Dominant Right Coronary Artery Research Articles

SEPTAL COLLATERAL PERFORATION COMPLICATED BY INTRAVENTRICULAR SEPTAL HEMATOMA: RESOLUTION BY COIL EMBOLIZATION

Abstract A 76–year–old man with effort angina was admitted to our cardiology department for an elective coronary angiography (CA). Diagnostic CA revealed severely calcified three–vessel coronary artery disease (CAD) with chronic total occlusions (CTO) of the right dominant coronary artery (RCA) and left circumflex artery (LCX), and severe calcific stenosis of the left descending artery (LAD). An urgent percutaneous coronary intervention (PCI) to treat the LAD was carried out because of ECG modifications and chest pain immediately after CA. During the procedure a septal collateral perforation occurred leading to abrupt development of a large intraventricular septal hematoma (IVSH). Urgent embolization of the culprit vessel with coils was performed using block and deliver (BAD) technique. Rapid hematoma expansion involved another proximal septal collateral. A prompt second coil embolization was carried out arresting the growth of the septal hematoma. The patient was discharged in stable condition and complete resolution of IVSH was confirmed by transthoracic echocardiogram two months later. Timely management of the septal perforation and close echocardiographic monitoring resulted in complete hematoma resolution and a satisfactory outcome.

A SURVIVAL STORY OF 47 YEARS OLD MALE WITH ACUTE TOTAL OCCLUSION OF LEFT MAIN AND COEXISTING OSTIAL RIGHT CORONARY ARTERY LESION

Left main coronary artery (LMCA) thrombus occlusion causing acute coronary syndrome is an uncommon event and associated with severe life-threatening presentations. The clinical outcome depends on the age of the patients, presence of cardiogenic shock and the presence of dominant Right Coronary Artery (RCA) Early reperfusion is associated with improved outcomes. A 47-years man presented with sudden substernal burning sensation and dry cough for 1 hour. Coronary angiography revealed an acute totally occlusion of ostial left main (LM) with TIMI flow grade 0 and dominant RCA with ostial 80% stenosis having TIMI flow grade 3 and Grade 1 contralateral collaterals from RCA to left system. Emergency percutaneous coronary intervention (PCI) was performed to ostial LMCA toward the proximal LAD to cover the whole LMCA and stage PCI was performed to ostial RCA. Patient was discharge on 7th day with good general condition. An electrocardiographic pattern is associated with collateral filling territories in unprotected left main (ULM) occlusion. In our case diagnosis was completely made after diagnostic coronary angiogram. Acute total occlusion of LMCA is associated with arrhythmias, cardiogenic shock and sudden death. However, Patient was hemodynamically stable that showed indubitably the importance of dominant RCA with TIMI 3 flow and Grade 1 contralateral collaterals to left coronary circulation. We perform successful primary PCI of acute total occluded LMCA which shortened the ischemic time to salvage the ischemic myocardium.

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.

Impact of right coronary artery dominance on the long-term mortality in the patients with acute total/subtotal occlusion of unprotected left main coronary artery

BackgroundPatients with a right dominant coronary artery anatomy account for a significant proportion of acute myocardial infarction cases, and this condition is associated with a better prognosis. However, there are limited data on the impact of coronary dominance on patients with acute total/subtotal occlusion of unprotected left main coronary artery (ULMCA). MethodsThis study aimed to assess the impact of right coronary artery (RCA) dominance on long-term mortality in patients with acute total/subtotal occlusion of the ULMCA. From a multicenter registry, 132 cases of consecutive patients who had undergone emergent percutaneous coronary intervention (PCI) due to acute total/subtotal occlusion of the ULMCA were reviewed. ResultsPatients were classified into two groups according to the size of their RCA (dominant RCA group, n = 29; non-dominant RCA group, n = 103). Long-term outcomes were examined according to the presence of dominant RCA. Cardiopulmonary arrest (CPA) occurred in 52.3 % of patients before revascularization. All-cause death was significantly lower in the dominant RCA group than in the non-dominant RCA group. In the Cox regression model, dominant RCA was an independent predictor of all-cause death, as well as total occlusion of ULMCA, collateral from RCA, chronic kidney disease, and CPA. Patients were further analyzed according to the degree of stenosis of the ULMCA; patients with non-dominant RCA and total occlusive ULMCA had the worst outcome compared with the other groups. ConclusionsA dominant RCA might improve long-term mortality in patients with acute total/subtotal occlusion of the ULMCA who were treated with PCI.

