Segment Of Right Coronary Artery Research Articles

P1003New onset atrial fibrillation after stenting of the right coronary artery in patients with ischemic disease of the heart

Abstract Background Atrial fibrillation (AF) is a major heart rhythm disorder among population older age. Percutaneous coronary intervention (PCI) with stenting of the right coronary artery may increase the new onset AF. Aim of the study was to estimate the new onset AF after stenting of the right coronary artery (RCA) in patients with stable ischemic disease of the heart and its effect on short-term prognosis. Methods 765 patients in whom performed PCI with stenting of the proximal and medial segment of RCA were enrolled in this study (aged 41-71 years; mean age 55.8 ± 12.0 years; male 51%). Short-term outcomes were analyzed in median 1.1-year follow-up due to the development of new onset AF. Results Among 765 patients, after PCI in RCA developed AF in 58 patients (7.5%) within follow-up. Among them, 40 patients (5.2%) with type 2 diabetes mellitus, 37 patients (4.8%) hypertension, 34 patients (4.4%) older than 60 years old, 30 patients (3.9%) myocardial infarction in history. Restoration of sinus rhythm (cardioversion rate) was in 86%. Majority of the patients in whom sinus rhythm was not recovered were older (11.0%) and diabetic mellitus (8.0%). The propensity-matched model showed that new onset AF was associated with an increased risk of bleeding during the procedure (OR 1.4; 95% confidence interval, 1.27-1.74) and heart failure (OR 1.27; 95% confidential interval, 1.16-1.45). Conclusion: New onset AF is common within short-term period after PCI in proximal and distal segments of the RCA and it was independently associated with post procedural complications and heart failure.

Feasibility of Non-contrast-enhanced Coronary Magnetic Resonance Angiography at 3.0T

Objective To evaluate the feasibility of non-contrast-enhanced magnetic resonance angiography (NCE-MRA) on a 3.0T scanner. Methods Totally 36 volunteers and 24 patients with clinically suspected coronary artery disease underwent NCE-MRA. The quality of the NCE-MRA images was graded for each segment on a four-point scale. The subjects were divided into two groups according to image quality. The age,body mass index (BMI),heart rate,end-expiratory diaphragm displacement,and respiratory diaphragm motion amplitude were evaluated and compared. Results The average image quality score of every segment was above 2 points. The proximal and middle segments of left anterior descending artery had significantly higher quality scores than the distal segments (P=0.000) and the proximal segment of left circumflex coronary artery had significantly higher quality scores than the distal segments (P=0.000),the proximal segment of right coronary artery also had a significant higher quality score than its distal segment (P=0.001). The image quality was good in 38 subjects (64.4%). The heart rate [(66.35±9.39) beat/min vs. (75.32±11.67) beat/min] (P=0.002) and the body mass index [(24.72±3.33) kg/m 2 vs. (27.82±3.61) kg/m 2] (P=0.002) were significantly different between the good image quality group and the poor image quality group. The end-expiratory diaphragm displacement in good image quality group was (4.43±2.07)mm,which was significantly lower than that in poor image quality group [(9.26±7.62)mm](P=0.013). The respiratory diaphragm motion amplitude [(21.35±6.02) mm] in good image quality group was significantly lower than that in poor image quality group [(30.68±14.20)mm](P=0.012). Conclusion NCE-MRA on 3.0T is a feasible tool for visualization of the proximal and middle segments of coronary arteries,and the image quality can be optimized by controlling heart rate and respiration in the future.

