fraction (LVEF) was comparable in the two stenosis groups, indicating similar left ventricular performance. Echocardiography showed significant RV function differences in acute inferior wall ST-segment elevation myocardial infarction (STEMI) patients with proximal and distal RCA lesions. RV dysfunction is linked to right ventricle myocardial infarction (RVMI), and echocardiographic markers can provide valuable insights. Results emphasizethat acute inferior wall STEMI is diagnosed by electrocardiogram (ECG) criteria, particularly ST-segment elevation. However, these markers emphasize the importance of RV assessment in RCA involvement assessment. These findings suggest that RV function can help diagnose acute inferior wall STEMI RCA involvement. In acute inferior STEMIs, RV function echocardiography is essential for RCA lesion location.

Assessment of Clinical Profile and Echocardiographic Parameters of Right Ventricle in Correlation with Proximal RCA Lesion in Patients with Inferior Wall Myocardial Infarction

Assessment of Clinical Profile and Echocardiographic Parameters of Right Ventricle in Correlation with Proximal RCA Lesion in Patients with Inferior Wall Myocardial Infarction

Isolated Right Ventricular Infarction without Right Ventricular Dysfunction: A Case Report

BACKGROUND: Myocardial infarction is the leading cause of the occlusion of the coronary artery. Meanwhile, right ventricular myocardial infarction (RVMI) is usually associated with inferior left ventricular infarction in 10–50% of cases. We presented isolated RV infarcts which are rare cases that happen in only 3% of total myocardial infarction. CASE PRESENTATION: We presented a case of a 67-year-old man with sudden chest pain, shortness of breath, and a history of diabetes mellitus. From his 12 lead electrocardiogram, there is no specific ST elevation yet elevation in V3R and V4R and elevated troponin I highly sensitive value. The patient developed junctional bradycardia and early percutaneous coronary intervention backup temporary pacemaker showed total occlusion in the proximal right coronary artery (RCA) CONCLUSION: The RVMI commonly occurs in the dominant RCA that also supplies the sinoatrial node and atrioventricular node. Therefore, due to its location that passed through the RCA, bradycardia to complete heart block may happen. Isolated right ventricular (RV) infarction may happen because either RV marginal as the predominant location is occluded, or non-dominant RCA occluded by thrombus. RV infarction may impair RV contractility causing a decrease in RV stroke volume and this condition leads to hypotension, shock, and severe hemodynamic derangement. Meanwhile, acute proximal RCA occlusions do not result in significant RV necrosis, one of the reasons is collateral flow from the left coronary system further protects from RV dysfunctions in our patient.

A case report: anteroseptal ST elevation due to acute isolated right ventricular infarction

BackgroundElectrocardiogram (ECG) is the first diagnostic tool physicians use in diagnosing acute myocardial infarction (MI). In this case report, we present a case where the initial ECG diagnosis was that of an acute anteroseptal MI but emergency coronary angiography showed that the infarct-related artery was a small non-dominant right coronary artery (RCA) instead of the anticipated left anterior descending artery (LAD). Isolated right ventricular (RV) infarction from a non-dominant RCA is rarely seen in clinical practice, and it may exhibit ECG changes that can be confused with an acute anteroseptal MI. It is important to appreciate the subtle differences in the ECG changes that occur in either of these two types of MI for appropriate diagnosis and treatment.Case presentationA 49-year-old non-smoking male with prior coronary stent implantation in LAD presented with acute chest pain and his pre-hospital ECG indicated an anteroseptal STEMI possibly due to stent thrombosis, but an emergency angiogram showed patent LAD and Circumflex arteries. There was however thrombotic occlusion of the right, non-dominant coronary artery, which was revascularized with a drug-eluting stent. The patient’s chest pain and ST elevations resolved, and subsequent echo showed moderate RV systolic dysfunction in keeping with RV myocardial infarction.DiscussionRV myocardial infarction is usually due to an occlusion of the dominant RCA proximal to the origin of its RV wall branch, which often results in inferior ST elevation with reciprocal anterior ST depression. The ST elevation over V1 which would accompany RV infarction is often masked due to the more dominant electrical forces of inferior and posterior LV wall infarction. Our case demonstrates that in isolated RV infarction due to non-dominant proximal RCA occlusion, anterior ST elevation can be seen over V1-3, being most prominent in V1, which overlies the right ventricle, and resolved after restoring flow to the RCA. Spatial vector analysis of the ECG or right-sided ECG leads would be helpful to aid the diagnosis of RV infarction when clinical suspicion is present, for example when there is significant hypotension, raised jugular venous pressure but clear lung fields or deterioration after nitrate administration.

