Acute myocardial infarction during pregnancy caused by coronary artery spasm

Abstract. A 33-year-old pregnant woman suffered from acute anteroseptal myocardial infarction at the 19th gestational week. Despite periodic attacks of myocardial ischaemia after admission, the coronary arteriograms under the use of nitroglycerin were normal. Thereafter, she remained free from the ischaemic events with diltiazem hydrochloride and delivered a healthy baby. The coronary arteriography at puerperium also showed no organic narrowing. However, the provocative test with acetylcholine chloride caused severe spasm of the left anterior descending coronary artery. These findings strongly suggest that acute myocardial infarction in this pregnant woman was caused by coronary artery spasm.     

自发性冠状动脉夹层并血栓形成致急性心肌梗死2例

急性心肌梗死(AMI)是心内科的常见急症,其病死率和致残率较高。自发性冠状动脉夹层(SCAD)可因假腔压迫及合并血栓形成导致冠状动脉闭塞,是AMI的罕见病因之一。本文报告2例SCAD并血栓形成致AMI,并行冠状     

急性下壁心梗右冠不同闭塞节段心电图差异

目的回顾性分析急性下壁心肌梗死(IAMI)患者右冠状动脉(RCA)不同闭塞节段的心电图(ECG)差异,评估其应用价值,期望发现新的ECG预测标准。方法收集本院6年间符合标准的IAMI患者,对不同RCA闭塞节段的ECG特征进行比较分析。结果 58例患者,男性51例,女性7例,平均年龄65.00±13.61岁。ST_(V1)抬高≥0.5mm对提示RCA近段闭塞有显著的统计学意义(p=0.001)。ST_(V3)压低/ST_(Ⅲ)抬高比率0.5、ST_(V4R)抬高在RCA近段组的出现率明显高于中远段组(80.95%vs.50.00%,p=0.058、91.67%vs.60.00%,p=0.191),但差异无统计学意义。结论 ST_(V1)抬高与否对判断急性下壁心肌梗死RCA闭塞节段具有良好的预测价值,若能联合STV3抬高/ST_(Ⅲ)压低比率以及ST_(V4R)抬高与否做共同分析,将进一步提高诊断的灵敏度和特异性。     

Inferior wall myocardial infarction caused by anomalous right coronary artery

A 50-year-old man without previous coronary disease presented with an inferior myocardial infarction following exercise. He was initially treated with thrombolytic therapy and nitroglycerin. Subsequent coronary angiography and cardiac computed tomography demonstrated an anomalous right coronary artery originating from the left coronary sinus and passing between the aorta and main pulmonary artery. The coronary arteries were otherwise patent. The patient later underwent transaortic unroofing of the anomalous right coronary artery and was discharged in good condition.     

Primary percutaneous coronary intervention of an anomalous right coronary artery originating from the left sinus of valsalva

The presence of an anomalous origin of a coronary artery as the infarct related vessel during primary percutaneous coronary intervention for acute ST elevation myocardial infarction is rare and may present a technical challenge. We reported on a primary coronary percutaneous intervention performed in a right coronary artery originating from the left coronary sinus. The technical tips and tricks of treating congenital coronary anomalies are reviewed.     

Percutaneous coronary intervention for acute myocardial infarction due to unprotected left main coronary artery occlusion

Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) occlusion is an uncommon clinical entity, but often leads to severe clinical deterioration, with devastating sequalae including fatal arrhythmias, abrupt and severe circulatory failure, and sudden cardiac death. Recent guidelines have promoted treatment with percutaneous coronary intervention (PCI) as a class IIa recommendation alongside coronary artery bypass grafting (CABG), but the data are still unclear regarding optimal revascularization strategy for patients with ST‐segment elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI) with ULMCA culprit. PCI has the advantages of offering rapid reperfusion to critically ill patients, often those with prohibitive risk for surgical revascularization, with acceptable short‐ and long‐term outcomes. Recent studies demonstrate that PCI of the ULMCA is a viable alternative to CABG for appropriate patient populations, including those with ULMCA occlusion and those in cardiogenic shock, Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, and significant comorbidities. A randomized trial comparing PCI with CABG is needed to clarify the ideal revascularization strategy, though the clinical picture of these critically ill patients may preclude such studies. © 2014 Wiley Periodicals, Inc.     

