Occlusion Of Right Coronary Artery Research Articles

A case of subacute thyroiditis associated with complete occlusion of right coronary artery

Case presentation: A case is a 72-year-old male, and developed fever, sore throat and immigrating neck pain, without shortness of breath (SOB). He showed pulse 96/min, Temp 38.8C, BP 146/90mmHg, respiration and SpO2 normal. Physicals were slight tenderness in thyroid, and laboratory data revealed free T3/T4 10.7pg/mL/5.4ng/dL. He was diagnosed as subacute thyroiditis. ECG showed incomplete right bundle block branch (RBBB) and Holter ECG showed pulse rate 70-144/min and the average was 95.8/min for 24 hours. HbA1c increased from 6.4% to 7.4% for 6 weeks. For the treatment, prednisolone 20mg/day was started and reduced gradually, and thyroid function was normalized. Consecutively, he developed chest discomfort and oppression with unremarkable ECG changes and chest CT showed only the calcification of coronary arteries. Coronary angiography showed occlusion of the right proximal coronary artery (RCA, #2:100%), left anterior descending (LAD, #6:75%, #7:90%). Coronary angioplasty was operated immediately. By placing a drug-eluting stent, RCA was re-opened successfully. His symptoms disappeared, and clinical course was improved. Discussion: Subacute thyroiditis may bring hyperthyroidism and tachycardia, increased metabolism for circulatory system. Then, subacute thyroiditis would give burden and stress for coronary heart function. It is suggested that hyperthyroidism would aggravate the coronary stenosis. We have to consider such complex pathophysiology for the diseased states in the clinical medical practice.

Diagnostic value of standard electrocardiogram in acute right ventricular myocardial infarction.

Myocardial infarction (MI) (i.e., heart attack) is the irreversible death (necrosis) of heart muscle secondary to prolonged lack of oxygen supply (ischemia) which accounts for a large number of deaths in the hospital. Diagnosis of myocardial infarction is confirmed based on clinical manifestations and electrocardiographic changes along with increased cardiac enzymes. Electrocardiogram (ECG) is one of the safest and easiest methods in the first place. Therefore, this study aimed to investigate the diagnostic value of standard electrocardiogram in the diagnosis of acute right ventricular infarction following lower cardiac infarction. This research was carried out at a time interval of one and a half years to diagnose acute primary infarction. In this method, the diagnostic value of ST↓ in lead I, ST↓ in lead aVL and I ST↓ + aVL, compared with ST↑ in lead V4R was investigated for diagnosis of right ventricular infarction. ST↑ in the lead V4R is a gold standard for the detection of right ventricular MI. All the patients who had the inclusion criteria were allowed to participate in the study. A total of 66 patients participated in the study. Accordingly, 58 (87%) were male and 8 (13%) were female. The mean age of the population was 54.9 ± 11.41. According to the ST↑ standard in lead V4R, 26 patients (39%) had right ventricular myocardial infarction. There was no significant relationship between angina pectoris and premature infarction (P-Value = 0.869). In this study, the right ventricular was most commonly involved in right coronary artery (78%). There was no significant relationship between the occlusion of right coronary artery and right ventricular infarction in 60 patients (P-Value = 0.94). The results showed that electrocardiogram manifestations help determine the occlusion site and the area at risk (ST↓ in lead aVL and aVL + I, sensitivity = 96%). In myocardial infarction, symptoms such as the ST-Segment elevation in lead aVR and ST-Segment depression in the lower leads are possible. Accordingly, in the lower infarction, ST changes in the leads V1-V6 are helpful in detecting patients at risk. Thus, the use of electrocardiogram in acute myocardial infarction helps detect more invasive patients and prevents extensive myocardial damage and other complications.