222 INFARCT-LIKE MYOCARDITIS IN A PATIENT WITH CORONARY ARTERY DISEASE PRESENTING WITH CHEST PAIN: LOOKING BEYOND THE SIMPLEST DIAGNOSIS

Abstract Background A significant proportion of patients with acute myocarditis (AM) presents with chest pain as their first symptom, with ST-segment elevation, regional myocardial dysfunction and cardiac enzyme release (“infarct-like” pattern). Case description A 68-year-old patient, already known for coronary artery disease (CAD) who underwent a percutaneous coronary intervention (PCI) with drug eluting stent (DES) implantation of distal left anterior descending artery (LAD) six months before, presented with chest pain at rest. An ECG showed ST elevation in the infero-postero-lateral leads with specular ST-depression in aVL; hsTnI was 5900 ng/L (UNL < 51 ng/L). A coronary angiography excluded acute thrombosis, and showed a normal right coronary artery (RCA), significant (70%) stenosis of proximal LAD and left circumflex artery, both treated with PCI + DES. A transthoracic echocardiogram (TTE) showed hypokinesia of the middle portions of the inferior, posterolateral and inferior interventricular septum (SIV) walls. According to a research protocol ongoing in our hospital in post-myocardial infarction patients, a cardiac magnetic resonance (CMR) was performed 48 hours later, showing signs of acute non-ischemic myocardial damage (myocardial edema involving the whole infero-septal wall, late gadolinium enhancement with subepicardial – non-coronary - distribution at apical and antero-apical septum). A final diagnosis of infarct-like AM was established. No complications occurred during the hospital stay and hsTnI progressively decreased (at discharge 37 ng/L). A 6-month follow-up CMR showed normal biventricular function and kinesis, and absence of alterations in tissue characterization sequences. Conclusion This case highlights how even patients with a known CAD can present with AM mimicking myocardial infarction. Multimodality evaluation, including CMR, can help make the right diagnosis to avoid unnecessary therapies or procedures (i.e. PCI), especially in case of discrepancy between different clinical findings, (i.e. ST-elevation in the inferior leads with a dominant unscathed RCA, non-occlusive stenosis at angiography, echocardiography wall motion abnormalities in RCA territory).

Abstract 13039: A Rare Case of Anomalous Aortic Origin of Right Coronary Artery From Left Coronary Cusp Presenting With Recurrent Atypical Chest Pain

Background: The incidence of anomalous aortic origin of the right coronary artery (AAORCA) is between 0.026% and 0.25%. There is limited data regarding medical versus surgical management. We present a case of AAORCA which did not “qualify” for surgical intervention but remained symptomatic on medical management. Presentation: A 58-year-old female with paroxysmal atrial fibrillation presented for the eighth time in the past two years with recurrent atypical chest pain and lightheadedness. Vital signs and cardiac biomarkers were normal. Work-up: EKG showed normal sinus rhythm. TTE revealed EF 68%. Myocardial perfusion imaging was normal but exercise stress test showed ventricular ectopy, ventricular bigeminy, short bursts of ventricular tachycardia (VT) at peak exercise, and a 7-beat run of VT. A 30-day event monitor revealed a 17-beat run of VT at a rate of 173 bpm (Figure A). Management: Cardiac catheterization showed the dominant right coronary artery (RCA) arising from the left coronary cusp with a shared ostium to the left coronary system (Figure B-D). A coronary CT scan confirmed dominant RCA arising from left coronary cusp (Figure E) with an interarterial course (Figure F) and slit-like appearance of the proximal RCA, with a likely intramural course (Figure G).She was managed conservatively with restriction of vigorous exercise, up-titration of beta-blockers, addition of anti-anginal agents and implantation of loop recorder. Conclusion: The most updated consensus statement for AAORCA recommends surgical intervention for those with signs or symptoms of myocardial ischemia (true angina, findings on provocative testing, aborted sudden cardiac arrest or non-vagally-mediated arrhythmia).Although our patient did not “qualify” for surgical intervention, she continued to experience refractory symptoms. Hence, it is of utmost importance to consider surgical intervention in patients who have failed medical management, for improved quality of life.

