Acute myocardial infarction showing total occlusion of right coronary artery and thrombus formation of left anterior descending artery

A 33-year-old Japanese man had an attack of chest pain associated with ST-segment elevation in the inferolateral leads on his electrocardiogram. Emergency coronary angiography showed total obstruction in the mid right coronary artery (RCA) and a movable thrombus in the proximal left anterior descending artery (LAD). We performed emergency percutaneous transluminal coronary angioplasty (PTCA) for the RCA lesion. The operation was successful and we then conducted intracoronary thrombolysis (ICT) with tisokinase 6,400,000 IU for the LAD thrombus. Its size was reduced by ICT. He had an uneventful hospital course. After 1 month, repeat coronary angiography showed no significant stenosis in the RCA nor thrombus in the LAD. A coronary spasm provocation test was performed using acetylcholine. Coronary spasm in the LAD was induced by an intracoronary injection of 100 microg acetylcholine. In this case, we observed a unique condition suggesting simultaneous double coronary artery occlusion.     

Simultaneous multivessel coronary spasm causing acute myocardial infarction: a case report

Spontaneous simultaneous multivessel coronary artery spasm in patients with acute myocardial infarction (AMI) is uncommon. A 79-year-old Japanese man was transferred to this hospital because of severe prolonged chest pain and faintness. Left coronary angiography revealed total occlusion of the left anterior descending and the left circumflex coronary arteries. Moreover, right coronary angiography revealed 99% stenosis of the right coronary artery. After intracoronary administration of nicorandil, left coronary artery and right coronary artery angiography revealed no organic stenosis or thrombus. This is the first report in which simultaneous 3-vessel spasm was documented by emergency angiography in AMI.     

Coronary artery multistenting in the treatment of life-threatening refractory coronary spasm after coronary artery bypass grafting

A 74-year-old man had undergone on-pump coronary artery bypass grafting (CABG) for effort-induced angina pectoris. Soon after CABG using the left internal thoracic artery for the left anterior descending artery and saphenous vein for the left circumflex artery, ST elevation was found in the inferior leads and complete atrioventricular block, ventricular tachycardia, and circulatory collapse occurred. Emergent coronary angiography revealed diffuse severe spasm of the right coronary artery (RCA). Despite the intravenous and intracoronary administration of massive doses of vasodilators and intra-aortic balloon pumping, the coronary spasm did not resolve. Five stents were deployed from the distal to the proximal portion of the RCA. After multistenting, coronary flow was dramatically improved and the ST elevations in the inferior leads were also improved. Coronary artery spasm after CABG is relatively rare, but when it occurs, it can be fatal. Multistenting is a useful treatment for life-threatening refractory coronary spasm after CABG.     

Congenital absence of left circumflex coronary artery presented with vasospastic angina and myocardial bridge in single left coronary artery

Congenital absence of left circumflex coronary artery (LCX) is a very rare congenital anomaly of the coronary circulation, and few cases have been reported in the literature. We report a case of a 48-year-old male who had congenital absence of LCX presented with vasospastic angina. Routine coronary angiography showed congenital absence of the LCX, typical myocardial bridge in the mid left anterior descending coronary artery (LAD) and super-dominant right coronary artery (RCA). The dominant LAD showed a spastic appearance at the baseline coronary angiography and significant spasm was induced by incremental intracoronary acetylcholine (ACh) provocation test at mid LAD where the myocardial bridge site was observed and was extended to the distal LAD. Typical anginal chest pain was documented during the Ach provocation test and the patient was stabilized with conventional anti-anginal medication. Precise morphological and functional evaluation of the anomalous coronary artery is important for selecting the best treatment modality and better prognosis.     

Exercise-induced plaque rupture producing myocardial infarction

A 37-year-old man with unstable angina was subjected to coronary angiography. The right coronary artery showed a minor proximal stenosis, but there were no obstructive lesions in the left coronary artery. He developed a small inferior infarction. He was asymptomatic until re-admission 1 month later, 1 hour after a normal exercise test, with anterior myocardial infarction. Acute coronary angiography showed sub-total occlusion of the left anterior descending artery. The occlusion was partially relieved after intracoronary injection of nitroglycerin. Intracoronary infusion of streptokinase had no further effect. Balloon angioplasty was then successfully performed. It is suggested that stress-induced plaque rupture with intimal hemorrhage and secondary spasm resulted in sub-total occlusion of the left anterior descending artery producing the second myocardial infarction.     

