Emergency angioplasty and stent deployment for acute occlusion of an anomalous single coronary artery (all three coronary arteries from one ostium in the right sinus of Valsalva)

A single coronary ostium is traditionally considered to be of little clinical significance. We report a case of a single ostium in the right sinus of Valsalva, giving rise to the right coronary artery, from which the left main coronary artery originated. Sudden death occurred seven days after acute gastrointestinal bleeding and subsequent interruption of aspirin therapy. Acute coronary angiography following successful resuscitation revealed an ascending thrombus in the right coronary artery. The patient underwent a complex percutaneous coronary angioplasty with stent deployment. We conclude that coronary artery disease may lead to severe ischemia with a large area at risk and major complications in patients with coronary anomalies. Patients with acute stent implantation might benefit from platelet aggregation even in cases of recent intestinal bleeding.     

Spontaneous Left Main Coronary Artery Dissection and the Role of Intravascular Ultrasonography

Objective. Spontaneous left main coronary artery (LMCA) dissection is a rare event with an unknown incidence and high risk of sudden cardiac death. The diagnosis of LMCA dissection is often challenging given the limitations of 2‐dimensional angiography. The 3‐dimensional perspective of intravascular ultrasonography (IVUS) is often indispensable in confirming or excluding the diagnosis of spontaneous LMCA dissection. We report 2 cases of spontaneous LMCA dissection with unique angiographic presentations wherein IVUS was essential in defining the extent of LMCA involvement and facilitated the subsequent referral for emergent coronary artery bypass grafting. Methods. Two patients presented to our facility with acute coronary syndrome prompting coronary angiography, which was notable for an unusual angiographic appearance of the LMCA. Intravascular ultrasonography was performed in each case, revealing spontaneous LMCA dissection. Results. Intravascular ultrasonography permitted the prompt diagnosis and aided in definitive surgical intervention in our 2 cases of spontaneous LMCA dissection. Conclusions. Intravascular ultrasonography is a useful adjunctive imaging modality in the diagnosis and management of spontaneous LMCA dissection.     

冠状动脉夹层的造影诊断与内支架治疗

目的　评价冠状动脉造影 (CAG)和内支架置入 (CASI)治疗对冠状动脉夹层的诊断及治疗价值。方法　10 82例冠状动脉造影及 434例冠状动脉成形术 (PTCA)检出 12例冠状动脉夹层患者 ,均行内支架置入治疗。结果　 12例冠状动脉夹层患者全部成功置入内支架 ,夹层闭合 ,患者症状缓解。结论　冠脉造影是诊断冠状动脉夹层的最佳方法 ,而内支架置入对治疗冠脉夹层安全有效     

The pre-procedural platelet state predicts clinical recurrence after coronary angioplasty

Percutaneous transluminal coronary angioplasty is an established therapy for coronary artery disease, but restenosis still occurs at a rate of 25%-40%. The aim of this study was to investigate the acute effect of percutaneous transluminal coronary angioplasty on platelet function and the relationship between platelet function and clinical recurrence. Spontaneous platelet aggregation was assessed before and after successful coronary angioplasty in 155 patients (120 men, 35 women). Patients were followed for a mean time of 20 months; follow-up angiography was performed only in patients with clinical recurrence. In 122 of 155 patients (79%) a significant increase in spontaneous platelet aggregation was observed immediately after coronary angioplasty. Baseline spontaneous platelet aggregation in platelet-rich plasma was significantly lower in patients with clinical recurrence than in those without (P<0.05). Kaplan-Meier event-free survival estimate showed a significant difference in clinical recurrence between patients with spontaneous platelet aggregation in platelet-rich plasma below and above the first quintile (P<0.05) with a relative risk of 2.5. In conclusion. these results indicate that percutaneous transluminal coronary angioplasty enhances spontaneous platelet aggregation and that the platelet state before coronary angioplasty affects the risk of clinical recurrence after the procedure.     