Abstract P1017: Tissue Engineered Human Acellular Blood Vessels For Coronary Artery Bypass Grafting

Objective: Conduit for coronary artery bypass grafting (CABG) can be limited due to poor quality or prior removal of saphenous veins. A human acellular vessel (HAV) bioengineered from vascular cells and then decellularized for implantation may provide a readily available, off-the-shelf conduit for CABG. Here we evaluate the use of small diameter HAV for CABG in a non-human primate model. Methods: Adult male baboons (n=7; 26.8 - 37.0 kg) were imaged by left heart catheterization and computed tomography angiography. CABG was performed using a 3.5 mm diameter HAV to the left anterior descending (LAD) or right coronary artery (RCA) via sternotomy with cardiopulmonary bypass. The proximal coronary artery was ligated to prevent competitive flow and graft transit time flowmetry (TTFM) was assessed after implant. Angiography at 2 weeks, 1, 3, and 6 months evaluated graft patency and heart function. HAVs explanted at 6 months were assessed by immunohistochemistry for host cellular response and remodeling. Results and Conclusion: Baboons underwent CABG using a 3.5 mm HAV from the ascending aorta to the LAD (n=2) or RCA (n=5). The diminutive LAD led to early graft loss due to size mismatch and poor runoff. HAV bypass to the dominant RCA (TTFM: 22 ± 7.7 mL/min) resulted in sustained graft patency for up to 6 months post-implantation. HAV explant histology revealed infiltration of multiple host cell populations with formation of a neoadventitial layer and evidence of luminal endothelization. HAV conduits retained structural integrity with no evidence of mechanical failure throughout the study. These results demonstrate that tissue-engineered HAVs may provide an off-the-shelf conduit for CABG.

Phasic flow patterns of right versus left coronary arteries in patients undergoing clinical physiological assessment.

Coronary blood flow in humans is known to be predominantly diastolic. Small studies in animals and humans suggest that this is less pronounced or even reversed in the right coronary artery (RCA). This study aimed to characterise the phasic patterns of coronary flow in the left versus right coronary arteries of patients undergoing invasive physiological assessment. We analysed data from the Iberian-Dutch-English Collaborators (IDEAL) study. A total of 482 simultaneous pressure and flow measurements from 301 patients were included in our analysis. On average, coronary flow was higher in diastole both at rest and during hyperaemia in both the RCA and LCA (mean diastolic-to-systolic velocity ratio [DSVR] was, respectively, 1.85±0.70, 1.76±0.58, 1.53±0.34 and 1.58±0.43 for LCArest, LCAhyp, RCArest and RCAhyp, p<0.001 for between-vessel comparisons). Although the type of RCA dominance affected the DSVR magnitude (RCAdom=1.55±0.35, RCAco-dom=1.40±0.27, RCAnon-dom=1.35; standard deviation not reported as n=3), systolic flow was very rarely predominant (DSVR was greater than or equal to 1.00 in 472/482 cases [97.9%] overall), with equal prevalence in the LCA. Stenosis severity or microvascular dysfunction had a negligible impact on DSVR in both the RCA and LCA (DSVR x hyperaemic stenosis resistance R2 =0.018, p=0.03 and DSVR x coronary flow reserve R2 <0.001, p=0.98). In patients with coronary artery disease undergoing physiological assessment, diastolic flow predominance is seen in both left and right coronary arteries. Clinical interpretation of coronary physiological data should therefore not differ between the left and the right coronary systems.