Multiple coronary thrombosis in a patient with thrombocytosis

A 59-year-old woman was admitted with acute inferior myocardial infarction. Cardiac catheterization revealed total occlusion in the right coronary artery and thrombus-like filling defect in the left anterior descending coronary artery. With simultaneous intracoronary urokinase infusion to the right and left coronary arteries, the right coronary artery became patent and the thrombus in the left anterior descending coronary artery was released to the distal coronary artery. Thrombocytosis was disclosed by laboratory examination. The relationship between myocardial infarction and thrombocytosis is discussed.     

Coronary spasm-induced acute myocardial infarction associated with intracoronary thrombosis]

A 63-year-old man was admitted with an acute anteroseptal myocardial infarction. Coronary angiography performed 3 hours after the onset of chest pain revealed 99% stenosis of the proximal left anterior descending coronary artery (LAD) with delayed filling and intraluminal thrombus distal to the stenosis. After the intracoronary injection of isosorbide dinitrate, the delayed filling disappeared and a subsequent intracoronary urokinase partially dissolved the thrombus. Repeat coronary angiography in the chronic phase disclosed 75% stenosis of the LAD and disappearance of the thrombus. Intracoronary acetylcholine provoked a coronary spasm at the stenotic site of the LAD, concomitantly with chest pain and ST-segment elevation in the anterior leads. The present case demonstrated that coronary spasm plays an important role in thrombus formation and acute myocardial infarction. To date, the concept has been postulated that a dynamic interaction between atherosclerosis, platelet aggregation and spasm may work to cause coronary thrombosis and subsequently lead to acute myocardial infarction. Our report shed light on the importance of coronary spasm in the pathogenesis of myocardial infarction.     

Anomalous origin of the right coronary artery from the pulmonary artery

Two patients with an anomalous right coronary artery arising from the pulmonary artery are presented. The first patient was asymptomatic and had a continuous murmur. The correct diagnosis was established by cardiac catheterization and selective angiography. There was a moderate sized shunt from the dilated left anterior descending coronary artery to the right coronary artery, which arose from the main pulmonary artery. The second patient was also asymptomatic but died several days after a sudden cardiorespiratory arrest. On postmortem examination she was demonstrated to have anomalous origin of the right coronary artery from the pulmonary artery. The left coronary artery was completely occluded at the orifice by a thrombus, and microscopic examination demonstrated evidence of both acute and chronic left ventricular ischemia and infarction. The pathophysiologic alterations and potential danger to patients with this anomaly are discussed.     

Anomalous origin of the left circumflex coronary artery from the right coronary artery and the left anterior descending artery from the right coronary sinus

We present the case of a 67-year-old female who was admitted to our institution because of anginal chest pain. Selective coronary angiography revealed separate ostial origins of the left anterior descending (LAD) artery and the right coronary artery (RCA) from the right coronary sinus (RCS). The left circumflex (LCx) coronary artery arose from the proximal RCA. The left anterior descending had an anterior free wall and the LCx had a retroaortic course. To our knowledge, this type of combination of anatomical variation of coronary circulation has not been described in the literature.     

Left anterior fascicular block secondary to coronary artery spasm

Spasm of the left anterior descending coronary artery occurredduring cardiac calheterization in a 52 year old patient witha history of syncope and a chest pain syndrome. The main featureof coronary spasm was left axis deviation consistent with leftanterior fascicular block. Electrical axis reverted to normalityafter sublingual nitroglycerin. Coronary angiography was repeatedand showed a normal coronary artery tree. This report documentsaxis shift as a feature of coronary spasm and supports the conceptofischemic left anterior hemiblock.     

Vasospastic coronary occlusion associated with a myocardial bridge

A 53-year-old woman was admitted with unstable angina. Acute coronary angiography showed myocardial bridging and total occlusion of the left anterior descending artery in the middle one-third of its course. The occlusion was completely relieved by intracoronary administration of nitroglycerin. The occurrence of coronary spasm may explain angina and myocardial infarction in symptomatic patients with myocardial bridges.     