冠状动脉血栓抽吸联合经皮冠状动脉介入术治疗急性心肌梗死合并冠状动脉血栓疗效观察

目的:探讨冠状动脉血栓抽吸术联合经皮冠状动脉介入术治疗急性心肌梗死合并冠状动脉血栓的疗效。方法:79例急性心肌梗死合并冠状动脉血栓患者,其中38例行急诊冠状动脉血栓抽吸术联合经皮冠状动脉介入术(治疗组),41例行择期经皮冠状动脉介入术(对照组)。比较2组急性期、术后1 a心脏事件发生率,病死率。结果:治疗组与对照组急性期心脏事件发生率分别为21.1%和34.1%,病死率分别为5.3%和9.7%,2组比较差异有统计学意义(P<0.01)。术后1 a治疗组与对照组心脏事件发生率分别为8.6%和13.9%,病死率分别为2.8%和5.5%,2组比较差异有统计学意义(P<0.01)。结论:急诊行冠状动脉血栓抽吸术联合经皮冠状动脉介入术治疗急性心肌梗死合并冠状动脉血栓安全、有效,对心功能的恢复,减少心脏事件和并发症的发生有重要意义。     

冠状动脉内超声成像的临床应用

35例冠脉造影患者行冠脉内超声成像检查（ICUS）。定性分析斑块成分、性质及夹层形成；测量冠脉最小管腔内径、面积、斑块面积及血管狭窄百分数等。冠脉造影结果10例正常，25例冠脉狭窄≥70％，其中17例行PTCA术。10例冠脉造影正常者中，5例ICUS有粥样硬化病变。17例左冠狭窄而左主干正常者中，ICUS示12例（70．6％）左主干有不同程度病变。另17例PTCA后，5例植入支架。对植入与未植入支架的ICUS定性和定量方面的特征进行比较。结论：ICUS可发现冠脉造影正常的冠脉病变。I－CUS为PTCA后的冠脉提供了理想的形态学资料，PTCA后残余狭窄＞50％，钙化偏心斑块或PTCA后有夹层者应植入支架。根据支架成功植入的超声诊断标准，ICUS可指导支架成功植入，避免急性血栓闭塞。     

Successful bailout stenting strategy against rare spontaneous retrograde dissection of partially absorbed magnesium-based resorbable scaffold: A case report

BACKGROUNDIn the development of coronary stent technology, bioresorbable scaffolds are promising milestones in improving the clinical treatment of coronary artery disease. The “leave nothing behind” motto is the premise of the fourth revolution in percutaneous coronary intervention (PCI). Studies proving the safety and efficacy of the magnesium-based resorbable scaffolds (MgBRSs) include the BIOSOLVE-I and BIOSOLVE-II trials and the latest BIOSOLVE-IV registry. However, spontaneous retrograde dissection of a partially absorbed MgBRS may still occur, albeit rarely.CASE SUMMARYWe describe an unusual case of coronary artery disease in a patient who had undergone a successful PCI 8 mo earlier, where an MgBRS was implanted into the left anterior descending artery (LAD) and left circumflex artery with drug-coated balloons for a ramus intermedius branch stenosis to achieve the “leave nothing behind” therapeutic intention and was currently presenting with a gradual worsening of chest tightness. The distal edge vascular response, during subsequent attempts with balloon angioplasty was performed smoothly. However, spontaneous retrograde dissection of a partially absorbed MgBRS in the LAD ensued. Successful bailout stenting was performed with revascularization of the entry and exit sites created by spontaneous dissection and complete sealing of the intramural hematoma. The patient recovered well and was discharged after 2 d of intervention. When followed up in August 2020 (7 mo later), the patient showed uneventful recovery.CONCLUSIONSpontaneous retrograde dissection of a partially absorbed MgBRS was successfully treated using bailout sirolimus-eluting coronary stent strategy.     

尿毒症合并急性冠脉综合征患者冠脉介入诊疗安全性及疗效观察

目的 探讨尿毒症并接受规律的血液及腹膜透析的急性冠脉综合征（ACS）患者进行冠状动脉（简称冠脉）介入治疗的安全性及疗效。方法回顾分析从2010年5月至2013年3月已维持规律透析并因ACS在我院住院连续的10例患者,均在适当水化和透析基础上,应用非离子型等渗造影剂进行冠脉造影检查及经皮冠脉介入术（PCI）。结果7例（70％）成功植入支架,2例行外科搭桥手术,1例冠脉造影术后第6天等待外科手术时发生脑出血死亡。术后监测肾功能无进一步恶化,临床随访期间无主要心脏不良事件发生。结论对血液透析患者行冠脉造影及介入治疗是安全可行的,临床疗效良好。     

Ventricular septal rupture,right ventricular dissection,and tricuspid chordae rupture—A rare complication after inferior and right ventricular infarction