272 Combined rotational atherectomy and intravascular lithotripsy for heavy calcified coronary artery

Abstract Aims Percutaneous coronary intervention (PCI) of heavily calcified coronary lesions still represents a challenge for interventional cardiologists, with higher risk of immediate complications, late failure due to stent underexpansion or malapposition and consequent poor clinical outcome. Rotational atherectomy (RA) is a well-known calcium debulking modality. However, when coronary plaques present a significant amount of circumferential deep calcium, RA alone may not be able to achieve adequate lesion preparation. The combined use of intravascular lithotripsy (IVL) and RA, a technique called ‘Rotatripsy’, can be an effective approach in order to enable optimal stent implantation. We present a case of a calcific right coronary artery (RCA) PCI successfully treated by ‘Rotatripsy’ technique. Methods and results A 78-years-old man presented to our emergency department complaining of acute chest pain and dyspnoea. The electrocardiogram revealed ST-segment elevation in aVR and a diffuse ST-segment depression. Transthoracic echocardiography showed left ventricular anterior, septal, and apical walls akinesia. An urgent coronary angiography showed a critical distal left main (LM) stenosis involving the left anterior descending (LAD) artery ostium and a heavy calcified dominant RCA with two tandem sub-occlusive stenosis in the mid segment (Figure 1A). An immediate PCI with two drug eluting stents (DES) in the LM and LAD was performed. The patient was scheduled two days later for RCA PCI. RCA was engaged via left radial approach with a 6-Fr AL1 guiding catheter and the lesions were crossed with a Sion Blue wire. Using a Finecross MG microcatheter, an extra-support Rotawire was placed distally in the RCA. However, after multiple rotablation with 1.5 mm burr (Figure 1B), the mid segment lesion (Figure 1C) was still undilatable with a 3.5 mm non-compliant balloon (NCB) at 22 atm showing a partial dog bone effect (Figure 1D). We decided to attempt adjunctive IVL for calcium debulking. Using a Finecross MG and the trapping technique, a Gran Slam wire was placed distally; a 4.0 mm IVL balloon was delivered at the undilatable lesion and 80 pulses were applied (Figure 1E). Once the IVL treatment was completed (Figure 1F), a 4.0 mm NCB was inflated to 20 atm to further dilate the segment with an optimal expansion (Figure 1G). Finally, a DES Synergy 4.0 × 48 mm was implanted (Figure 1H) and it was post-dilated with a 4.5 mm NCB inflated to 22 atm (Figure 1I) with a perfect angiographic result (Figure 1J). Conclusions Coronary calcifications can lead to stent underexpansion, which is related to a higher rate of future complications, such as restenosis or thrombosis. If conventional lesion dilatations are not effective, alternative techniques should be considered (cutting balloon, scoring balloon, RA, orbital atherectomy, IVL). In case of circumferential deep calcium plaques, RA may not be able to achieve an adequate lesion preparation. RA allows the treatment of intimal calcium and permits to cross balloons or stents through severe lesions. However, when adequate expansion of the balloons is not achieved after RA, Shockwave IVL, that is not usually able to cross critical stenosis due to its bulky profile, represents an optimal complementary device, in order to fracture deep calcium and facilitate stent delivery and optimal expansion. In this case, we have successfully used the hybrid approach called ‘Rotatripsy’, which combines RA and IVL, in order to avoid more aggressive RA, which would have required the use of 7-Fr guiding catheter setting and may have increased the risk of complications.

