Septal Perforator Branch Research Articles

Significance of Wellens Pattern in Electrocardiogram Revisited – Electrocardiogram and Angiographic Correlation

Abstract Background: In patients with non-ST elevation acute coronary syndrome (NSTEACS), electrocardiogram (ECG) may show deep or biphasic T-wave inversions in precordial leads. Previous reports had linked this ECG change with a lesion in the left anterior descending artery (LAD). However, it is often overlooked in the emergency department and is not included in the major scoring systems for risk stratification of acute coronary syndrome. Objectives: We assessed coronary angiogram (CAG) lesions in patients with biphasic T inversion and/or deep T inversions by ECG. Methods: From July 2019 to November 2021, ECGs of all NSTEACS patients were analyzed and 202 patients who satisfied the criteria were chosen. CAGs were analyzed for the site, severity, and type of lesion. Treatment modality advice was noted. Results: One hundred and ninety-five patients had severe disease in the LAD, of which 178 patients had a lesion proximal to the first septal perforator branch. LAD lesions were discrete in 98, tubular in 68, diffuse in 25, and total occlusion in 11 patients. One hundred and thirty-four patients were advised to have percutaneous coronary intervention (PCI) as treatment. Sixty-three patients with a severe lesion had no recurrent angina and 103 were negative for troponin. Conclusion: 96.5% of patients with NSTEACS and an ECG abnormality had a significant lesion in the LAD. In 88.1% of patients, the lesion was before the first septal perforator branch. Overall, 66.3% of patients were advised to undergo PCI. The sensitivity of troponin in predicting severe lesion was 47.7%, and the sensitivity of recurrent angina was 67.7% only. This ECG abnormality by itself, even without recurrent angina or troponin elevation, should be an indication for invasive evaluation such as CAG.

An Acute Anterior Reinfarction Complicating with Transient Symptomatic Total Atrioventricular Block

Abstract
 Background
 Acute stent thrombosis is a frequent cause of myocardial infarct (MI) after stent placement. Total atrioventricular (AV) block is frequently become the conductive disturbance complication of acute reinfarct. Inferior MI has Low long-term mortality and greater reversibility than anterior MI which has higher in-hospital and long-term mortality.
 
 Case Illustration 
 44 years man, came to emergency department Cardiovascular Centre Harapan Kita with altered mental status since 12 hours ago. PPCI stenting at proximal LAD of his acute anterior MI 2 days ago. Patient had acute stent thrombosis then underwent urgent PCI at referring hospital. Patient present with blood pressure 57/30, heart rate 20 -30 with TAVB rhythm. Laboratory showed increased serum lactate level 5.2. Patient was diagnosed with Total AV block caused by MI. Patient was planned for emergency temporary pacemaker (TPM) implantation. After 24 hours close monitoring, the patient intrinsic rhythm resolved with spontaneous recovery. Patient was hemodynamically stable until discharge.
 
 Discussion 
 Stent thrombosis of proximal stent of LAD will cause TAVB because of the source of the distal portion of the AV node is originating from septal branch of LAD. It is caused by extensive necrosis with higher in-hospital and long-term mortality, often culminated in permanent pacemaker. However, spontaneous recovery of TAVB into sinus rhythm take place. This could be caused by transient reversible ischemia of infra nodal region of AV node which supplied by septal perforator branch
 
 Conclusion 
 This case reporting a complete atrioventricular block during the course of acute anterior reinfarct and had spontaneous resolution of the AV block. Mechanisms of spontaneous resolution of complete AV block in the setting of acute MI is associated transient ischemia after occlusion of proximal LAD.
 