Woven-like change following intracoronary thrombosis recanalization: a case report

BackgroundA woven coronary artery is a rare congenital coronary anomaly and incidentally found in coronary angiogram. Coronary angiography is the major diagnostic modality, which shows the main trunk of coronary divides into several channels which later reconnect with normal blood flow (J Int Cardiol 113:121-123 2006). However, some cases and reviews inferred that this characteristic might be mimicked by recanalized coronary thrombus, which occurs following thrombotic occlusion. In some case, the multiple intraluminal channels have a ‘Swiss cheese’, a ‘Spider web-like’, a ‘Honeycomb’ or a ‘Lotus root’ appearance and most of them appear in local segment (Int J Cardiol 186: 239–240, 2015). As these images are nonspecific findings, there is no angiographic uniform definition of intracoronary thrombus. More information about the characteristics and the development of this woven-like structure is needed.Case presentationA 67-year-old male patient was admitted to our hospital because of chest pain. Coronary artery angiogram revealed that the right coronary artery (RCA) divided into multiple thin channels from proximal to distal, which was similar to the so-called woven coronary artery. Compared with his prior coronary angiograms which showed a tiny hazy lesion in distal segment of RCA, we found the woven-like phenomena should be caused by a late-stage recanalized coronary thrombus. Percutaneous coronary intervention (PCI) was performed to restore the RCA flow, and the angina symptom was extremely improved during clinical follow-up.ConclusionsThe diagnostic criteria of woven coronary artery was based on angiographic image. However, some cases and reviews inferred that thrombotic recanalization might also share the same characteristic. In this case, we collected the baseline angiograms and intracoronary images then successfully diagnosed the woven-like RCA as thrombotic recanalization. For this kind of woven-like coronary artery, PCI could be a better treatment strategy. Detailed history collection and intracoronary image techniques should be emphasized in future clinical practice in the differentiating and treatment of woven-like phenomena.

TIMING OF SURGICAL INTERVENTION AFTER VENTRICULAR SEPTAL RUPTURE

Ventricular septal rupture (VSR) is a rare but lethal complication of acute myocardial infarction (AMI). patients presenting with ST-elevation MI (STEMI) were evaluated for heart rupture (VSR ) based on reperfusion strategy. , After undergoing a primary percutaneous coronary intervention (PCI), VSR was reported to occur in 0.23-0.71% of patients. Post-infarction VSR carries significant mortality (36.%) despite aggressive surgical management. Rupture develops after full-thickness (transmural) infarction of the ventricular septum and can occur at any anatomic location. Ventricular septal rupture is likely to be associated with total occlusion of the infarct-related artery. the newly formed communication results in left to right shunting of oxygenated blood from the high-pressure left ventricle to the lower-pressure right ventricle. .Mortality was highest in patients who underwent operation in the first 24 h, consistent with other investigators. The case reflects the important problem after myocardial infarction , ventricular septal rupture and challenges the timing of intervention Patient 70 year old,male,caucasion was admitted in our hospital with encephalopathy and hypotension.ECG revealed ST segment elevation in II,III,AVF,V4-V6 lead,ST segment depression in AVL,V1-V3 lead. Koronarography detected left main artery without important stenosis, 95 % stenosis of middle segment and 75% stenosis of distal part of left anterior descending artery.40% stenosis of middle segment of right coronary artery, occlusion of posterior descending artery.After recanalization and balloon predilatation of posterior descending artery, was parformed drug eluted stant implantation. transthoracic echocardiography (TTE) detected of postinfarction VSR (pict 3). The Colour Doppler was demonstrated of flow across the septum and left to rigt shunt. Conclusion: Ventricular septal rupture (VSR) is a rare but lethal complication of acute myocardial infarction (AMI). Mortality of patients is significantly depending o n timing of surgery. Operative management of patients can be complex, and having a systematic approach is helpful. The cornerstone of medical management of VSR is afterload reduction, and may be considered routine care.. According our case , surgical intervention was delayed and dispite adequate treatment patient was died . There is no clear evidence to guide the surgical management of patients who are in shock, as all approaches have shown extremely high mortality. Possible strategies include emergent surgery on individuals with marked haemodynamic instability and circulatory compromise.