The impact of right coronary artery support on outcomes of patients with unprotected left main disease undergoing percutaneous coronary intervention.

Many operators are discouraged from performing left main (LM) percutaneous coronary interventions (PCI) in the absence of right coronary artery (RCA) support due to the increased procedure risk. We aimed at assessing the impact of absent functional RCA on prognostic implications in patients undergoing unprotected LM PCI. 613 patients underwent LM PCI in our department between 2015 and 2019. Consecutive 385 patients with unprotected LM and at least 1-year follow-up were included in the study. The study population comprosed 272 patients with unprotected left main coronary artery disease (ULMCAD) with dominant RCA, without any significant lesions (Group 1), and 113 ULMCAD patients and without RCA support (Group 2). In Group 2, 32.7% patients had a significant RCA stenosis, 48.7% had chronic total occlusion (CTO) of RCA, and 18.6% had recessive RCA. Patients in Group 2 were older and had higher prevalence of chronic obstructive pulmonary disease (COPD). SYNTAX Score (median [IQR] 26.0 [20.0-33.0] vs 19.0 [13.0-25.5]; P <0.001) was higher and left ventricular ejection fraction was lower (median [IQR] 50.0 [40.0-60.0]% vs 55.0 [45.0-60.0]%; P = 0.01) in this group. All periprocedural complications did not differ among the groups. Long-term all-cause mortality at a median follow-up of 1149 days did not differ significantly (23% vs 20%; P = 0.37). The long-term mortality in CTO-RCA group was also not significantly different. Patients with ULMCAD who have undergone LM PCI in the absence of RCA support, compared with those with ULMCAD and RCA support, differed neither in the prevalence of periprocedural complications nor in long-term all-cause mortality.

Comparing the clinical and prognostic impact of proximal versus nonproximal lesions in dominant right coronary artery ST-elevation myocardial infarction.

To evaluate the prognostic significance of culprit lesion location in dominant right coronary artery (RCA) ST-elevation myocardial infarction (STEMI). In RCA STEMI, proximal culprit lesions have been shown to have higher rates of acute complications such as bradycardia and cardiogenic shock (CS) but data on mortality is limited. We retrospectively identified and analyzed data from consecutive patients with a dominant RCA STEMI who underwent either primary or rescue percutaneous coronary intervention (PCI) between January 2003 and December 2016. We compared the rates of sustained ventricular tachycardia (VT), CS, intra-aortic balloon pump (IABP), temporary cardiac pacing (TCP) and death between culprit lesions located proximal and distal to the origin of the last right ventricular (RV) marginal artery >1 mm in diameter. The 939 patients were included; 599 (63.7%) had a proximal lesion and 340 (36.3%) had a nonproximal lesion. The 801 (85.3%) underwent primary PCI and 138 (14.7%) underwent rescue PCI. There was no difference in first medical contact to balloon or fibrinolysis times between the groups; p = .98 and .71. There was no significant difference in the rate of sustained VT (3.0%vs. 3.2%, p = .85) but proximal lesions were more likely to develop CS (10.9%vs. 5.8%, p = .01), require IABP (7.3%vs.2.9%, p < .01) and TCP (6.3%vs. 2.6%, p = .01). Thirty-day mortality was higher for proximal lesions (5.0%vs. 0.9%, p < .01) particularly for those with CS (35.3%vs. 10.0%, p = .05). Culprit lesions located proximal to the origin of the last RV marginal artery had a higher rate of acute complications such as CS and mortality.