Myocardial ischemia in patients with fixed occlusive coronary artery disease secondary to vasospasm in the “normal” vessel

Seven patients with significant fixed occlusive coronary artery disease had coronary artery spasm in a “normal” vessel. All patients had one or more episodes of rest angina and six had exertional angina as well. Four sustained previous myocardial infarction. During spontaneous angina, five patients had ST-segment elevation in the inferior electrocardiographic leads. One patient had ST-segment elevation in anterior leads. During angiography, spasm was demonstrated in the right coronary artery in three patients and in the left anterior descending coronary artery in one patient. This study emphasizes the interaction of fixed and vasospastic disease and has strong implications concerning the management of patients with ischemic heart disease.     

Multivessel coronary vasospasm mimicking triple-vessel obstructive coronary artery disease

Spontaneous coronary artery spasm is an important cause of morbidity both in patients with atherosclerotic coronary artery disease and in those with Prinzmetal's angina. Coronary vasospasm tends to occur in focal areas in the coronary tree and can be readily induced by the use of various agents. Spontaneous severe multivessel spasm, mimicking severe obstructive coronary artery disease, has been infrequently described. The therapeutic dilemma in such a clinical situation is highlighted in our current case where an unnecessary coronary artery bypass graft surgery (CABG) was performed due to the lack of clinical suspicion of spasm. This patient presented 5 years after triple-vessel CABG with an episode of rest angina, and was initially found to have severe obstruction of all three native coronary arteries with patent grafts to the right coronary and left anterior descending arteries. After nitroglycerin injection, all three native vessels appeared large and normal. This report raises the question of whether the routine use of intracoronary nitroglycerin, largely abandoned over the past 20 years, should be revisited, at least for certain patient populations such as those with rest angina.     

Recurrence of coronary artery spasm after successful percutaneous transluminal coronary angioplasty

A 47-year-old man presented with angina, and coronary angiograms showed a significant organic stenosis with spasm in the left anterior descending coronary artery. Percutaneous transluminal coronary angioplasty was successfully performed for the organic lesion in the left anterior descending coronary artery. Symptom of angina due to coronary artery spasm recurred, even without restenosis at the site of successful angioplasty.     

Severe coronary artery spasm with anaphylactoid shock caused by contrast medium--case reports

This study reports 2 cases of severe coronary artery spasm with anaphylactoid shock caused by contrast medium. The first patient had anaphylactoid shock in response to contrast medium and severe coronary spasms of both the left anterior descending coronary artery and the left circumflex coronary artery. The patient developed ventricular arrhythmia and complete atrioventricular block following the severe coronary spasm. The second patient had a totally occluded right coronary artery, owing to a spasm after anaphylactoid shock. Anaphylactoid shock should always be considered when persistent shock is noted after the coronary artery spasm has been relieved.     

Spasm of left main coronary artery.

A 46-year-old male patient with atypical angina pectoris appeared to have an important elongated stenosis of the left main coronary artery on coronary arteriography, and slight irregularities in the left anterior descending, circumflex, and right coronary arteries. A saphenous vein bypass graft to the left anterior descending artery was performed, and this relieved the patient's symptoms. Postoperative coronary arteriography demonstrated a widely patent left main coronary artery and graft. The original narrowing of the left main coronary artery was probably caused by spasm and the source of the patient's anginal symptom.     

Spasm of left main coronary artery.

A 46-year-old male patient with atypical angina pectoris appeared to have an important elongated stenosis of the left main coronary artery on coronary arteriography, and slight irregularities in the left anterior descending, circumflex, and right coronary arteries. A saphenous vein bypass graft to the left anterior descending artery was performed, and this relieved the patient's symptoms. Postoperative coronary arteriography demonstrated a widely patent left main coronary artery and graft. The original narrowing of the left main coronary artery was probably caused by spasm and the source of the patient's anginal symptom.     