TCTAP C-145 Rota Burr Incarceration (Entrapment) During Percutaneous Coronary Intervention for a Long, Calcified Chronic Total Occlusion of Right Coronary Artery

### Patient Initials or Identifier Number ABC ### Relevant Clinical History and Physical Exam A 63 years male, hypertensive, diabetic presented with chronic stable angina for 6 months. An echocardiogram was showing good left ventricular systolic function (EF-65%) and no regional wall motion

Application of selective coronary angiography in children with Kawasaki disease complicated with severe coronary artery lesion

Objective: To investigate the application of coronary angiography (CAG) in children with Kawasaki disease complicated with coronary artery lesion (CAL). Methods: A total of 139 patients (115 boys and 24 girls, age (48±42) months) with Kawasaki disease complicated with CAL underwent CAG between June 2006 and June 2018 in Children's Hospital of Fudan University. CAL in all children were at grade Ⅲ and above assessed by echocardiography and underwent CAG under general anesthesia with parental consent. A retrospective analysis was performed to identify the safety and complication of CAG, degree of satisfaction of image, distribution of CAL, and the treatment and follow-up management according to the result of CAG. Results: All the 139 patients underwent CAG, and 17 patients received CAG twice. In these cases, there was a total of 309 CAL with an average of 2.22 CAL per patient. After CAG, children were re-graded as grade Ⅲ in 33 cases, grade Ⅳ in 56 cases, grade Ⅴa in 33 cases and grade Ⅴb in 17 cases according to the clinical severity. Ten patients (7.2%) had only aortic root angiography and 129 (92.8%) patients had selective left or right CAG. Among these, 27 cases (19.4%) showed thrombosis in coronary aneurysm, 23 cases (16.5%) showed coronary artery stenosis, 4 cases (2.9%) showed recanalization after occlusion in right coronary artery. All the patients obtained satisfied images, and no complication was found. Eight of the grade Ⅴb patients underwent coronary artery bypass grafting (CABG). One patient died during the surgery due to severe heart failure, and the other seven patients received CABG successfully and recovered well during a long-term follow up (18 to 108 months). Conclusions: CAG is safe for children with Kawasaki disease with CAL, and the images of CAG are satisfied. Patients who were graded according to CAG and received the corresponding surgical treatment could get satisfied effect in the medium and long-term follow-up.

Electrocardiographic Distinction of Left Circumflexand Right Coronary Artery Occlusion in PatientsWith Inferior Acute Myocardial Infarction

Previously reported electrocardiographic (ECG) criteria to distinguish left circumflex (LCCA) and right coronary artery (RCA) occlusion in patients with acute inferior ST-segment elevation myocardial infarction (STEMI) afford a modest diagnostic accuracy. We aimed to develop a new algorithm overcoming limitations of previous studies. Clinical, ECG, and coronary angiographic data were analyzed in 230 nonselected patients with acute inferior STEMI who underwent primary percutaneous coronary intervention. A decision-tree analysis was used to develop a new ECG algorithm. The diagnostic accuracy of reported ECG criteria was reviewed. LCCA occlusion occurred in 111 cases and RCA in 119. We developed a 3-step algorithm that identified LCCA and RCA occlusion with a sensitivity of 77%, specificity of 86%, accuracy of 82%, and Youden index of 0.63. The area under the ROC curve was 0.85 and resulted 0.82 after a 10-fold cross validation. The key leads for LCCA occlusion were V3 (ST depression in V3/ST elevation in III >1.2) and V6 (ST elevation ≥0.1 mV or greater than III). The key leads for RCA occlusion were I and aVL (ST depression ≥ 0.1 mV). Fifteen of 21 reviewed studies had less than 20 cases of LCCA occlusion, only 48% performed primary percutaneous coronary intervention, and previous infarction or multivessel disease were often excluded. The diagnostic accuracy of reported ECG criteria decreased when applied to our study population. In conclusion, we report a simple and highly discriminative 3-step ECG algorithm to differentiate LCCA and RCA occlusion in an "all comers" population of patients with acute inferior STEMI. The diagnostic key ECG leads were V3 and V6 for LCCA and I and aVL for RCA occlusion.