A 76‐year‐old man under stable hemodynamic condition was admitted to our hospital for delayed percutaneous coronary intervention following a diagnosis of acute inferior myocardial infarction. Bedside echocardiography revealed ventricular septal rupture at the basal posteroinferior wall with a large left‐to‐right shunt. Right ventricular free‐wall intramyocardial dissection and tricuspid chordae rupture were noted. Coronary angiography demonstrated occlusion of the proximal right coronary artery, which was treated by balloon angioplasty and stenting. While preparing for surgical repair, the patient's overall cardiac and renal function deteriorated and surgery was contraindicated. The patient died 16 days after discharge. © 2014 Wiley Periodicals, Inc. J Clin Ultrasound 43:512–515 2015     

青年女性自发冠状动脉夹层导致急性心肌梗死1例并文献复习

目的 探讨自发性冠状动脉夹层的临床特点,以期提高对该病的诊治与认识。方法 回顾性分析1例青年女性自发性冠状动脉夹层导致急性心肌梗死患者的临床资料,并以“自发性冠状动脉夹层”、“急性心肌梗死”以及“青年女性”等关键词,通过检索中国知网、PubMed及万方数据库,筛选公开发表的相关中英文文献,以分析自发性冠状动脉夹层的临床特点。结果 本例为青年女性,35岁,因间断胸痛就诊,心电图检查提示I、aVL及V2-V5导联ST段抬高,肌钙蛋白T升高(>2 000 ng/L),冠状动脉造影结果示左主干(LM)自开口可见夹层,延伸至左前降支(LAD)远段及回旋支(LCX)中段,管腔全程受压,近段血管部分不能显影,经血管内超声(intravenous ultrasound, IVUS)指导下行经皮冠状动脉介入(percutaneous coronary intervention, PCI)治疗,随访1个月并复查冠状动脉造影(coronary angiography, CAG)患者治疗效果良好。结论 自发性冠状动脉夹层是导致急性冠脉综合征的罕见病因,其疾病特点及治疗方法与冠状动脉粥样硬化不同,诊断具有...     

Large atherosclerotic plaque related severe right coronary artery dissection during coronary angiography

Catheter-induced coronary artery dissection and occlusion is a rare but serious complication of diagnostic cardiac angiography. A 50 year-old man presented with unstable angina. ECG, exceptional of bradycardia, was normal (57 beat/min). Selective coronary angiography demonstrated 98% narrowing in the mid-portion of the left anterior descending coronary artery (LAD). During the right coronary angiography, following catheter manipulation in the vicinity of the aortic valve, the patient complained of severe chest discomfort, and he had electrocardiographic evidence of acute inferior wall myocardial infarction. Right coronary artery (RCA) was free of the significant obstruction, and it was observed to be having a dominant artery with a spiral dissection (NHLBI Grade IV) located between ostium and the proximal portion of the posterior descending and posterolateral artery bifurcation. The patient was immediately operated with off-pump coronary artery bypass surgery. Consequently, iatrogenic right coronary dissection that is a very rare condition as a cause of myocardial infarction, is discussed in this case report.     

Acute multi-vessel coronary stent thrombosis

Background: Coronary artery stent thrombosis is a rare but often fatal complication associated with percutaneous coronary intervention (PCI) using both bare-metal stents and drug-eluting stents. Although strict adherence to dual anti-platelet therapy (aspirin plus clopidogrel) minimizes this risk, stent thrombosis will still occur in rare patients, leading to acute, subacute, or late life-threatening acute coronary syndromes. Objectives: To present a rare case of acute stent thrombosis involving multiple vessels to increase awareness of this life-threatening condition among emergency physicians, and to review the current guidelines for anti-platelet therapy in this patient population. Case Report: A 52-year-old man who underwent PCI using drug-eluting stents in two separate coronary vessels presented to the Emergency Department within 2 h of discharge from the hospital with chest pain, dynamic electrocardiogram changes, and elevated cardiac markers. Despite compliance with the current recommendations for post-PCI anti-platelet therapy, urgent repeat catheterization revealed total thrombotic occlusion of both stents, requiring urgent repeat intervention. Conclusion: Despite patient compliance with the currently recommended anti-platelet regimen after stent therapy for coronary artery disease, acute stent thrombosis remains a rare but life-threatening risk in both the immediate and delayed post-intervention period. In addition, premature cessation of this anti-platelet therapy stands as the greatest risk factor for such thrombotic events. This case is presented to inform emergency physicians of the current post-PCI anticoagulation recommendations to help mitigate the risk of such complications.     