Extremely tortuous coronary arteries - when optical coherence tomography and fractional flow reserve did not help us much

Introduction. Extreme coronary tortuosity may lead to flow alteration resulting in a reduction in coronary pressure distal to the tortuous segment, subsequently leading to ischemia. Therefore the detection of a true cause of ischemia, i.e. whether a fixed stenosis or tortuosity by itself is responsible for its creation, with non-invasive and invasive methods is a real challenge. Case report. We presented a case of a patient with a history of stable angina [Canadian Cardiovascular Society (CCS class II)], an abnormal stress test and coronary tortuosity without hemodynamically significant stenosis. Due to suspected linear lesion between the two bends in proximal segment of Right coronary artery (RCA) we performed optical coherence tomography (OCT), minimum lumen area (MLA)-13.19 mm2) and fractional flow reserve (FFR) RCA (0.94). We opted for conservative treatment for stable angina. Conclusion. When tortuosities are associated with atherosclerosis in coronary artery for determination of true cause of ischemia invasive methods can be used, such as OCT and FFR. <br><br><font color="red"><b> This article has been corrected. Link to the correction <u><a href="http://dx.doi.org/10.2298/VSP1912304E">10.2298/VSP1912304E</a><u></b></font>

Sağ Koroner Arter Anjiyografisi Sırasında Opak Basıncına Bağlı Distalde Kese Görüntüsüne Neden Olan Subadventisiyal Diseksiyon Olgusu

Iatrogenic dissections during coronary interventions can be observed in daily practice. However, dissections due to opaque injection are much less common. Herein, we present a case of subaventitial dissection developed in the distal segment of right coronary artery after opaque injection. Dissection was not catheter-related and was conservatively treated as there was no leak out of the coronary artery.

Disparity in Coronary Artery Diameter in Diabetic and Nondiabetic Subjects undergoing Percutaneous Coronary Intervention in Bangladesh: A 2-Year Retrospective Analysis

Objective: Coronary arteries in diabetic patients were found to be narrower than in non-diabetic subjects. The aim of the study was to compare the coronary arteries diameter between diabetic and non-diabetic patients undergoing percutaneous coronary intervention (PCI) using stent diameter for greater accuracy.Methods: This was a randomized observational study. From a dedicated database, we retrospectively analysed all consecutive patients of both gender who underwent PCI in the cardiac catheterization laboratory of Ibrahim Cardiac Hospital and Research Institute, Dhaka, Bangladesh, from January 2011 to December 2012. Patients who required left main coronary artery stenting were excluded from this study. Patients were divided into two groups; diabetics and non-diabetics. We calculated the coronary artery diameter according to the diameter of the stent, achieved at the final pressure at which the stent was deployed. The diameter which was achieved at a given atmospheric pressure was taken from the attached booklet provided with the stent packaging. If post dilatation was required then the diameter achieved by the non-compliant balloon after post dilatation was taken as the reference diameter of the artery.Results: A total of 571 patients, 333 in diabetic and 238 in non-diabetic group were included in the study. Proximal segments of left anterior descending (LAD) coronary artery in diabetics and non-diabetics were 2.99±0.44 vs 3.14±0.50 mm (p=0.00) while mid and distal segments were 2.90±0.38 vs 3.10±0.42 mm (p=0.00) and 2.25±0.39 vs 2.42±0.45 mm (p=0.00) respectively. Various segments of proximal left Circumflex (LCx) coronary artery in diabetics and non-diabetics were 2.98±0.21 vs 3.01±0.25 mm (p=0.39) while distal circumflex were 2.35±0.40 vs 2.49±0.43 mm (p=0.00) respectively. Proximal segments of right coronary artery (RCA) in diabetic and nondiabetics were 3.0±0.28 vs 3.28±0.25 mm (p=0.00) while mid and distal segments were 2.97±0.26 vs 3.19±0.25 mm (p=0.00) and 2.43±0.51 vs 2.87±0.32 mm (p=0.00) respectively. The number of stents (1.34±0.87 vs 1.30±0.65; p=0.40) and type of stent utilized (DES & non DES: 87.3 & 12.7% vs 85.2 & 14.8%; p=0.50) between diabetic & non-diabetic groups were not significantly different; however the total stent length (23.1±13.3 vs 21.5±9.52 mm; p=0.03) in diabetic group was significantly longer.Conclusions: The diameter of LAD, distal circumflex and right coronary arteries were significantly narrower in diabetic than non-diabetic subjects.Bangladesh Heart Journal 2017; 32(1) : 23-28