Atypical location of ST elevation acute myocardial infarction in relation to the electrocardiogram

Introduction. Electrocardiography is an initial non-invasive diagnostic algorithm for ST elevation acute myocardial infarction. Specific electrocardiographic phenomenon is described, when the occlusion of the proximal segment of the right coronary artery or the isolated occlusion of its ventricular branch is presented with ST elevation in the precordial leads. Case Report. A 78-year-old woman was admitted as an emergency due to chest pain and electrocardiographically recorded concave elevation in leads V1 - V3. She was diagnosed with ST elevation myocardial infarction of the anterior region and sent to catheterization laboratory for emergency coronary angiography. It showed an occlusion of the proximal-medial right coronary artery. Behind the occlusion, the right coronary artery, posterior descending artery and posterior lateral artery, a hetero-collateral circulation was seen. Two drug-eluting stents were implanted into the proximal segment of the right coronary artery. Discussion. The phenomenon of acute myocardial infarction caused by occlusion of the proximal right coronary artery and/or ventricular branches of the right coronary artery, presenting with ST segment elevation in the precordial leads, is a consequence of several anatomical variations: occlusion of nondominant right coronary artery, isolated occlusion of the ventricular branch of the right coronary artery, and the occlusion of the right coronary artery proximal to the ventricular branch with hetero collateral circulation on the periphery of the right coronary artery, like in our case. Electrocardiographic characteristic pointing to the occlusion of the proximal right coronary artery and/or ventricular branches of the right coronary artery is higher ST elevation in the lead V1 than in the other leads, followed by the absence of Q wave development. This ST elevation is concave. Conclusion. It is necessary to emphasize the significance of differential diagnosis of culprit lesion in patients with chest pain and elevation of the ST segment in the precordial leads having in mind further different thera peutic algorithms. Patients with right ventricular myo cardial infarction need to maintain an adequate ?preload? and avoid vasodilators in order to maintain the right ventricular stroke volume.

A Complete Occlusion of Right Coronary Artery Due to Stanford Type A Aortic Dissection - Successful Treatment with Extracorporeal Membrane Oxygenation (ECMO)

We present a patient diagnosed Stanford Type A aortic dissection, who was misdiagnosed as acute myocardial infarction for 5 days. In the surgery, the right coronary ostium was totally occluded, and the right coronary artery (RCA) was bluish from the trunk to branches. The true lumen couldn’t be found when we opened the RCA. We had to give up coronary artery bypass grafting (CABG). After a regular surgery of type A aortic dissection, the patient was failed to wean from cardiopulmonary bypass due to the right heart dysfunction. The Extracorporeal membrane oxygenation (ECMO) was instituted. The right ventricular wall motion was gradually improved during the post-operation period. This is the first report of using ECMO to successfully treat a complete occlusion of the right coronary artery due to a Type A aortic dissection. This case demonstrates the value of ECMO in assisting right heart function to ensure stable hemodynamics and myocardial recovery in the type A aortic dissection with coronary involvement.

METHYLENETETRAHYDROFOLATE REDUCTASE POLYMORPHISM AND PREMATURE CORONARY ARTERY DISEASE

SESSION TITLE: Cardiovascular Disease 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Methylenetetrahydrofolate reductase (MTHFR) catalyzes the conversion of 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate, a co-substrate for homocysteine remethylation to methionine. Its deficiency leads to increased homocysteine levels. Elevated serum levels of homocysteine have been associated with premature coronary artery disease (CAD). we present a case of recurrent acute coronary syndrome in patient with heterozygote mutation for methylenetetrahydrofolate reductase (MTHFR) with normal homocysteine level. CASE PRESENTATION: A 23 year-old man with history of MTHFR polymorphism and anterior wall ST segment elevation myocardial infarction requiring drug eluting stent (DES) in the left anterior descending artery (LAD) presented to the emergency department with substernal chest pain, T wave inversions in inferior leads on his ECG and elevated troponin levels. Coronary angiography demonstrated an acute occlusion of the proximal right coronary artery (RCA) and a chronic total occlusion of the proximal LAD with collaterals from the circumflex territory. Aspiration thrombectomy of the RCA lesion was partially successful and required continuous infusion of unfractionated heparin and tirofiban for 48 hours in addition to aspirin and ticagrelor. He underwent a successful deployment of 3 DES to his RCA. His left ventriculogram showed a mildly reduced left ventricular ejection fraction of 45 % with hypokinesis of the basal inferior wall segment. DISCUSSION: Hypercoagulability workup was unrevealing. Homocysteine levels were normal at the time of his first myocardial infarction two years prior. Repeat homocysteine level was 11.7 mg/dl (n <11.2mg/dl). His total cholesterol was 153mg/dl, LDL 80mg/dl, Apo lipoprotein B was 67 (n 52-109mg/dl), Lp(a) <10(n <75nmol/L). He was then discharge on folic acid. He was brought back to the cardiac catheterization laboratory a month later to reassess the LAD lesion but the angiogram showed complete re-occlusion of RCA. The patient was referred for coronary artery bypass surgery. CONCLUSIONS: This case demonstrates the association of MTHFR polymorphism with premature CAD and myocardial infarction despite normal homocysteine levels. Screening for MTHFR polymorphisms in addition to homocysteine levels should be considered for patients presenting with premature CAD and a normal lipid profile. Aggressive risk reduction with lifestyle modification, guideline-driven medical therapy and folic acid might be necessary for secondary cardiovascular disease prevention until more specific therapeutic options are available for this subgroup of patients. Reference #1: Frosst P, Blom HJ, Milos R, et al. A candidate genetic risk factor for vasculardisease: a common mutation in methylenetetrahydrofolate reductase. Nat Genet.1995; 10: 111–113 Reference #3: DISCLOSURES: No relevant relationships by Corina Iorgoveanu, source=Web Response No relevant relationships by Ahmed Zaghloul, source=Web Response