A Case of Spontaneous Coronary Artery Dissection: It is Not Always Plaque Rupture

Background

Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of acute coronary syndrome (ACS). Patients may present with a broad spectrum of clinical scenarios, ranging from angina pectoris to myocardial infarction, cardiogenic shock, and sudden death. Standard therapy has not been established; current treatments range from conservative management to percutaneous revascularization or coronary artery bypass surgery.

Objective

SCAD greatly mimics ACS, and this diagnosis should be considered when evaluating young patients who present with ACS with or without classical risk factors for coronary artery disease.

Case Report

We report a case of a 45-year old man who presented with chest pain typical of ACS. He had no risk factors except for a smoking history of 2.5 pack-years. Once the clinical findings suggested acute inferolateral myocardial infarction, the patient underwent emergent cardiac catheterization, which revealed left anterior descending coronary artery dissection. This in itself is not a common cause of inferolateral ST elevation changes on electrocardiogram.

Conclusion

This case highlights the fact that although SCAD is a rare entity, it is increasingly being recognized as a significant cause of ACS. Urgent angiography should be considered if SCAD is suspected, because early diagnosis and appropriate management significantly improve the outcome in these patients.     

Pregnancy-associated coronary artery dissection: a case report

We describe the case of a 38-year-old woman who presented with a chief complaint of chest heaviness approximately 2 weeks postpartum. She was otherwise healthy with no cardiac risk factors. Coronary angiography revealed a spiral dissection of the left main coronary artery that extended to the left anterior descending coronary artery. Pregnancy-associated coronary artery dissection is a disease that has in the past carried a high mortality rate. Even today many women die before reaching medical help. Early diagnosis and intervention are crucial. Percutaneous transluminal coronary angioplasty for single vessel disease and coronary artery bypass grafting for multi-vessel disease are becoming the treatments of choice.     

Early outcome after placement of a metallic intracoronary stent: initial Mayo Clinic experience

After percutaneous transluminal coronary angioplasty, 3 to 7% of patients have in-hospital coronary closure, and the risk of subsequent myocardial infarction is high, even with an urgent bypass operation. Disrupted coronary morphologic integrity, particularly with large dissections, may be associated with an increased risk of acute coronary closure. A percutaneously placed coronary vascular stent may rapidly alleviate acute or threatened coronary closure and could reduce morbidity. Between October 1989 and June 1990, placement of a balloon-expandable, flexible metallic coil (Gianturco-Roubin) coronary stent was attempted 16 times in 15 Mayo Clinic patients--for treatment of actual or threatened abrupt coronary closure in 10 patients, for primary treatment of a lesion judged to be at high risk for dissection with conventional balloon angioplasty in 1, and for elective treatment of restenotic lesions in 5. Placement of the stent was successful in 15 attempts (94%). Associated complications, which were uncommon, were similar to those noted after balloon angioplasty. No early deaths occurred, and no patient required coronary artery bypass grafting. Stents were successfully placed in both urgent and elective circumstances in native coronary arteries and saphenous vein grafts, and they were used in primary atheromatous and restenotic lesions. Our initial experience with this metallic coil stent indicates that it is efficacious for vascular disruption that is threatening or causing coronary closure after angioplasty. Furthermore, elective placement of a stent may be safely undertaken in patients with high-risk coronary lesions or recurrent restenotic lesions. The long-term outcome in all groups of patients who receive coronary stents is unknown.     

冠状动脉造影及支架植入术在冠状动脉狭窄中的应用

目的：探讨冠状动脉造影术对冠状动脉狭窄的诊断价值和FTCA、支架植入术对冠状动脉狭窄病人的治疗效果。方法：回顾性分析冠状动脉造影143例，其中的54例76支病变冠状动脉植入支架59枚，包括前降支25枚、回旋支12枚和右冠状动脉22枚。结果：冠状动脉狭窄发生率依次为前降支、右冠、回旋支及其他分支。老年人冠状动脉狭窄的严重程度及多支病变狭窄的发生率较中青年明显增加。狭窄血管经PTCA及支架植入后血供明显改善，但仍有可能发生再狭窄。结论：冠状动脉造影术是诊断冠状动脉狭窄的金标准，经皮冠状动脉内支架植入术是治疗冠心病的有效方法。     

Surgical procedures after percutaneous transluminal coronary angioplasty

Since Gruentzig's introduction of percutaneous transluminal coronary angioplasty in 1974, there has been increasing clinical use of this technic. At St. Thomas Hospital in Nashville, 50 patients were selected for coronary angioplasty through December 1981. Twenty of the 50 have ultimately had coronary artery bypass surgery. Excellent dilatation of the selected coronary artery was accomplished in 19 patients. Fair dilatation was achieved six times, and four of these patients have had elective coronary artery bypass surgery. In 18 patients the vessels could not be dilated, and 12 of this group had coronary artery bypass, three on an urgent basis. In the remaining seven patients, the affected coronary stenosis was converted to 100% occlusion during the angioplasty, resulting in four emergency operations and one death. It appears that percutaneous transluminal coronary angioplasty is not as easy to master as had been anticipated, and that the results are just good enough in our hands to justify perseverence.     