Early Management of Shock Condition in STEMI Patient

Background: Acute myocardial infarction is one of the emerging cardiovascular events worldwide. Infarcts of the inferior wall were present between one-third and half of the patients with RV involvement. The worse outcome was strongly associated with cardiogenic shock, and 7% of cases were caused by RV failure. Objective: This study aimed to describe the diagnosis and management of cardiogenic shock in STEMI Case presentation: A male in his 40s was brought to our hospital 12 hours after the onset of persistent epigastric pain. He had a history of hypertension and a family history of diabetes Mellitus. Diagnostic procedures included blood tests, ECG, X-rays, coronary angiogram, and echocardiography. He underwent PCI to implant DES in his proximal RCA, which had 100% occlusion. The patient was admitted to the intensive cardiovascular care unit for 30 hours and died due to various complications. Conclusion: Current case was very complicated and seriously life-threatening. After acute myocardial infarction, Important problems kept coming up one after the other, and they all affected each other. Patients with cardiogenic shock must be found quickly and treated quickly and aggressively.

Characterization of plaque phenotypes exhibiting an elevated pericoronary adipose tissue attenuation: insights from the REASSURE-NIRS registry.

Inflammation has been considered to promote atheroma instability. Coronary computed tomography angiography (CCTA) visualizes pericoronary adipose tissue (PCAT) attenuation, which reflects coronary artery inflammation. While PCAT attenuation has been reported to predict future coronary events, plaque phenotypes exhibiting high PCAT attenuation remains to be fully elucidated. The current study aims to characterize coronary atheroma with a greater vascular inflammation. We retrospectively analyzed culprit lesions in 69 CAD patients receiving PCI from the REASSURE-NIRS registry (NCT04864171). Culprit lesions were evaluated by both CCTA and near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS) imaging prior to PCI. PCAT attenuation at proximal RCA (PCATRCA) and NIRS/IVUS-derived plaque measures were compared in patients with PCATRCA attenuation ≥ and < -78.3 HU (median). Lesions with PCATRCA attenuation ≥ -78.3 HU exhibited a greater frequency of maxLCBI4mm ≥ 400 (66% vs. 26%, p < 0.01), plaque burden ≥ 70% (94% vs. 74%, p = 0.02) and spotty calcification (49% vs. 6%, p < 0.01). Whereas positive remodeling (63% vs. 41%, p = 0.07) did not differ between two groups. On multivariable analysis, maxLCBI4mm ≥ 400 (OR = 4.07; 95%CI 1.12-14.74, p = 0.03), plaque burden ≥ 70% (OR = 7.87; 95%CI 1.01-61.26, p = 0.04), and spotty calcification (OR = 14.33; 95%CI 2.37-86.73, p < 0.01) independently predicted high PCATRCA attenuation. Of note, while the presence of only one plaque feature did not necessarily elevate PCATRCA attenuation (p = 0.22), lesions harboring two or more features were significantly associated with higher PCATRCA attenuation. More vulnerable plaque phenotypes were observed in patients with high PCATRCA attenuation. Our findings suggest PCATRCA attenuation as the presence of profound disease substrate, which potentially benefits from anti-inflammatory agents.

Characteristics of conventional high-risk coronary plaques and a novel CT defined thin-cap fibroatheroma in patients undergoing CCTA with stable chest pain

BackgroundCoronary computed tomography angiography (CCTA) can identify high-risk coronary plaque types. However, the inter-observer variability for high-risk plaque features, including low attenuation plaque (LAP), positive remodelling (PR), and the Napkin-Ring sign (NRS), may reduce their utility, especially amongst less experienced readers. MethodologyIn a prospective study, we compared the prevalence, location and inter-observer variability of both conventional CT-defined high-risk plaques with a novel index based on quantifying the ratio of necrotic core to fibrous plaque using individualised X-ray attenuation cut-offs (the CT-defined thin-cap fibroatheroma - CT-TCFA) in 100 patients followed-up for 7 years. ResultsIn total, 346 plaques were identified in all patients. Seventy-two (21%) of all plaques were classified by conventional CT parameters as high-risk (either NRS or PR and LAP combined), and 43 (12%) of plaques were considered high-risk using the novel CT-TCFA definition of (Necrotic Core/fibrous plaque ratio of >0.9). The majority (80%) of the high-risk plaques (LAP&PR, NRS and CT-TCFA) were located in the proximal and mid-LAD and RCA. The kappa co-efficient of inter-observer variability (k) for NRS was 0.4 and for PR and LAP combined 0.4. While the kappa co-efficient of inter-observer variability (k) for the new CT-TCFA definition was 0.7. During follow-up, patients with either conventional high-risk plaques or CT-TCFAs were significantly more likely to have MACE (Major adverse cardiovascular events) compared to patients without coronary plaques (p value 0.03 & 0.03, respectively). ConclusionThe novel CT-TCFA is associated with MACE and has improved inter-observer variability compared with current CT-defined high-risk plaques.