 Keyword: Reinfarct, Stent Thrombosis, Total AV Block

Intramyocardial mapping of ventricular premature depolarizations via septal venous perforators: Differentiating the superior intraseptal region from left ventricular summit origins

The intramyocardial aspect of the left ventricular summit (LVS) can be mapped by advancing a unipolar guidewire into septal perforator branches of the anterior interventricular vein. The purpose of this study was to differentiate between ventricular premature depolarizations (VPDs) with a basal superior intraseptal (SIS) site of origin and those originating from the epicardial LVS using septal intramyocardial mapping. A retrospective cohort of patients with suspected LVS VPDs who underwent SIS unipolar mapping were reviewed for their clinical characteristics, mapping findings, and procedural outcomes. SIS mapping was successful in 44 of 47 cases (93.6%). VPD origin was SIS (defined as earliest activation from the intraseptal wire) in 20 patients (45.5%; median 23 ms pre-QRS). Procedure success was similar in patients with (group 1) and without (group 2) SIS origin (84% vs 87.5%, respectively; P = .842). Of the 10 patients in group 1 without presystolic endocardial activation, 5 (11.3% of all 44 cases) were successfully ablated from the left ventricular endocardium by using an anatomical approach targeting the endocardium closest to the earliest intraseptal activation site. A significant proportion (45.5%) of VPDs that appear to arise from the left ventricular summit can be demonstrated to have a SIS origin using septal perforator venous mapping. A significant minority (11.3%) of these can be ablated from the endocardium by targeting from an anatomic vantage point closest to the earliest intraseptal activation site. The described strategy may help differentiate true LVS VPDs from those with SIS sites of origin.

Feasible stenting of a large septal perforator providing a sizeable coronary collaterals

While coronary artery disease involving the septal perforator branches presents similar to diseases of major coronary arteries, management can present a challenge. Owing to their relatively small size, performing interventional procedures is often impractical in terms of selecting appropriate devices. Although larger septal perforator branches have been managed percutaneously, similar to major vessels, long-term sequelae and clinical effectiveness have been indeterminate. We present our experience in managing a patient with a stenosed septal perforator branch and challenging comorbidities.

Slight Increases of Phosphorus and Sulfur in Human First Septal Perforator Branches of the Left Anterior Descending Artery with Aging

To elucidate age-related changes of the first septal perforator branch (FSB), the authors investigated age-related changes of elements in the FSBs by direct chemical analysis. In addition, the effects of different arterial sizes and genders on element accumulation were investigated in the FSBs. Sixty-two formalin-fixed adult Thai hearts were used and the FSBs were carefully dissected in the hearts. After the arteries were incinerated with nitric acid and perchloric acid, element contents were determined by inductively coupled plasma-atomic emission spectrometry.

Cerclage parahisian septal pacing through the septal perforator branch of the great cardiac vein: Bedside-to-bench development of a novel technique and lead

Cerclage parahisian septal pacing through the septal perforator branch of the great cardiac vein: Bedside-to-bench development of a novel technique and lead

Septal Coronary Venous Mapping to Guide Substrate Characterization andAblation of Intramural Septal Ventricular Arrhythmia.

This study describes the use of septal coronary venous mapping to facilitate substrate characterization and ablation of intramural septal ventricular arrhythmia (VA). Intramural septal VA represents a challenge for substrate definition and catheter ablation. Between 2015 and 2018, 12 patients with structural heart disease, recurrent VA, and suspected intramural septal substrate underwent a septal coronary venous procedure in which mapping was performed by advancement of a wire into the septal perforator branches of the anterior interventricular vein. A total of 5 patients with idiopathic VA were also included as control subjects to compare substrate characteristics. Patients were 63 ± 14 years of age, and 11 (92%) were men. Most patients with structural heart disease had nonischemic cardiomyopathy (83%). Six patients underwent ablation for premature ventricular contractions (PVC) and 6 for ventricular tachycardia. All patients had larger septal unipolar voltage abnormalities than bipolar voltage abnormalities (mean area 35.3 ± 16.8cm2 vs. 10.7 ± 8.4cm2, respectively; p= 0.01), Patients with idiopathic VA had normal voltage. Septal coronary venous mapping revealed low-voltage, fractionated, and multicomponent electrograms in sinus rhythm in all patients with substrate compared to that in patients with idiopathic VA (amplitude 0.9 ± 0.9mV vs. 4.4 ± 3.7mV, respectively; p= 0.007; and duration 147 ± 48ms vs. 92 ± 10ms, respectively; p= 0.03). Ablation targeted early activation, pace map match, and/or good entrainment sites from intraseptal recording. Over a mean follow-up of 339 ± 240days, the PVC and insertable cardioverter-defibrillator therapies burden were significantly reduced (from a mean of 22 ± 11% to 4 ± 8%; p= 0.005; and a mean 5 ± 2 to 1 ± 1; p= 0.001, respectively). Most patients (80%) with idiopathic VA remained arrhythmia free. In patients with suspected intramural septal VA, mapping of the septal coronary veins may be helpfulto characterize the arrhythmia substrate, identify ablation targets, and guide endocardial ablation.