P243 A rare association of isolated persistent left superior vena cava(PLSVC) with anomalous right coronary artery (RCA) in a symptomatic patient. Role of saline contrast echo (SCE) with multimodal imaging

Abstract Funding Acknowledgements Nil Introduction PLSVC with absent right superior vena cava (RSVC) is an extremely rare venous anomaly. Most of the patients with this anomaly have other associated cardiac anomalies. However, presence of an anomalous RCA has not been one of these anomalies. Case report A 36-year-old Asian healthy female with no significant medical history presented with over 3 years symptoms of chest heaviness and shortness of breath on walking two blocks. Examination was unremarkable. 2D echocardiogram revealed a 36mm dilated coronary sinus (CS), grade II tricuspid regurgitation (TR) with estimated right ventricular systolic pressure (RVSP) of 40 mmhg. Normal right and left side of the heart. SCE using 50:50 agitated saline and Gelofusine injected intravenously through the left arm showed opacification of the dilated CS first before opacifying the right atrium (RA). Right arm injection depicted the same pattern of contrast opacification which denotes presence of PLSVC with congenital absence of RSVC. No detected intracardiac shunts by SCE. No partial anomalous pulmonary venous connection (PAPVC). However, findings did not justify patient’s symptoms. Seven days loop recorder ruled out any arrhythmias that might be associated with isolated PLSVC. An exercise stress ECG was equivocal with chest discomfort but no ECG changes. We opted for CT coronary angiography (CTCA) to rule out obstructive coronary artery disease (CAD). CTCA confirmed our diagnosis of isolated PLSVC with absence of RSVC with huge CS. In addition, there was an anomalous origin of RCA from sinotubular junction above the commissure between left and right aortic CS and not from LM CS proper, taking a malignant interarterial course of a slit origin RCA with first part of it showing intramural course within the aortic wall. In view of symptoms we as a heart team explained the present risk of sudden cardiac death and possible indication for corrective surgery. A month later patient again presented with chest discomfort. We decided to do Coronary angiography to delineate actual size and dominance of RCA. RCA was a non-dominant small 1.75 mm vessel. There was a left anterior descending artery myocardial bridge. We started a beta blocker (BB) for the patient after which her symptoms improved. Patient followed up for two years later with no symptoms. We attributed her chest pain to the myocardial bridge since she improved on BB. We found there was no solid role for surgery in view of a very small non dominant RCA with no further chest pain. Conclusions Isolated PLSVC is a very rare condition. It is usually asymptomatic. But since our patient had symptoms, a search for another diagnosis was convenient. A dilated CS should always alert us to search for PLSVC. SCE is a simple, inexpensive and reproducible diagnostic tool that might help in solving a challenging diagnosis. Multimodal imaging has a leading role in both proper diagnosis and in management of this condition Abstract P243 Figure. Anomls. RCA - PLSVC to CS -Contrast echo

The Importance of the Type of Heart Circulation for the Prognosis of Pulmonary Embolism

To study the distribution of the type of heart circulation (left- dominant, right- dominant, and mixed (balanced) in patients with pulmonary thromboembolism of fatal and non-fatal outcome. More than 36,000 case histories, protocols and findings of post-mortem examinations of patients hospitalized in 2003-2012 were subjected to analysis. (ten year period). Statistical processing of the actual material was carried out using the SAS 9 and SPSS 21 software packages. The critical level of significance p for all used procedures of statistical analysis was assumed to be 0.05. Results of the study. The study included 893 cases of pulmonary embolism registered in the data of the case histories and materials of the pathoanatomical studies. Data on the type of heart circulation and a detailed description of the coronary artery atherosclerosis were present in 264 cases: in 171 patients with pulmonary embolism and fatal outcome, and in 93 patients with pulmonary embolism and non-fatal outcome. A clear predominance was found in the group with pulmonary embolism and non-fatal outcome of patients with the right type of heart circulation - 78.5% versus 7% in the group of people who died with pulmonary embolism (p&lt;0.0001). Accordingly, persons with "non-right type of heart circulation" (left and balanced) predominantly prevailed among patients with pulmonary embolism and fatal outcome. At the same time, the dead with the right type of heart circulation in all cases had a stenosis of the right coronary artery (RCA) more than 60%. RCA dominance in the heart circulation with absence its significant stenosis creates more favorable hemodynamic conditions for survival in patients with pulmonary embolism. Owners of other types of organization of coronary blood flow ("non-right type of heart circulation") have a worse prognosis both in the absence of coronary atherosclerosis and, moreover, in its presence, especially in the case of significant atherosclerotic lesion of the RCA pool. At the same time, in patients with the right type of heart circulation and hemodynamically significant atherosclerosis RCA in conditions of pulmonary embolism the prognosis is also unfavorable. In view of the above, in patients with coronary atherosclerosis, timely restoration of blood flow in RCA (coronary artery stenting) is great importance in relation to the prognosis associated not only with coronary heart disease, but also with PE.