Zakończona powodzeniem przezskórna interwencja wieńcowa z zastosowaniem techniki Szabo w przypadku zmian aortalno-ostialnych z przewlekłym całkowitym zamknięciem prawej tętnicy wieńcowej

Percutaneous coronary intervention (PCI) in aorto-ostial lesions with chronic total occlusion is one of the most challenging scenarios, because geographic miss may lead to a higher rate of immediate and late adverse events when comparing with non-ostial lesions. Here we report a case, where aorto-ostial chronic total occlusion of right coronary artery in a 39-year-old male was successfully recanalised and perfectly stented using the Szabo technique.

TCT-833 Does an Occluded RCA Affect Prognosis in Patients Undergoing PCI or CABG for Left Main Coronary Artery Disease? Analysis From the EXCEL Trial

The impact of an occluded right coronary artery (RCA) in pts with left main coronary artery disease (LMCAD) undergoing revascularization is unknown. We compared outcomes for pts with LMCAD randomized to PCI or CABG according to the presence of an occluded RCA in the EXCEL trial. EXCEL randomized

TCT-597 GLP-1 does not protect against right ventricular stunning or cumulative ischemic dysfunction following right coronary artery balloon occlusion in humans.

GLP-1 protects against left ventricular stunning and cumulative ischemic dysfunction after brief coronary balloon occlusion, which can be measured with a conductance catheter. We sought to establish whether brief occlusion of the proximal right coronary artery (RCA) also caused right ventricular (RV

Anterior ST-segment elevation secondary to right coronary occlusion: The sheep in wolf's clothing

We present a case of an anterior ST-segment elevation acute coronary syndrome secondary to occlusion of a non-dominant right coronary artery. Usually, an anterior ST-segment elevation corresponds to a left anterior descending artery occlusion; however, in rare cases it can be secondary to a non-dominant right coronary artery occlusion. The two causal entities may be adequately differentiated by the detailed analysis of the ECG. The electrocardiographic criteria that allow the proper prediction of the culprit artery in anterior ST-segment elevation acute coronary syndrome are reviewed.

Is right coronary artery chronic total vessel occlusion impacting the surgical revascularization results of patients with multivessel disease? A retrospective study.