Transient left septal fascicular block in a patient with stable effort angina and critical proximal obstruction of left anterior descending coronary artery

Several publications from our group and others have shown that a main cause of middle fiber block or left septal fascicular block of the left bundle of His is proximal obstruction of the left anterior descending coronary artery, before its first septal perforator branch, since this fascicle is the only one of the three fascicles irrigated exclusively by this artery. We present a case in which the phenomenon occurred transiently, causing prominent anterior QRS forces, confirmed by coronary angiography.

Transient prominent anterior QRS forces in the setting ST segment elevation coronary syndrome: Left septal fascicular block

Numerous successive publications have shown that transient prominent anterior QRS forces (PAF) in the setting of acute coronary syndrome (ACS) is suggestive of critical proximal obstruction of left anterior descending coronary artery (LAD) before its first septal perforator branch (S1). Transient ischemia of the left septal fascicle resulting in left septal fascicular block has been proposed as the causative mechanism. We present a case of acute inferior ST-elevation myocardial infarction caused by acute proximal occlusion of the right coronary artery associated with proximal critical obstruction of the left anterior descending coronary artery.

Transient left septal and anterior fascicular block associated with type 1 electrocardiographic Brugada pattern

The left septal fascicular block (LSFB) or blockage of the middle fibers of the left bundle branch is probably caused mainly by - in the developed world - the proximal obstruction of the left anterior descending artery (LAD) before its first anterior septal perforator branch (S1). The association of transient LSFB and left anterior fascicular block (LAFB) - left bifascicular block - and the electrocardiographic type 1 Brugada pattern (BrP) has not been described in the literature yet.

Alcohol septal ablation: in which patients and why?

At present, surgical septal myectomy is regarded as the "gold standard" treatment for most patients with obstructive hypertrophic cardiomyopathy (HCM) and drug-refractory symptoms. However, the best results are obtained by those surgeons who have extensive experience with this operation at a small number of referral centers. In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to myectomy to reduce LV outflow gradient and heart failure symptoms in patients with obstructive HCM. However, certain features of alcohol ablation limit its applicability to carefully selected patients. Because this procedure involves the injection of 1-4 mL of 96% ethanol into a septal perforator of the left anterior coronary artery to produce a myocardial infarction (with septal thinning, outflow tract widening and gradient reduction), alcohol ablation is limited by the size and distribution of the septal perforator branches. In addition, rich blood supply from other septal branches not occluded by the balloon and from the posterior descending coronary artery may restrict myocardial ischemia to portions of the septum that do not contribute to outflow obstruction. Septal hypertrophy may be either mild or particularly marked, and abnormalities of mitral valve apparatus may also play a major role in outflow obstruction. When such features are present, alcohol-induced septal thinning is unlikely to significantly reduce the gradient. In addition, persisting uncertainties regarding the risk for ventricular tachyarrhythmias after alcohol ablation suggest this procedure should be limited to patients of advanced age, patients at unacceptable operative risk due to comorbidities, or those with strong aversion to surgery. Further progress in the treatment for patients with obstructive HCM and severe refractory symptoms will come from assuring proper patient selection for alcohol septal ablation, as well as increasing the number of surgeons and centers experienced in performing septal myectomy.