急性下壁心肌梗死心电图对右冠状动脉病变的诊断价值

目的探讨心电图在ST段抬高型急性下壁心肌梗死(IWAMI)时右冠状动脉(RCA)病变位置的诊断价值。方法对109例经冠状动脉造影证实右冠状动脉为梗死相关动脉患者的18导联心电图进行回顾性分析。结果心电图STV1抬高≥2mm、STV4R抬高≥1mm、STV3压低/STⅢ抬高<0.5对右冠状动脉近段闭塞的判断有较大的价值,其阳性率与右冠状动脉远段闭塞组有显著性差异,其诊断的特异性、敏感性均较高。结论ST段抬高型急性下壁心肌梗死时体表心电图与右冠状动脉闭塞位置有明显相关性。     

起源异常的右冠状动脉闭塞病变经皮冠状动脉介入治疗病例报道及文献回顾分析

目的:探讨先天性起源异常的右冠状动脉(冠脉)闭塞病变经皮冠脉介入(PCI)治疗的效果。方法:回顾性分析1例右冠脉起源异常伴心肌梗死患者的诊治经过,并总结近20年来报道的30余例右冠脉起源异常病例,通过对发病率、起源部位、指引导管选择等方面进行探讨。结果:异常右冠脉起源于左冠脉窦的报道较多,应用的指引导管类型以Amplatz、Judkins多见,但病例报道较少。结论:仍需更多的手术经验积累以及对磁共振成像、多排CT等诊断工具的科学应用。     

经桡动脉途径行急诊冠状动脉介入治疗急性心肌梗死的临床应用研究

目的探讨经桡动脉途径行急诊冠状动脉介入治疗的疗效及安全性。方法回顾性分析596例急性心肌梗死患者经桡动脉途径(桡动脉组,n=296)或股动脉途径(股动脉组,n=300)行急诊冠状动脉介入治疗的临床资料,着重分析比较两种穿刺途径的方法和并发症情况。分别记录动脉穿刺时间、X-线暴光时间、造影时间、经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗时间、住院时间及血肿等血管并发症的发生率。结果 295例经桡动脉治疗患者穿刺成功,穿刺时间(4.4±1.6)min,X-线暴光时间(4.6±1.4)min,造影时间为(8.0±2.4)min,PCI治疗时间为(30.0±4.8)min,住院时间为(3.2±1.6)d,有6例发生前臂血肿,发生率为2.03%(6/296);股动脉组299例患者穿刺成功,穿刺时间(2.4±0.8)min,X-线暴光时间(4.4±1.3)min,造影时间为(7.6±2.0)min,PCI时间为(28.6±4.4)min,住院时间为(5.4±1.8)d,有18例发生股动脉血肿,发生率为6.0%(18/300),其中2例为假性股动脉瘤形成。造影时间、PCI治疗时间两组比较,差异无统计学意义(P0.05);住院时间、并发症的发生率股动脉组高于桡动脉组,差异有统计学意义(P0.05)。结论经桡动脉行急性心肌梗死的急诊冠状动脉介入治疗是安全和可靠的,在临床实践中值得在有条件的单位有选择性地应用推广。     

Clinical implications of precordial ST-segment elevation in acute inferoposterior myocardial infarction caused by proximal right coronary artery occlusion

BACKGROUND: The clinical significance of inferior wall acute myocardial infarction (MI) with combined ST-segment elevation in both anterior and inferior leads, compared with inferior leads alone, is unknown. HYPOTHESIS: Despite having more leads with precordial ST-segment elevation, these patients may have a better outcome due to less posterior involvement, which tends to drag down the precordial ST-segment. METHODS: A total of 158 postinferior MI patients with documented proximal right coronary artery occlusion were retrospectively studied. They were divided into three subgroups according to the magnitude of concurrent ST-segment deviation in lead V2: Group A (n = 19) had ST-segment elevation >/= 2.0 mm; Group B (n = 74) had ST-segment lay between + 2.0 mm and - 2.0 mm; and Group C (n = 65) had ST-segment depression >/= 2.0 mm. The clinical and electrocardiographic characteristics were then compared among these threes subgroups. RESULTS: The baseline demography, prevalence of risk factors, and treatment received were of no difference among the subgroups. However, Group A patients had significantly lower peak creatinine phosphokinase level and more preserved left ventricular function than Group B and C. Moreover, they had lower total sum of inferior ST-segment magnitude, less ST-segment depression in V4-6, and more ST-segment elevation in V(4R) than Group C. Group C patients had highest in-hospital and one-year mortality although it did not reach statistical significance. CONCLUSIONS: Precordial ST-segment elevation in inferior wall acute MI was associated with smaller infarct size and better left ventricular function, probably secondary to occlusion of a less dominant RCA, which did not result in a significant posterior infarction.     