IntroductionChronic total occlusion (CTO) is common in the presence of other significantly narrowed coronary arteries. The impact of total occlusion and its association with completeness of revascularization on patients with multivessel disease undergoing coronary artery bypass graft (CABG) remains largely unknown.AimThe aim of our study was to compare CABG operation characteristics, as well as 30-day mortality, incidence of post-operative major adverse cardiac and cerebrovascular events (MACCE) between patients with and without CTO in right coronary artery (RCA).Materials and MethodsA total of 156 consecutive patients were included in the analysis. CTO of RCA or right posterior descending artery (RPD) was diagnosed in 57 patients (CTO-RCA group). Coronary stenosis without CTO in RCA was diagnosed in 99 patients (nonCTO-RCA group). Baseline characteristics were comparable in both groups.ResultsThe majority of patients had class II (49.1% vs. 46%, p = 0.86) or class III (42.1% vs. 43%, p = 1.0) Canadian Cardiovascular Society grading system symptoms. Patients in the CTO-RCA group had in average 2.2 grafts implanted, as opposed to 2.4 grafts in patients in the nonCTO-RCA group (p = 0.003). Graft to the RCA was performed in 40.3% patients in the CTO-RCA group and in 81% patients in the nonCTO-RCA group (p = 0.001). The 30-day mortality from any cause or cardiac cause did not differ between groups (7% vs. 2%, p = 0.14 and 3.5% vs. 2%, p = 0.57 respectively). In a multivariate analysis CTO in RCA or RPD and peripheral artery disease were independent predictors of post-operative MACCE (7.9 (1.434–43.045) p = 0.02; 18.8 (3.451–101.833) p < 0.01, respectively).ConclusionsChronic total occlusion of RCA was found to be associated with smaller number of grafts performed during the CABG procedure. Although mortality between patients in the CTO-RCA and nonCTO-RCA groups did not differ, patients in the CTO-RCA group had higher incidence of post-operative MACCE.

PP-441 - Unseen Part of the Iceberg Before Obesity Surgery: Multivessel Coronary Artery Disease

Case report: 47 years old man evaluated for class II exertional dsypnea before obesity surgery as an outpatient. He had a history of hyperlipidemia and smoking with 30 packs a year. Physical examination revealed obesity (body mass index 36.2 kg/m2, 120 kg, 1.82 cm). Electrocardiography demonstrated sinus rhythm, and left anterior hemiblock. Echocardiography demonstrated normal systolic function, and mild mitral regurgitation. Due to the exertional dyspnea, he underwent myocardial perfusion scintigraphy which is showed myocardial ischemia of inferior and anterior myocardial wall. The coronary angiography showed severe stenosis of proximal left anterior descending and circumflex coronary artery. The retrograd collaterals from left coronary system to right coronary artery and total occlusion and antegrad bridge collaterals at proximal right coronary artery were also demonstrated in left and right coronary angiography. Coronary bypass surgery recommended for the complete revascularization but the patient didn't accept the surgery. First, the opening of the chronic total occlusion of right coronary artery, and then left coronary system were planned. 7F JR4 guiding, and 6F JL4 diagnostic catheters used for dual injection. The conus branch was use to anchor with 1,5 × 15 mm semi-compliant balloon. Gaia-3 guidewire was used to advance proximal cap under back-up with Corsair microcatheter and using drilling technique. By using Gaia 3 guidewire we weren't able to enter from distal cap to true lumen. Therefore, microcatheter changed to Twinpass microcatheter and the Fielder FC was used to enter acute margine branch or distal right coronary artery. Fielder FC was penetrated into the acute margine branch, and distal cap was punctured with the Conquest Pro through the side hole of the Twinpass microcatheter by advancing wire into the distal right coronary artery. By using TRAP technique, Twinpass microcatheter was removed and Corsair microcatheter was advanced into distal right coronary artery to protect coronary perforation by Conquest Pro manipulation. Grand Slam guidewire was advanced through Corsair microcatheter. After removing Corsair microcatheter by TRAP technique, multiple balloon dilatations were performed. 3.0 × 48 mm Xience Pro and 3.0 × 38 mm Cre8 DES were implanted mid-distal right coronary artery while 3.5 × 23 mm Xience Pro was implanted proximally. Multiple post-dilatations were performed with 3.5 × 18 mm non-compliant balloon and TIMI III flow was achieved. The revascularization of left coronary system was planned for two weeks later. Firstful, 4.0 × 26 mm Resolute stent was succesfully implanted to circumflex coronary artery. At the same procedure, 4.0 × 38 mm Resolute stent was succesfully implanted to the left anterior descending coronary artery. Control coronary angiography of the right coronary artery also showed that TIMI III flow with no evidence of thrombosis or stenosis. He discharged with the advice of the lifestyle changes, quit smoking, and weight lost. The obesity surgery was postponed until the 6 months from the procedure for reducing stent thrombosis risk.