Clinical Cases: Ischaemic heart disease899Asymptomatic very late presentation of ALCAPA900Usefulness of 3-dimensional contrast echocardiography in the diagnosis of a left ventricular pseudoaneurysm after acute myocardial infarction901Peri-procedural jailing of septal perforator branch retrospectively identified using speckle tracking echocardiography902Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA)903Coronary artery compression by aneurysmal pulmonary artery904A rare complication of myocardial infarction: pseudoaneurysm

Clinical Cases: Ischaemic heart disease899Asymptomatic very late presentation of ALCAPA900Usefulness of 3-dimensional contrast echocardiography in the diagnosis of a left ventricular pseudoaneurysm after acute myocardial infarction901Peri-procedural jailing of septal perforator branch retrospectively identified using speckle tracking echocardiography902Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA)903Coronary artery compression by aneurysmal pulmonary artery904A rare complication of myocardial infarction: pseudoaneurysm

Surgical septal myectomy versus alcohol septal ablation: assessing the status of the controversy in 2014.

In hypertrophic cardiomyopathy (HCM), left ventricular (LV) outflow tract obstruction, caused by mitral valve systolic anterior motion (SAM) with elevated intracavitary LV pressures, can produce disabling symptoms of heart failure and excess cardiovascular mortality.1–7 Outflow gradients are common in HCM, present in 70% of patients at rest or with physiological exercise4 (Figure 1). Fifty years ago, early HCM investigators recognized the importance of obliterating LV outflow obstruction (and mitral regurgitation) and restoring normal hemodynamics, initially with the septal myectomy operation advanced by Dr Andrew Morrow at the National Institutes of Health.6,7 However, HCM has not been immune to controversy, and through the years, several debates have focused on the significance of dynamic outflow obstruction and its treatment.7 The most recent of these conversations concerns the most effective strategy for reducing gradient and symptoms, triggered by the introduction of catheter-based percutaneous alcohol septal ablation (ASA) as an alternative to myectomy.8–19 Figure 1. Treatment algorithm for hypertrophic cardiomyopathy (HCM) patients with heart failure symptoms of exertional dyspnea with or without chest pain. LVOT indicates left ventricular outflow tract; and NYHA, New York Heart Association. The nonsurgical technique, introduced by Professor Ulrich Sigwart at the Royal Brompton Hospital in 1994,8 involves injection of 1 to 4 mL of 96% ethanol into the first septal perforator branch of the left anterior descending coronary artery to produce a basal septal myocardial infarction and ultimately remodeling of the LV outflow tract. ASA avoids the recovery time with loss of work, residual discomfort, and anxiety associated with surgery. It was soon enthusiastically embraced and heavily promoted by many clinicians and interventional cardiologists, initially in Europe, thereby expanding the treatment armamentarium of HCM and triggering a polarized and sometimes contentious debate within the cardiovascular community. Indeed, many related …

Coronary artery occlusions diagnosed by transthoracic Doppler

BackgroundOur aim was to assess whether anterograde flow velocities in septal perforating branches could identify an occluded contralateral coronary artery, and to assess the feasibility and accuracy of diagnosing occlusions in the three main coronary arteries by the combined use of several noninvasive parameters indicating collateral flow.MethodsA total of 108 patients scheduled for coronary angiography because of chest pain or acute coronary syndromes were studied using transthoracic Doppler echocardiography.ResultsAnterograde peak diastolic flow velocities (pDV) in septal perforating branches were higher in patients with angiographic occluded contralateral artery compared with corresponding velocities in patients without significant disease in the contralateral artery (0.80 ± 0.31 m/sec versus 0.37 ± 0.13 m/sec, p < 0.001). Receiver operating characteristic curve showed pDV ≥ 0.57 m/sec to be the optimal cutoff value to identify occluded contralateral artery, with a sensitivity of 79% and a specificity of 69%. Demonstration of at least one positive parameter (retrograde flow in main coronary arteries, reversed flow in septal perforating and left circumflex marginal branches, pDV ≥ 0.57 m/sec, or demonstration of other epicardial or intramyocardial collaterals) indicating collateral flow to an occluded main coronary artery had sensitivity, specificity, positive and negative predictive value of 89%, 94%, 63%, and 99%, respectively, for detection of a coronary occlusion. With this combined use of several parameters, 25 of 28 coronary occlusions were identified.ConclusionsBy investigating several parameters indicating collateral flow, we were able to identify most of the main coronary occlusions in the patient cohort. Furthermore, our study demonstrated that coronary artery occlusions may result in complex and diverging coronary pathophysiology depending on which coronary artery segment is occluded and the extent of accompanying coronary artery disease.Trial registrationClinicalTrials.gov number NTC00281346.