应用快速起搏支架定位治疗前降支开口病变的效果观察

目的探讨应用快速起搏支架定位方法治疗前降支开口病变的临床疗效。方法2008年6月至2010年11月我院收治前降支开口病变患者38例,随机分为起搏组19例及非起搏组19例,起搏组应用右心室快速起搏支架定位方法释放支架,非起搏组直接支架定位方法释放支架,对上述两组患者进行术后9个月临床随访并行定量冠状动脉造影复查,比较两组患者手术即刻成功率、术后住院及随访过程中主要不良心脏事件（包括心源性死亡、再发心肌梗死和靶病变血运重建）发生率,以及晚期管腔丢失、支架内血栓、支架内再狭窄发生率。结果两组患者术前临床基线特征、冠状动脉病变情况及经皮冠状动脉介入术后即刻情况差异均无统计学意义（P均〉0．05）。术中支架定位时间起搏组和非起搏组分别为（16．5±0．5）、（46．6±1．4）S,差异有统计学意义（t=88．256,P=0．004）。起搏组术后无一例发生急性或亚急性血栓、支架内再狭窄或支架内闭塞,非起搏组1例术后出现支架急性血栓闭塞,经血栓抽吸及球囊扩张急诊介入处理症状消失。随访270～275d,起搏组及非起搏组于介入治疗术后9个月完成了冠状动脉造影,均无死亡和心肌梗死以及靶病变重建事件发生,无再狭窄及闭塞,非起搏组5例患者发生左前降支支架近端再狭窄50％～60％,因无症状而未再行靶病变重建。结论应用快速起搏支架定位治疗前降支开口病变安全、有效,有利于支架精确定位,改善预后,减少急性血栓及支架内再狭窄发生。     

心脏介入治疗合并急性心包填塞的早期识别和处理

目的：探索介入治疗并发急性心包填塞的早期识别和治疗方法。方法：采用回顾分析的方法,分析介入治疗病人心包填塞发病特点、发生原因、治疗方法和预后。结果：9例急性心包填塞,5例为女性,4例男性；年龄在45～70(平均50±10．8)岁。3例发生在冠状动脉造影术,2例发生在体内埋藏式DDD起搏器安置术中,3例发生在射频消融术中。1例发生在二尖瓣球囊分离术。5例急性心包填塞病人给予了穿刺引流成功治愈,3例急性心包填塞病人因为生命体征不稳定,开胸手术后皆抢救成功,1例死亡。结论：起搏器安装、PTCA、射频消融和瓣膜成形术均可引起急性心包填塞。早期识别、正确处理对预后至关重要。     

血清tPSA、fPSA和f/tPSA在前列腺癌合并冠状动脉支架置入患者中的诊断作用评价

目的:探讨冠状动脉支架置入患者血清总PSA(tPSA)、游离PSA(fPSA)和游离PSA/总PSA比值(f/tPSA)水平变化,以评价其在前列腺癌合并冠状动脉支架置入患者诊断中的价值。方法:对50例可疑冠心病男性患者行冠状动脉造影术,20例冠状动脉造影正常(组1),30例患者行冠状动脉支架置入术(组2)。测定两组冠状动脉造影和支架置入前、后24h和30d时的tPSA,fPSA和f/tPSA值。结果:组1tPSA、fPSA和f/tPSA值在冠状动脉造影术前后差异无显著性(P>0.05)。组2术后24htPSA、fPSA差异有显著性(P<0.01),而f/tPSA差异无显著性(P>0.05),术后30dtPSA、fPSA和f/tPSA值差异均无显著性(P>0.05)。结论:冠状动脉置入术可引起tPSA、fPSA值明显升高,到术后30d时恢复正常范围。tPSA、fPSA值不能用于冠状动脉置入术后30d内前列腺癌的早期诊断。