19例梗死相关动脉为优势左回旋支的急性心肌梗死心电图表现

目的分析19例梗死相关动脉为优势左回旋支的急性心肌梗死患者的心电图表现,总结其特点。方法回顾性分析2000年9月至2005年12月急性心肌梗死患者的心电图资料,25例急性心肌梗死经冠状动脉造影证实梗死相关动脉为优势左回旋支,选取其中发病12h内有12或18导联心电图记录的19例,分析其发病时心电图表现及特征。结果19例患者中2例表现为非ST段抬高性心肌梗死,冠脉造影证实血管已再通,血流正常。17例表现为下壁ST段抬高性心肌梗死,15例合并后壁ST段抬高,2例V4RST段抬高,14例V4RST段压低。12例ST段抬高(STIII↑>STII↑)和ST段压低(STaVL↓>STI↓)同时出现。12例aVR导联ST段压低。19例中3例合并有完全性房室阻滞,1例合并高度房室阻滞。结论梗死相关动脉为优势左回旋支的急性心肌梗死患者心电图图形特点类似右冠脉闭塞的ST段抬高心肌梗死,STIII↑>STII↑,STaVL↓>STI↓,两者很难鉴别,下壁、后壁ST段抬高而RV4和STaVR压低可能是重要特点。     

Circumflex coronary artery injury after mitral valve surgery: A report of four cases and comprehensive review of the literature

As the LCx is closely related to the mitral valve annulus, it is susceptible to perioperative injury. Various underlying mechanisms, predisposing factors, and therapeutic strategies have been suggested but disagreement exists. Using a MeSH terms‐based PubMed search, 44 cases of mitral valve surgery‐related LCx injury were detected, including our 4 cases. We provide a comprehensive review of current knowledge regarding mitral valve surgery‐related left circumflex coronary artery (LCx) injury. Preoperative coronary angiography was performed in 55% (n = 24). Coronary abnormalities were present in 11% (n = 5). Coronary dominance was reported in 73% (n = 32), predominantly showing left (69%, n = 22) or balanced (19%, n = 6) circulations. Right coronary dominance was present in 12% (n = 4). Ischemia was detected in the perioperative or early postoperative phase in 86% (n = 30). Delayed symptoms were present in 14% (n = 5). Echocardiography demonstrated new regional wall motion abnormalities in 80% (n = 24), but was negative in 20% (n = 6) despite coronary compromise. Electrocardiography showed myocardial ischemia in 97% (n = 34), including regional ST‐segment elevations in 68% (n = 23). Primary treatment was surgical in 42% (n = 15) and percutaneous in 58% (n = 21), reporting success ratios of 87% (n = 13) and 81% (n = 17), respectively. We confirm an augmented risk of mitral valve surgery‐related LCx injury in balanced or left‐dominant coronary circulations. Preoperative knowledge of coronary anatomy does not preclude LCx injury. An anomalous LCx arising from the right coronary cusp was identified as a possible specific high‐risk entity. Electrocardiographic monitoring and intraoperative echocardiography remain paramount to ensure a timely diagnosis and treatment. © 2016 Wiley Periodicals, Inc.     

左主干急性闭塞的急诊PCI分析

目的探讨左主干病变导致的急性心肌梗死与心源性休克的关系以及急诊经皮冠状动脉介入对其的疗效。方法1999年9月至2005年6月连续就诊于中国医科大学附属盛京医院心内科并且行急诊冠脉造影的急性心肌梗死患者752例，发现因左主干急性闭塞导致血管床灌注评分（TIMI）血流在2级或2级以下者16例（2．12％），所有患者行急诊经皮冠状动脉介入（PCI）治疗，观察住院期间病死率。结果16例患者中，9例（56.25％）住院期间死亡，7例（43．75％）出院。死亡组再灌注成功率42．86％。生存组为100％，两组间比较差异有显著性意义（P=0．029）。未成功再灌注的5例均由无复流引起，其中3例可见肉眼血栓，5例患者均死亡。16例患者中有12例发生心源性休克，发生率为75．00％，死亡组发生率100％，生存组42．85％，两组间比较差异有显著性意义（P=0．019）。心源性休克患者住院病死率为75．00％高于无休克者，死亡风险是无休克者的4倍[比值比（OR）=4．0，95％可信区间1．50—10．66，P=0．019]。结论左主干闭塞导致的急性心肌梗死患者出现心源性休克的发生率较高，且即使成功地施行了PCI治疗，也有较高的病死率。不过，急诊PCI在临床实践仍然是有效可行的治疗手段，可以有效地挽救部分生命。     