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 patients with left main coronary artery disease (LMCAD) undergoing revascularisation is unknown. We compared outcomes for patients with LMCAD randomised to percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) according to the presence of an occluded RCA in the EXCEL trial. The EXCEL trial randomised 1,905 patients with LMCAD and SYNTAX scores ≤32 to PCI with everolimus-eluting stents versus CABG. Patients were categorised according to whether they had an occluded RCA at baseline, and their outcomes were examined using multivariable Cox proportional hazards regression. The primary endpoint was a composite of death, stroke, or myocardial infarction at three years. Among 1,753 patients with a dominant RCA by core laboratory analysis, the RCA was occluded in 130 (7.4%) at baseline. PCI was attempted in 34 of 65 patients with an occluded RCA (52.3%) and was successful in 27 (79.4% of those attempted; 41.5% of all RCAs recanalised). The RCA was bypassed in 42 of 65 patients with an occluded RCA (64.6%; p=0.0008 versus PCI). The three-year absolute and relative rates of the primary endpoint were similar between PCI and CABG, in patients with or without an occluded RCA (pinteraction=0.92). In the EXCEL trial, the presence of an occluded RCA at baseline did not confer a worse three-year prognosis in patients undergoing revascularisation for LMCAD and did not affect the relative outcomes of PCI versus CABG in this high-risk patient cohort.

A Rare Case of Left Main Coronary Artery Atresia

Left main coronary artery (LMCA) atresia remains one of the most rare congenital coronary anomalies. On average, there is less than one reported case each year. Because patients with LMCA atresia that make it to adulthood tend to remain asymptomatic and often are unaware of their condition, the diagnosis is often made incidentally. We report a case of LMCA atresia in a 76-year-old male with a history of seizure disorder and medication non-compliance who presented to the hospital with acute coronary syndrome in the setting of status epilepticus. Workup revealed ST elevation and minimally elevated troponin levels. Hours later, troponin levels continued to trend up, but the ST elevation resolved. Catheterization and coronary angiography revealed a dominant right coronary artery and absent LMCA. Aortography confirmed the diagnosis of LMCA atresia. J Med Cases. 2017;8(12):381-382 doi: https://doi.org/10.14740/jmc2946w

Effects of a 3D segmental prosthetic system for tricuspid valve annulus remodelling on the right coronary artery: a human cadaveric coronary angiography study.

A prosthetic system to repair secondary tricuspid valve regurgitation was developed. The conceptual engineering of the current device is based on 3D segmental remodelling of the tricuspid valve annulus in lieu of reductive annuloplasty. This study was designed to investigate the operational safety of the current prosthetic system with regard to the anatomical integrity of the right coronary artery (RCA) in fresh cadaveric human hearts. During the study period, from January to April 2016, the current prosthetic system was implanted on the tricuspid valve annulus in fresh cadaveric human hearts that met the study's inclusion criteria. The prepared specimens were investigated via selective coronary angiography of the RCA in the catheterization laboratory. The RCA angiographic anatomies were categorized as normal, distorted, kinked or occluded. Sixteen specimens underwent implantation of the current prosthetic system. The mean age of the cadaveric human hearts was 43.24 ± 15.79 years, with vehicle accident being the primary cause of death (59%). A dominant RCA was noticed in 62.5% of the specimens. None of the specimens displayed any injury, distortion, kinking or occlusion in the RCA due to the implantation of the prostheses. In light of the results of the present study, undertaken on fresh cadaveric human heart specimens, the current segmental prosthetic system for 3D remodelling of the tricuspid valve annulus seems to be safe vis-à-vis the anatomical integrity of the RCA. Further in vivo studies are needed to investigate the functional features of the current prosthetic system with a view to addressing the complex pathophysiology of secondary tricuspid valve regurgitation.