VARYING DEGREES OF ADVANCED HEART BLOCKS IN ASSOCIATION WITH ACUTE INFERIOR MYOCARDIAL INFARCTION

Acute inferior myocardial infarction (MI) is often associated with heart blocks as acute occlusion of the right coronary artery (RCA) compromises flow to sinoatrial nodal and atrioventricular nodal branches that arise from the proximal and distal parts of RCA, respectively. This phenomenon can happen in up to 20% of the cases, is usually transient and rarely requires pacemaker implantation. Still, when present, it raises alarms and poses significant monitoring and management challenges to the physicians. We report a similar case where the patient presented with inferior MI complicated by complete heart block. The patient went through varying degrees of advanced heart blocks before finally reverting to normal sinus rhythm. Subsequent coronary angiogram showed total thrombotic occlusion of proximal RCA. To the best of our knowledge, such a case has not been described before in literature where a complete array of heart blocks is reported in the context of acute MI. This case illustrates the importance of recognizing advanced heart blocks in acute MI. Although usually transient, these arrhythmias need careful monitoring during the initial days after MI.

Acute Thrombotic Occlusion of Non-Dominant Right Coronary Artery Presenting as Acute Coronary Syndrome and Hemodynamic Instability

It is generally believed that the occlusion of a non-dominant right coronary artery is not associated with significant consequences. Atherosclerotic disease of non-dominant right coronary in the absence of significant left coronary artery disease is rare, and the prevalence is substantially lower as compared to dominant right coronary artery. We report a case of young male presenting with acute coronary syndrome and hemodynamically significant atrial fibrillation. Coronary angiography showed thrombotic occlusion of non dominant right coronary artery. After the stenting of this artery, patient improved hemodynamically with complte resolution of ECG changes.

Acute Inferior Myocardial Infarction Presenting as Anterior ST Segment Elevation Myocardial Infarction on ECG

A 51-year-old man presented to the emergency department with acute substernal chest pain. ECG showed ST-segment elevation in the left precordial leads. Coronary angiography demonstrated an occlusion of the right coronary artery (RCA) and no significant stenosis in left anterior descending coronary artery (LAD). The occlusion of a non-dominant RCA may result in anterior ST-segment elevation ECG changes, which could disorient both general and interventional cardiologists.

Proximal RCA occlusion producing anterior ST segment elevation, Q waves, and T wave inversion

An ST segment elevation myocardial infarction (STEMI) that produces anterior ST segment elevation (STE) is typically caused by acute occlusion of the left anterior descending (LAD) artery. Anterior STE, however, may also be caused by acute occlusion of either the proximal right coronary artery (RCA) or the right ventricular marginal branch (RVB). It has been thought that, in contrast to occlusions of the LAD, proximal RCA/RVB occlusion rarely causes Q waves in the right precordial leads. We present a case where a proximal RCA occlusion produced not only anterior STE, but also anterior T wave inversions and anterior Q waves.

Paradoxical Embolism Causing Myocardial Infarction

In this case report, we present a case of a likely paradoxical embolism in a young patient with no significant risk factor for coronary artery disease that initially presented with shortness of breath and bilateral calf pain that was found to have a deep vein thrombosis. There was a development of a pulmonary embolism that we believed due to right ventricular strain resulted in an embolus crossing into the arterial system via an intracardiac shunt causing a myocardial infarction via a distal occlusion of the right coronary artery. Patient was treated with full dose anticoagulation and a patent foramen ovale (PFO) closure was recommended. J Med Cases. 2017;8(11):365-367 doi: https://doi.org/10.14740/jmc2933w

TCTAP C-013 A Young CPA Case Of Von Recklinghausen’s Disease Caused by Acute Anterior Myocardial Infarction with Chronic Total Occlusion of Right Coronary Artery and Left Circumflex Artery

TCTAP C-013 A Young CPA Case Of Von Recklinghausen’s Disease Caused by Acute Anterior Myocardial Infarction with Chronic Total Occlusion of Right Coronary Artery and Left Circumflex Artery