Intra-Atrial Right Coronary Artery and its Ablation Implications.

The study examined the frequency in which a right coronary artery (RCA) anomaly resulting in intra-atrialization of the vessel might increase risk of RCA damage during routine radiofrequency ablation in the rightatrium even with low power or temperature. Right coronary artery (RCA) injury with endocardial RF ablation of the right atrium is a rare complication. This prospective observational study comprised an analysis of coronary artery anatomies in 331 patients who underwent autopsies at our institution from 2005 to 2014. The presence of intra-atrial RCA including the number and length of intra-atrial RCA segments with accompanying atherosclerosis and coronary anomalies were evaluated. The authors report a case series of 6 of 331 (1.8%) patients in whom autopsies showed evidence of an intra-atrial RCA. The patients were all men (average 69 ± 12 years of age). They observed 3 variations of the intra-atrial RCA course. In 2 similar variations, the RCA entered the anterolateral aspect of the right atrium, returning to its normaldistribution to supply the distal RCA (case 4 of 6) and the atrioventricular nodal artery (case 1 of 6). In the sixthcase, the atrialized artery was an anterior branch of the RCA, in which the artery similarly coursed across the pectinate muscles, extending to the region of the anterior crista terminalis, before diving into the muscle. The prevalence and variants of the intra-atrial RCA have not been reported before. In the presence ofan intra-atrial artery, RCA damage may occur due to direct injury rather than collateral injury due to transmuralextension of an ablation lesion.

9. Role of strain rate imaging in the detection of significant coronary artery stenosis

Clinical Research. Oral Presentation. Nowadays, there are many methods for detection of significant coronary artery stenosis and myocardial ischemia either by imaging the coronaries or detecting myocardial perfusion abnormalities, but the majority of these methods needs either stress imaging or injection of contrast especially in patients with stable coronary artery disease (SCAD) where there is no resting electrocardiogram (ECG) changes or resting echocardiography wall motion abnormalities. With the development of tissue Doppler imaging, new methods like strain and strain rate imaging were developed followed by the development of the speckle tracking imaging. Strain and strain rate imaging can detect myocardial deformation which is the basis of myocardial function, thus with impaired myocardial perfusion the amount and rate of deformation decreases. Thirty patients with SCAD and significant single vessel left anterior descending (LAD) coronary artery stenosis, diagnosed by invasive coronary angiography, undergoing elective percutaneous coronary intervention (PCI) of the LAD lesion with no significant lesions in the other coronary vessels, left circumflex (LCX) and right coronary artery (RCA). Patients with diabetes, regional wall motion and reduced left ventricular systolic function were excluded. Regional systolic strain and strain rate was measured in the ischemic LAD segments which are six, apicoseptal, mid anteroseptal, basal anteroseptal, apicoanterior, mid anterior and basal anterior, and measured in the non-ischemic LCX and RCA segments, before elective PCI of LAD and three months later. By comparing the strain and strain rate of the ischemic segments before and after PCI there was significant improvement of the systolic strain while there were non-significant changes in the non-ischemic segments. Tissue Doppler strain and strain rate imaging during resting echocardiography can be used to detect regional myocardial ischemia in patients with significant coronary artery stenosis.