A Giant Coronary Artery Aneurysm Treated With a New-Generation Drug-Eluting Stent

A 40-year-old man presented to our facility with progressive angina 1 month after an unsuccessful attempt at right coronary artery (RCA) revascularization following a non–ST-segment elevation myocardial infarction. Coronary angiography revealed a dominant RCA with a very large aneurysm in the mid-

Significance of inferior wall ischemia in non-dominant right coronary artery anatomy.

AIMTo investigate the relationship of inferior wall ischemia on myocardial perfusion imaging in patients with non-dominant right coronary artery anatomy.METHODSThis was a retrospective observational analysis of consecutive patients who presented to the emergency department with primary complaint of chest pain. Only patients who underwent single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) were included. Patients who showed a reversible defect on SPECT MPI and had coronary angiography during the same hospitalization was analyzed. Patients with prior history of coronary artery disease (CAD) including history of percutaneous coronary intervention and coronary artery bypass graft surgerys were excluded. True positive and false positive results were identified on the basis of hemodynamically significant CAD on coronary angiography, in the same territory as identified on SPECT MPI. Coronary artery dominance was determined on coronary angiography. Patients were divided into group 1 and group 2. Group 1 included patients with non-dominant right coronary artery (RCA) (left dominant and codominant). Group 2 included patients with dominant RCA anatomy. Demographics, baseline characteristics and positive predictive value (PPV) were analyzed for the two groups.RESULTSThe mean age of the study cohort was 57.6 years. Sixty-one point seven percent of the patients were males. The prevalence of self-reported diabetes mellitus, hypertension and dyslipidemia was 36%, 71.9% and 53.9% respectively. A comparison of baseline characteristics between the two groups showed that patients with a non-dominant RCA were more likely to be men. For inferior wall ischemia on SPECT MPI, patients in study group 2 had a significantly higher PPV, 32/42 (76.1%), compared to patients in group 1, in which only 3 out of the 29 patients (10.3%) had true positive results (P value < 0.001 Z test). The difference remained statistically significant even when only patients with left dominant coronary system (without co-dominant) were compared to patients with right dominant system (32/40, 76.1% in right dominant group, 3/19, 15.8% in left dominant group, P value < 0.001 Z test). There was no significant difference in mean hospital stay, re-hospitalization, and in-hospital mortality between the two groups.CONCLUSIONThe positive predictive value of SPECT MPI for inferior wall ischemia is affected by coronary artery dominance. More studies are needed to explain this phenomenon.

Spontaneous Vanishing of Coronary Collaterals During Cardiac Catheterization for Acute Myocardial Infarction

A patient with acute ST segment elevation inferior myocardial infarction underwent urgent cardiac catheterization. Left coronary arteriography demonstrated minor coronary disease with well-defined collateral filling of the dominant right coronary artery. Shortly thereafter, right coronary arteriography demonstrated entirely normal findings, and a repeat left coronary angiogram no longer demonstrated coronary collaterals. The “vanishing” coronary collaterals are consistent with acute myocardial infarction from transient occlusion of the right coronary artery. These findings are consistent with the phenomenon of myocardial infarction in the presence of angiographically normal coronary arteries. The transient coronary occlusion in this patient is likely secondary to spontaneous lysis of intracoronary thrombus or transient coronary vasospasm. J Med Cases. 2016;7(12):527-530 doi: https://doi.org/10.14740/jmc2667w