左主干急性闭塞的急诊PCI分析

目的探讨左主干病变导致的急性心肌梗死与心源性休克的关系以及急诊经皮冠状动脉介入对其的疗效。方法1999年9月至2005年6月连续就诊于中国医科大学附属盛京医院心内科并且行急诊冠脉造影的急性心肌梗死患者752例,发现因左主干急性闭塞导致血管床灌注评分(TIMI)血流在2级或2级以下者16例(2.12%),所有患者行急诊经皮冠状动脉介入(PCI)治疗,观察住院期间病死率。结果16例患者中,9例(56.25%)住院期间死亡,7例(43.75%)出院。死亡组再灌注成功率42.86%,生存组为100%,两组间比较差异有显著性意义(P=0.029)。未成功再灌注的5例均由无复流引起,其中3例可见肉眼血栓,5例患者均死亡。16例患者中有12例发生心源性休克,发生率为75.00%,死亡组发生率100%,生存组42.85%,两组间比较差异有显著性意义(P=0.019)。心源性休克患者住院病死率为75.00%高于无休克者,死亡风险是无休克者的4倍[比值比(OR)=4.0,95%可信区间1.50～10.66,P=0.019]。结论左主干闭塞导致的急性心肌梗死患者出现心源性休克的发生率较高,且即使成功地施行了PCI治疗,也有较高的病死率。不过,急诊PCI在临床实践仍然是有效可行的治疗手段,可以有效地挽救部分生命。     

Values of electrocardiography and two-dimensional echocardiography to identify myocardial infarction due to left circumflex and right coronary artery disease

To investigate the value of the 12-lead ECG and two-dimensional echocardiography (2DE) in the distinction of left circumflex (LCX) from right coronary artery (RCA) disease, we analyzed the location of Q waves, infarct lesions, and coronary artery narrowings in 26 patients with angiographically documented single-vessel disease. Q waves in leads II, III, and aVF were associated with the posterior wall (PW) lesions at the papillary muscle level. Extensive lesions from the PW to the posterior septum (PS) identified RCA disease, while extension to the lateral wall (LW) identified LCX disease. Eleven of 12 patients with high posterior infarction (tall R wave in V₁) were found to have extensive LW lesions and 10 of these had coronary narrowings in or proximal to the obtuse marginal branch of LCX. All 6 patients with high posterior infarction and high lateral infarction (Q in I or aVL) had infarct lesions extending from the LW to the anterior wall (AW) and were associated with LCX disease with a large obtuse marginal branch. Of 10 patients with Q waves in V₆, the apical LW and PW were involved in 7 and either segment in 3. Nine of these 10 patients had LCX disease. It is concluded that the location of Q waves in inferior infarction could aid in recognizing infarct extension and underlying coronary artery disease.     

急诊经桡动脉与股动脉入路介入治疗ST段抬高急性心肌梗死对比研究

目的观察经桡动脉入路行急诊ST段抬高急性心肌梗死直接经皮冠状动脉介入(PCI)治疗的有效性和安全性。方法选择沈阳军区总医院2005年1月至2006年10月连续607例ST段抬高性急性心肌梗死(STEMI)住院患者,分别接受经桡动脉入路(273例)或经股动脉入路(334例)途径行PCI治疗,观察两组手术成功率和并发症发生率。结果两组患者PCI成功率差异无统计学意义(97.07%对95.81%,P>0.05)。经桡动脉入路组局部血肿、假性动脉瘤、迷走反射发生率显著低于经股动脉入路组。结论行PCI治疗的STEMI患者经桡动脉入路途径是安全、有效和可行的方法,与经股动脉比较,经桡动脉途径可减少并发症的发生。