Managing practical issues with percutaneous treatment of spontaneous coronary artery dissection in the cardiac catheterization laboratory: An interesting case report

Spontaneous coronary artery dissection (SCAD) is a rare condition and uncommon cause of acute coronary syndrome which is associated with high acute phase mortality with an estimated prevalence of approximately 0.7%. SCAD is known to occur more commonly in young women during pregnancy or postpartum period, and in most cases, it involves a single coronary artery. It has also been reported in patients with atherosclerosis. SCAD is generally treated by percutaneous intervention and stenting. While stenting a segment of the right coronary artery (RCA) with dissection, opening the balloon in the false lumen or placing a stent in the false plane can lead to abrupt closure of the RCA leading to on table catastrophe, thereby confirming that we are in the true lumen is of pivotal importance. Simple maneuvers to prevent this error can be lifesaving. In this article, we have presented a few practical measures to deal with this dilemma in the background of a patient who was found to have spontaneous spiral dissection of the RCA while being evaluated for angina.

A Case of Vasospastic Angina Involving Erosion and Thrombus within the Spastic Segment Detected by Coronary Angioscopy

A-58-year-old female who had been treated for vasospastic angina had difficulty in breathing and palpitations during rest at night. She was admitted to our institution for a detailed examination of her symptoms. Coronary angiography showed no obvious coronary stenosis. Thereafter, we performed the spasm provocation test (SPT), firstly in the right coronary artery (RCA) and then in the left coronary artery (LCA), using intracoronary infusions of acetylcholine. SPT revealed a focal spasm at the distal segment of RCA and diffuse spasms at the left anterior descending coronary artery (LAD) and left circumflex artery. An intracoronary infusion of nitroglycerin relieved coronary spasms. Coronary angioscopy revealed erosions and white thrombus at the spastic segment of the proximal segment of LAD. Administration of two types of coronary vasodilators improved chest symptoms. Recent studies have focused on acute coronary syndrome without plaque rupture, and coronary spasm has been proposed as one of the underlying mechanisms responsible. The findings of the present case may support a relationship between coronary spasm and coronary erosion with thrombus formation.

Pathological analysis of a case with peri-stent contrast staining after BMS implantation

A 68-year-old female underwent bare-metal stent (BMS) implantation in the right coronary artery (RCA) for ST-segment elevation myocardial infarction. Recurrent refractory restenosis with peri-stent contrast staining (PSS) formation was observed in the stented lesion at follow-up angiography at 7, 11, and 14 months after the index stent implantation. After 2 repeated interventions, this patient was referred to coronary artery bypass grafting due to occlusion of RCA and progression of proximal left anterior descending coronary artery lesion at 15 months after stent implantation. Pathologic examination of the surgically resected specimen of stented RCA segment revealed total occlusion with dense fibrous collagenous tissue and significant inflammatory cell infiltration including scattered eosinophils. Extensive loss of medial smooth muscle layer was observed in the vessel wall, which was likely to be the cause of PSS. In the course of treatment, this patient was found to have chromium allergy with positive patch test. Allergic reactions to chromium released from the stent might be one of the triggering mechanisms for in-stent restenosis and PSS after BMS implantation.<Learning objective: Peri-stent contrast staining (PSS) was an abnormal angiographic finding suggesting presence of contrast material outside the stent border after sirolimus-eluting stent implantation. However, PSS is rarely seen with bare-metal stents (BMSs), and PSS and refractory restenosis after BMS implantation suggests the relation with metal allergy. We must think of metal allergy after the development of refractory restenosis and PSS with BMS implantation.>

Intravascular ultrasound imaging of recanalized spontaneous coronary artery dissection managed with percutaneous coronary intervention.