P303 ECMO–PROTECTED HIGH RISK PCI IN UNUSUAL CLINICAL AND ANATOMICAL SCENARIO

Abstract Background Non–emergent complex high–risk indicated procedure (CHIP) identify complex PCI according with clinical, anatomical and procedural features and prevent intraprocedural hemodynamic compromise represents a major issue. The aortic valve bypass (AVB) has been an uncommon surgical option performed by creating a heterotopic second left ventricular output bypassing native stenotic aortic valve with flow redistribution between the native left ventricular outflow tract and the apical–aortic bypass. AVB was phased out in “TAVI–era”. Case Report A 78 years–old obese and hypertensive male, with pulmonary fibrosis and previous AVB for severe aortic stenosis judged at unacceptable high surgical risk 10 years before, was admitted to the emergency department for chest pain and palpitation. Patient was in Killip class I. ECG showed rapid atrial fibrillation without ST–segment elevation. Atrial tachyarrhythmia, chest pain and palpitation spontaneously simultaneously resolved. A type 2 NSTEMI–ACS was suspected according to clinical features and pathological Hs–troponin. Multimodality imaging documented normal systolic function, normally operating AVB, paradoxical low flow severe native aortic valve stenosis, a chronic type B aortic dissection from distal anastomosis of AVB retrogradely extended to left subclavian artery origin and a wide aneurysm of the abdominal aorta (Fig. 1). Coronary angiography documented severely calcific multivessel disease. Prompt and complete revascularization was considered mandatory and a surgical redo was discarded. The use of an intraprocedural hemodynamic support was advisable, but anatomical context represented substantial contraindication to IABP and Impella. Heart Team decided to perform VA–ECMO–protected–PCI. After lesion preparation double kissing crush was performed on LMCA and single stents were implanted in proximal LAD and proximal RCA (Fig. 2). Despite signs of transient hemodynamic instability the patient tolerated the procedure thanks to the ECMO support. Complete myocardial revascularization was obtained without complications and the subsequent clinical course was uneventful. Discussion In this CHIP patient, hemodynamic support was vital to allow a safe complete myocardial revascularization. ECMO is a demanding system, not routinely used for “protected PCI”; however, the case here reported underlines that ECMO can be a feasible option, prerequisite in uncommon cases where other standard tMCS are contraindicated.

Treatment of Ostial Right Coronary Artery Narrowings: Outcomes From the Multicenter Prospective e-ULTIMASTER Registry

BackgroundTreatment of right coronary artery (RCA) aorto-ostial (AO) lesions with bare-metal stents and first-generation drug-eluting stents (DESs) was associated with worse outcomes. This study aimed to assess the effect of RCA-AO stenting with current-generation DESs on the clinical outcome.MethodsThe large all-comer, multicontinental e-ULTIMASTER registry included 37,198 patients of whom 4775 underwent ostial and proximal RCA percutaneous coronary intervention (PCI) using the Ultimaster stent (Terumo). The primary clinical end point was 1-year target lesion failure (TLF), a composite of cardiac death; target vessel–related myocardial infarction; or clinically indicated target lesion revascularization.ResultsWe compared 591 (12.4%) patients who underwent RCA-AO PCI with 4184 (87.6%) patients who underwent proximal RCA PCI. The RCA-AO group included more men and recorded significantly more comorbidities and more complex coronary anatomy. After propensity matching, the primary end point TLF occurred in 4.49% of the RCA-AO group compared with 3.00% of the proximal RCA group (P = .06). Target vessel revascularization (3.29% vs 1.90%; P = .03) and stent thrombosis (1.23% vs. 0.42%, P = .01) were significantly higher among patients with RCA-AO lesions than those among patients with proximal RCA lesions. All-cause mortality was similar between the groups (2.97% vs 2.26%; P = .30).ConclusionsThe treatment of RCA-AO with DESs is feasible, with similar rates of TLF but with an increased risk of target vessel revascularization and stent thrombosis.

A novel coronary artery healing pattern suggesting the axial progression of coronary plaques.

A 54-year-old man, current smoker, without previous cardiovascular history was admitted for an inferior transient ST-segment elevation myocardial infarction. An emergent coronary angiogram revealed an unstable, non-obstructive, thrombus-rich plaque in the mid segment of the right coronary artery (RCA) (Panel A). Optical coherence tomography (OCT) imaging disclosed a healthy vessel wall in the proximal RCA, along with a long, heterogenous plaque at the culprit lesion, where three distinct phenotypes were clearly recognized (Panels a-d, circle denotes wire artifact). First, the very proximal segment of the plaque showed a layered morphology with multiple high and low signal-rich strata, suggestive of an old healing process (Panels a and b, arrowheads). In the middle part of the plaque, a superficial, laden, organized circumferential thrombus was observed, probably reflecting an early healing stage (Panel c, asterisks). Finally, the most distal part of the lesion showed a plaque rupture with a large, ‘red’ fibrin-rich, fresh protruding thrombus (Panel d, star). Percutaneous coronary intervention with a new-generation stent obtained excellent results.