Infarct size and mortality in patients with proximal versus mid left anterior descending artery occlusion: The Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction (INFUSE-AMI) trial

This study aimed to compare infarct size and clinical outcomes in patients with proximal versus mid left anterior descending (mLAD) infarction. The extent of myocardium at risk is an important prognostic determinate in patients with ST-segment elevation myocardial infarction. The INFUSE-AMI trial randomized patients with anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with bivalirudin anticoagulation to intracoronary (IC) bolus abciximab versus no abciximab and to thrombus aspiration versus no aspiration. The primary end point was magnetic resonance imaging infarct size (% of left ventricular mass) at 30 days. Lesion location was independently assessed and was defined as proximal (pLAD) if present before or at first significant septal perforator branch, or mLAD if beyond. Among 452 patients, 292 (64.7%) had pLAD and 159 (35.3%) had mLAD occlusions. Patients with pLAD infarcts were significantly more likely to have Killip class >1 heart failure and ejection fraction <40% and to present earlier to the hospital. Proximal LAD infarcts had significantly lower rates of final Thrombolysis In Myocardial Infarction flow 3 and procedural success but similar rates of myocardial blush grade 2/3 and ST-segment resolution compared with mLAD infarcts. Infarct size at 30 days was significantly greater in the pLAD group (19.3% [9.2-25.9] vs 14.3% [6.2-18.9], P < .0001). Mortality at 30 days was also higher in the pLAD group (4.2% vs 0.6%, P = .04). The effect of IC abciximab on reducing infarct size was comparable in both groups. ST-segment elevation myocardial infarction caused by pLAD compared with mLAD occlusion results in larger infarcts and greater mortality even with contemporary reperfusion therapy.

Sudden death in a young female with an under-recognised coronary anomaly

Anomalies of coronary number and course represent an opinion-dividing topic in cardiopathology, particularly for their relationship with sudden cardiac death.To the best of our knowledge, we herein report the first fatal case of a young female whose coronary anatomy was characterised by the absence of any septal perforator branch in the proximal segment of the LAD.This case could be useful for pathologists, coronary angiographers, and interventional cardiologists in detecting this infrequent anomaly, thus providing a more accurate estimation of its incidence.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/3570015858473043

Cardiac MRI detected septal and lateral myocardial infarction by alcohol septal ablation through the intermediate artery

A 65-year-old woman with hypertrophic obstructive cardiomyopathy presented with dyspnea. Transthoracic echocardiography showed severe mitral regurgitation (MR) due to systolic anterior motion and a peak gradient of 102 mmHg across the LV outflow. Cardiac magnetic resonance imaging (CMR) showed patchy late gadolinium enhancement in the hypertrophied septum. Because of non-responsiveness to medical treatment, percutaneous alcohol septal ablation (ASA) was conducted. The septal perforator that supplied the hypertrophic myocardium originated from the intermediate artery. A 2.0-mm over-the-wire balloon was used to occlude the intermediate artery and 1.1 ml of ethanol was injected slowly into the target septal perforator branch. The gradient decreased markedly to 5 mmHg immediately after ASA, and electrocardiogram showed right bundle branch block. Echocardiographic findings at 1 week were satisfactory. However, CMR showed delayed enhancement in both the hypertrophic basal septum and the lateral wall. The clinical course was uneventful, and she has maintained NHYA functional class 1 so far. In this case, proximal migration of the balloon or an undersized occluding balloon may have caused lateral infarction through leakage of ethanol into another branch. CMR is a useful modality to verify whether the ASA procedure has induced the appropriate controlled infarction.