We present a 41-year-old male who was admitted because of high arterial blood pressure and chest pain. The patient’s risk factors were smoking, dyslipidemia and poorly controlled arterial hypertension. His 12-lead electrocardiogram on admission showed discrete ST-segment elevation and negative T-waves in anterior and lateral leads and Q-waves in inferior leads. Initial laboratory results revealed a slightly elevated troponin I, but other cardiac bio-markers were negative. Echocardiography showed marginally dilated left ventricle and left atrium, preserved global ejection fraction of left ventricle with regional wall motion abnormality involving apex and intraventricular septum. Coronary angiogram revealed a peculiar beaded-like appearance in middle segment of left anterior descending artery and similar finding in proximal segment of right coronary artery, but without angiographically evident stenosis. To further define the nature of the filling defects, an intravascular ultrasound (IVUS) was performed which showed dissection flaps with multiple false lumens involving middle left anterior descending artery (LAD) and proximal right coronary artery (RCA), a finding that indicates recanalized spontaneous coronary artery dissection. A successful percutaneous coronary intervention with drugeluting stents was done to the LAD and RCA with excellent angiographic result that was confirmed on repeated IVUS. The patient was discharged several days after the intervention with dual antiplatelet therapy, antihypertensive and antihyperlipidemic therapy. He was symptom-free and without any clinical sequelae in the follow-up.

Percutaneous coronary intervention in a rare variety of single coronary artery

We present a case of 50-year-old male having unstable angina. A rare type of single coronary artery was identified during the Coronary angiogram. The left anterior descending (LAD) and left circumflex artery (LCX) had originated from the proximal segment of right coronary artery along with significant lesion in LCX. Computed tomographic (CT) coronary angiogram confirmed the origin and course following which successful percutaneous coronary intervention (PCI) was done to LCX. The incidence of this type of coronary anomaly is 0.004%. We emphasize the importance of having a CT coronary angiogram to identify the course before the intervention. The procedural risk during PCI in patients with single coronary ostium is high. Moreover, the angulation and course of the culprit artery also pose a challenge. Good coaxial guide support by using an appropriate guiding catheter is the key to success.

Feasibility of proximal right coronary artery imaging by 2D and 3D echocardiography in comparison to coronary angiography.

The present study was carried out to test the feasibility of proximal right coronary artery (RCA) imaging and to detect proximal RCA narrowing and occlusion by 2D and 3D transthoracic echocardiography in comparison to coronary angiography (CA). Standardised 2D and 3D echocardiography were performed prior to CA in 97 patients with sinus rhythm. The following parameters were determined: the longest longitudinal detectable RCA segment, the minimum and maximum width of the RCA, the area and number of detectable narrowing >50% of the proximal RCA and the correlation between the echocardiographic and angiographic findings. The visualisation of the proximal RCA and the detection of coronary artery narrowing in the proximal RCA are generally possible. Differences in width and area were not statistically significant between 2D and 3D echocardiography, but showed significant differences between echocardiography and CA. For the detection of proximal RCA narrowing, higher sensitivity and specificity values were obtained by 2D than by 3D echocardiography. However, in patients with sufficient image quality 3D echocardiography permits a more detailed visualisation of the anatomical proportions and an en-face view into the RCA ostium. The visualisation of the proximal RCA is feasible and narrowing can be detected by 2D and 3D echocardiography if image quality is sufficient. CA is the gold standard for the detection of coronary artery stenoses. However, the potential of this new approach is clinically important because crucial findings of the proximal RCA can be presumably detected non-invasively prior to CA.

Value of electrocardiogram (ECG) in identifying acute occlusion sites of right coronary artery