Absent Right Coronary Artery in an Active Young Female

Absent Right Coronary Artery in an Active Young Female

Peri-Coronary Adipose Tissue Is a Predictor of Stent Failure in Patients Undergoing Percutaneous Coronary Intervention

PurposeCoronary inflammation is postulated as a driver of atherosclerosis and dysfunctional arterial healing which may trigger stent failure. Pericoronary adipose tissue (PCAT) attenuation, detected on computer tomography coronary angiography (CTCA), is an emerging non-invasive marker of coronary inflammation. This propensity matched study assessed the utility of both lesion specific (PCATLesion) and standardized PCAT attenuation as assessed in the proximal RCA (PCATRCA) as a predictor of stent failure in patients undergoing elective percutaneous coronary intervention. This is the first study to our knowledge that assesses the association of PCAT with stent failure. MethodsPatients undergoing CTCA assessment for coronary artery disease with subsequent stent insertion within 60 days and repeat coronary angiography for any clinical reason within 5 years were included in the study. Stent failure was defined as binary restenosis of >50 % on quantitative coronary angiography analysis or stent thrombosis. Both PCATLesion and PCATRCA was assessed utilizing semi-automated proprietary software on baseline CTCA. Patients with stent failure were propensity matched utilizing age, sex, cardiovascular risk factors and procedural characteristics. ResultsOne hundred and fifty-one patients met inclusion criteria. Of these, 26 (17.2 %) had study-defined failure. A significant difference in PCATLesion attenuation between patients with and without failure was observed (−79.0 ± 12.6 vs. −85.9 ± 10.3HU, p = 0.035). There was no significant difference in PCATRCA attenuation between the two groups (−79.5 ± 10.1 vs −81.0 ± 12.3HU, p = 0.50). Univariate regression analysis showed PCATLesion attenuation was independently associated with stent failure (OR 1.06, 95 % CI 1.01–1.12, P = 0.035). ConclusionsPatients with stent failure exhibit significantly increased PCATLesion attenuation at baseline. These data suggest that baseline plaque inflammation may be an important driver for coronary stent failure.

Correlation of Sum of ST Segment Depression in Leads V1 to V4 in Acute Inferior Myocardial Infarction with Angiographic Severity of Coronary Artery Disease

Background: Inferior wall acute myocardial infarction accounts for 40 to 50% of all acute STEMI. Patients of acute inferior myocardial infarction with ST depression in lateral leads often have greater incidence of triple vessel disease and proximal RCA lesion but in case of patients of acute inferior myocardial infarction with ST depression in precordial leads (leads V1 to V4), is a subject of determination whether it is associated with more sever coronary artery disease. The aim of this study is to determine the association of sum of ST depression in precordial leads with the probability of concomitant severity of coronary artery disease in patients with acute inferior STEMI. Methods: this cross sectional observational study was done at National institute of cardiovascular diseases (NICVD), Dhaka, Bangladesh. Total 90 patients of acute inferior myocardial infarction with precordial lead ST depression admitted at CCU within 12 hours of onset of chest pain were the study population. They were divided in two groups on the basis of sum of ST depression in precordial leads (Sum of ST depression d”4mm and &gt;4mm), 36 patients in group I and 54 patients in group II. Coronary angiography was performed during the index hospitalization period. Gensini score and Reardon score were measured. Results: Overwhelming majority of the patients was male (83.3% and 90.7%) with mean age of 51.0±9.7 and 51.0±9.9 years in group I and II respectively. Smoking, hypertension and diabetes mellitus were the most frequent risk factors in both groups. Serum troponin level was significantly high in group II (6.2±2.2 vs. 13.6±17.7, p &lt;0.05). Sum of ST depression in precordial leads was 2.84±0.66 and 7.53±3.51 in group I and group II respectively, and was statistically significant. Consideration of mean of ST depression in individual leads shows significantly higher mean in leads V2, V3 and V4 among group II patients. SVD was more frequent in group I but group II patients had higher statistically significant incidence of DVD and TVD. Gensini score (20.26±13.0 vs. 36.98±16.9) and Reardon score (4.63±2.2 vs. 6.83±2.2) was high in group II patients. Positive correlation had been depicted between summation value of ST segment depression with that of Gensini score &amp; Reardon score (Gensini score r=0.61 and Reardon score r= 0.52). Conclusion: Involvement Triple vessel and double vessel disease was remarkably higher with increasing sum of ST segment depression in precordial leads. The severity of ST segment depression in terms of summation of ST depression in leads V1 to V4 is directly proportional to the extent and severity of coronary artery disease. Bangladesh Heart Journal 2022; 37(2): 116-121