Intracoronary verapamil for reversal of refractory coronary vasospasm during percutaneous transluminal coronary angioplasty

Coronary artery spasm unresponsive to intracoronary nitroglycerin was observed in eight patients undergoing percutaneous transluminal coronary angioplasty for unstable ischemic symptoms (unstable angina or recent nontransmural infarction, or both). All patients manifested eccentric lesions angiographically with the right coronary artery involved in four, circumflex artery in two and left anterior descending in two. Severe coronary spasm was documented angiographically in all patients after angioplasty and resulted in symptomatic and electrocardiographic evidence of ischemia. Multiple sites of spasm were present in the dilated vessel in three patients. Coronary artery spasm persisted despite the infusion of large doses of intracoronary nitroglycerin (200 to 2,000 micrograms, mean 850 micrograms) over 10 min. Administration of intracoronary verapamil (1 to 1.5 mg over 10 min) resulted in complete relief of spasm with restoration of brisk anterograde flow in all patients. These findings suggest that intracoronary verapamil may be a useful agent for the relief of coronary spasm occurring in the setting of coronary angioplasty.     

Occluding spasm of the total left coronary artery during coronary angiography

Catheter-induced coronary artery spasms are rare during diagnostic coronary angiography, and they occur more often after PTCA because of local vessel wall injury. These spasms are rapidly reversible after administration of nitroglycerine and are normally no cause of serious complications. We report about a catheter-induced occlusive spasm of the entire left anterior descending and circumflex coronary artery in a 56-year-old patient with coronary double-vessel disease, 70% restenosis of the LAD, and a history of two coronary angiographic procedures and one PTCA without any complication. The spasm occurred immediately after the intubation of the left main stem with a 9F PTCA guiding catheter before the coronary guide wire or balloon was advanced into the LAD. Cardiac resuscitation was necessary due to acute left heart failure. The spasm was spontaneously reversible, but reproducible. Therefore, life-threatening coronary artery spasm can occur during coronary angiography or PTCA, but the tendency of spontaneous spasm relief seems to be high.     

Safety of intracoronary Doppler flow measurement

BACKGROUND: With the introduction of Doppler-tipped guide wires, intracoronary Doppler flow measurement has been increasingly accepted as an additional diagnostic approach in the catheterization laboratory. However, the safety of intracoronary Doppler flow measurement has not been well-investigated. The purpose of our study was to evaluate the safety of intracoronary Doppler flow measurement using the Doppler FloWire (Cardiometrics, Mountain View, Calif). METHODS AND RESULTS: A total of 906 patients were examined by intracoronary Doppler with a 0.014-inch or an 0.018-inch Doppler FloWire. For coronary flow reserve measurement, intracoronary injection of adenosine or papaverine was used. Of the patients studied, 77 were cardiac transplant recipients and 829 were patients who had not received a transplant, of whom 617 had undergone diagnostic coronary procedures and 212 had coronary interventions. In 27 (2.98%) of 906 patients adverse cardiac events were observed. Fifteen (1.66%) of 906 patients had severe transient bradycardia develop (asystole or second- to third-degree atrioventricular block) after intracoronary administration of adenosine, 14 of which occurred in the right coronary artery and 1 in the left anterior descending artery. Nine (0.99%) of 906 patients had coronary spasm during the passage of the Doppler wire (5 in the right coronary artery, 4 in the left anterior descending artery). Two (0.22%) of 906 patients had ventricular fibrillation during the procedure. Hypotension with bradycardia and ventricular extrasystole each occurred in 1 (0.11%) of 906 patients. The incidence of complication was significantly higher in transplant recipients than in patients who underwent either diagnostic or interventional procedures (12.99% vs 2.43% vs 0.94%, P <.001). The Doppler measurements in the right coronary artery were associated with a higher incidence of complications, especially bradycardia, compared with the left anterior descending and the left circumflex arteries (right coronary, 5.87% vs left anterior descending, 1.05% vs left circumflex, 0.17%; P <.001). All complications were cured medically. CONCLUSION: Intracoronary Doppler flow measurement with Doppler wires and intracoronary administration of adenosine is a safe method. However, severe complications such as bradycardia and coronary spasm can occur. Attention should be paid to the examination of the right coronary artery, especially in heart transplant recipients.