Clinical data of 151 patients with acute occlusion of right coronary artery were retrospectively analyzed. Coronary angiography and electrocardiography (EEG) were performed in all 151 patients, angiography showed proximal-middle segment occlusion in 114 cases and distant segment occlusion in 37 cases. The correlation of ECG findings with coronary artery occlusion sites was analyzed. Results showed that EEG findings related to proximal-middle segment occlusion were: ST segment elevation in lead V4R ≥0.05 mV, Ⅲ degree atrioventricular block, ST segment depression in lead Ⅰ>0.1 mV, ST segment depression in lead AVL≥0.2 mV, ST segment elevation in lead Ⅲ≥0.25 mV, the total ST depression in lead V2,V3 and V4 ≥0.4 mV , the total ST depression in lead I and aVL ≥0.25 mV; among which ST depression of Lead Ⅰ>0.1 mV, ST elevation of Lead V4R≥0.05 mV and Ⅲ degree atrioventricular block were used to predict occlusion of proximal-middle segment of right coronary artery with 100% specificity. ECG findings related to distal segment occlusion were: ST depression in lead Ⅰ≤0.1 mV, ST segment depression in lead AVL<0.2 mV, ST elevation in lead Ⅲ≤0.25 mV, the total ST depression in lead V2,V3 and V4 <0.4 mV, ST segment were not depression in lead V1-V5,the total ST depression in lead I and aVL<0.25 mV. Based on a 4-step flow method, ECG might be adopted to identify the acute occlusion sites in proximal-middle segment and distal segment of right coronary. Key words: Coronary occlusion; Inferior wall myocardial infarction; Electrocardiography

Ruptured Thin-Cap Fibroatheroma as Cause of Recurrent Stemi and Malignant Arrhythmias

86 years-old man with a previous PCI, was admitted to a hub hospital for an inferior STEMI and ventricular tachycardia. Coronary angiography showed stent thrombosis on distal segment of right coronary artery (RCA), which was treated by intracoronary adenosine and bare metal stent (BMS) implantation with restored TIMI 3 flow

Angiographic profile of coronary arteries in Keralite population

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

JAK2V617F mutant-positive polycythemia vera complicated with acute coronary syndrome: a report of 2 cases and literature review

Objective To review the clinical features, diagnosis, prognosis and treatment of polycythemia vera(PV)complicated with acute coronary syndrome(ACS). Methods The clinical data of 2 PV patients complicated with ACS admitted to Peking Union Medical College Hospital (PUMCH) were retrospectively analyzed and the recent literatures were reviewed. Results Case 1 was a 65-year old man who had been diagnosed PV with a positive JAK2V617F mutation 3 years ago. At presentation, the patient was suffering from recurrent angina pectoris, and coronary angiography revealed that there was a severe(80%)stenosis in the middle segment of left circumflex and a Xience V stent was implanted. After the percutaneous transluminal coronary intervention (PCI), secondary prevention for coronary heart disease and hydroxyurea for PV were given and the patient has been followed up regularly for more than three years and he is going well. Case 2 is a 44-year old man who was diagnosed PV with a positive JAK2 mutation 3 years ago and hydroxyurea, interferon, aspirin was prescribed. Then splenic infarction, thrombosis of splenic vein, regional portal hypertension, severe varices of fundus of stomach and upper gastrointestinal bleeding developed with him. Two months ago, an AMI of inferior wall occurred and the angiographic findings demonstrated an thrombotic lesion in the proximal segment of the right coronary artery with a moderate stenosis (60%); 1 month ago an AMI of anterior wall developed and coronary angiography discovered that there were diffuse thrombus in the proximal segment of left anterior descending artery with a severe stenosis (90%) and a complete occlusion in the right coronary artery. After double antiplatelet therapy with anticoagulation therapy of warfarin was given, the patient recovered gradually. Conclusions PV complicated with ACS is relatively rare. According to recent studies, positive JAK2V617F mutation, leukocytosis, age>65 years and positive history of thrombosis are the most important predictors of cardiovascular events. Clinicians should design individualized treatment strategies for patients on the basis of clinical features, coronary angiography findings and complications. For those with thrombotic lesion in the coronary artery due to the hypercoagulative state caused by PV, it should be cautious to carry out a coronary revascularization treatment. Key words: Vera polycythemia; Coronary disease; Review literature

Angiographic profile of coronary arteries in Keralite population

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