An unusual co-anomaly: multiple coronary-cameral fistulas and left main coronary artery arising from the right sinus of Valsalva

A 70-year-old female patient was referred to the Cardiology Department for preoperative evaluation before undergoing total hysterectomy. She had no chest pain, but had experienced exertional dyspnea over the past several months. Besides age, she had no additional risk factors for coronary artery disease. Electrocardiogram showed normal sinus rhythm and nonspecific T wave changes, with a heart rate of 81 beats per minute. The physical examination was unremarkable, and exercise stress test was non-diagnostic. Coronary angiography revealed anomalous left main coronary artery (LMCA) arising from the right sinus of Valsalva (Fig. A, Video 1*) and the presence of multiple coronary-cameral fistulas (CCF) between the left ventricle and septal perforating branches of the left anterior descending (LAD) and right coronary arteries (Fig. B, Video 2; Fig. C, Video 3). According to the eye-dot method (Fig. B) and given the septal perforator branch before the LMCA bifurcation (Fig. A), its course was considered as septal, which was confirmed by computed tomography coronary angiography (CTCA) (Fig. D). Because of the benign nature of the abnormal septal course of the LMCA and clinically insignificant CCF, the patient was treated conservatively with β-blockers. She did not experience any chest pain during the hysterectomy and had an uneventful postoperative course. CCF is an uncommon clinical entity, which is defined as an anomalous communication between any epicardial coronary artery and the cardiac chambers. The functional significance and treatment of these fistulas remain unclear. As in our case, CCF originating from both coronary arteries and terminating in cardiac chambers is one of the least common forms. The anomalous origin of LMCA arising from the right sinus of Valsalva is quite rare, with an incidence of 0.1%. It has four possible courses: inter-arterial, retro-aortic, septal, and anterior. The clinical significance and management strategies in these arteries depend on the initial course of the anomalous vessel. In 1990, Serota et al. defined the ‘Dot and Eye’ method for identification of the initial course of anomalous coronary arteries in coronary angiography. In a septal course, the circumflex artery (Cx) will form an ellipse to the left of the aorta, similar to an ‘eye’, with the LMCA forming the inferior portion and the Cx forming the superior portion during 30 RAO injection. In conclusion, CTCA can visualize coronary anomalies accurately; however, a correct diagnosis can be made safely in selected cases by conventional angiography in the presence of clues. 782

TCT-467 Clinical Outcomes after Anterior ST-Elevation Myocardial Infarction According to LAD Lesion Location: The INFUSE-AMI Trial

Background: Prognosis of ST-elevation myocardial infarction (STEMI) is determined predominantly by the extent of myocardial damage and hemodynamic status. Thus, in previous studies patients with proximal LAD occlusion have had worse outcome than those with more distal LAD lesions. It is not known whether modern reperfusion therapy has altered this relationship. Methods: The INFUSE-AMI trial randomized patients with anterior STEMI due to proximal or mid LAD occlusion to intracoronary bolus abciximab delivered locally via the ClearWay RX catheter vs. no abciximab, and to manual thrombus aspiration with the Export catheter vs. no aspiration. The primary endpoint was core laboratory assessed MRI infarct size (IS, % of LV mass) at 30 days. Lesion location was assessed at a core laboratory blinded to randomization and outcomes and was defined as proximal (pLAD) if present before or at first significant septal perforator branch, or mid (mLAD) if beyond it. Results: The study enrolled 452 patients. The median age was 61y, 74% were men and 11% had diabetes. Intracoronary abciximab reduced IS (% LV mass): 15.1[6.8-22.7] vs. 17.9[10.3-25.4], P=0.03. Thrombectomy had no effect on IS. There were 292 (64.7%) patients with pLAD and 159 (35.3%) with mLAD occlusion. Patients with pLAD presented more often within 3h of symptom onset and had lower systolic blood pressure, but did not differ from mLAD patients with respect to heart rate, Killip class or extent of coronary disease. Thrombectomy was performed in 49.3% and 56.0% of the two groups, P=0.18 and intracoronary abciximab was used in 46.9% and 47.2%, respectively, P=0.79. Reperfusion succes, infarct size and major clinical outcomes are listed in Table. Conclusions: These data confirm the excess risk of death associated with pLAD infarcts even with contemporary reperfusion therapy. Reduced TIMI 3 flow rates and larger IS in pLAD infarcts translate into increased mortality.

33-Year-Old Man With Syncope

33-Year-Old Man With Syncope