Left anterior descending coronary artery obstruction. Clinical, electrocardiographic, and angiographic correlates.

Seventy-six patients with severe (greater than 80%) occlusive left anterior descending coronary artery disease by coronary angiography were examined for the electrocardiographic characteristics of this disease in the presence (group A 59 patients) or the absence (group B 17 patients) of anterior wall asynergy (akinesis or dyskinesis). The incidence of clinically documented anterior myocardial infarction in these two groups of patients was examined. The collateral circulation to the left anterior descending coronary artery was also examined in the groups of patients with and without anterior wall asynergy. Thirty-eight of 59 (64%) patients with anterior wall asynergy (group A) showed electrocardiographic signs of anterior myocardial infarction, 17 per cent showed probable electrocardiographic signs of anterior myocardial infarction and 19 per cent showed no electrocardiographic signs. None of the 17 patients without anterior wall asynergy (group B) showed electrocardiographic signs of anterior myocardial infarction. In group A 74.6 per cent had documented clinical evidence of previous anterior myocardial infarction. Collateral filling of the distal left anterior descending coronary artery was seen in 71 per cent of group A and 100 per cent of group B patients. There was a significantly higher incidence (P = 0.02) of collateral filling in the patients without electrocardiographic evidence of definite anterior myocardial infarction (93% of 28 patients), than in those who showed definite electrocardiographic evidence of anterior myocardial infarction (66% of 38 patients).it is concluded that severe occlusive left anterior descending coronary artery disease with anterior wall myocardial asynergy is usually associated with electrocardiographic signs of anterior myocardial infarction, whereas equally severe left anterior descending coronary artery disease without anterior wall asynergy is rarely associated with electrocardiographic abnormalities of anterior myocardial infarction. Severe left anterior descending coronary artery obstruction without electrocardiographic and angiographic evidence of anterior myocardial infarction is usually associated with collateral circulation to the left anterior descending coronary artery and collateral circulation to the left anterior descending coronary artery is present less frequently when obstruction is associated with anterior myocardial infarction.     

An unusual electrocardiographic presentation of acute obstruction of the left anterior descending coronary artery

Acute obstruction of the left anterior descending coronary artery is generally presented electrocardiographically as isolated anterior or combined anterior and inferior ST-elevation myocardial infarction. We described an isolated inferolateral ST-elevation myocardial infarction due to acute occlusion of the distal left anterior descending coronary artery.     

Left anterior descending artery length in left and right coronary artery dominance

BACKGROUND: Coronary stenosis of the left anterior descending artery (LAD) is respected by cardiologists because of its negative influence on morbidity and mortality. An important anatomical consideration is the length of the LAD. OBJECTIVE: To investigate the relationship between length of LAD and coronary dominance. DESIGN: Retrospective comparison of 100 consecutive angiograms with left coronary dominance with 100 consecutive angiograms with right coronary dominance. The relationship between the length of the LAD and coronary dominance was analyzed. METHODS: We retrospectively compared 100 consecutive angiograms with left coronary dominance (the posterior descending artery being supplied by the circumflex artery) with 100 consecutive angiograms with right coronary dominance (the posterior descending artery being supplied by the right coronary artery). LADs were categorized into three types: type A, LAD terminating before the cardiac apex; type B, LAD reaching the apex but not supplying the inferoapical segment of the left ventricle; and type C, LAD wrapping around the apex and supplying the inferoapical segment. LAD typing was also analyzed in relation to gender. RESULTS: It was found that the LAD wrapped around the apex in 87% of cases of left coronary dominance but only in 47% of patients with right coronary dominance, and that the long LADs were more frequently seen in women than in men, irrespective of coronary dominance. CONCLUSIONS: We found that the LAD in left coronary dominance is usually long and wraps around the apex, and believe that angiographic interventions in such cases have important clinical significance.     

Left anterior descending coronary artery to right ventricular fistula complicating coronary stenting.

Coronary artery perforation is a rare complication of percutaneous transluminal coronary angioplasty (PTCA) and coronary stenting, most commonly creating a communication between the coronary artery lumen and the pericardial space. We report a case where vessel rupture following stent deployment led to the development of a fistula between the left anterior descending coronary artery and the right ventricle.     

Ectopic origin of the left anterior descending coronary artery from the right coronary sinus. Report of a case simulating anterior descending obstruction.

A patient with anomalous aortic origin of the left anterior descending coronary artery was studied. The clinical picture and the preliminary angiographic findings simulated obstruction of the left anterior descending coronary artery near its origin. Careful catheter exploration of the right coronary sinus led to the correct diagnosis, emphasizing the importance of complete visualization of all branches of the coronary tree, including distal radicles of a supposedly occluded vessel.     

Left coronary dominance due to direct continuation of the left anterior descending to form the posterior descending coronary artery.

Continuation of the left anterior descending to form the posterior descending artery is rarely observed. We describe the first patient with this variant in whom the coronary artery extends beyond the crux, supplying branches to the atrioventricular node and both atrioventricular grooves.     

Clinical, angiographic, hemodynamic, perfusional and functional changes after one-vessel left anterior descending coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) was successfully performed in 20 patients with 1-vessel left anterior descending (LAD) coronary artery disease. Exercise capacity in terms of peak workload, heart rate and systolic blood pressure all increased significantly 1 week after PTCA. All patients had some decrease in stenosis size and gradient. All patients except 1 had an improvement in functional class. Eight of 12 patients with abnormal exercise electrocardiograms before PTCA had normal electrocardiograms after the procedure. Exercise thallium-201 (TI-201) myocardial perfusion images obtained in all 20 patients before and 1 week after PTCA were analyzed using a new computer method designed to quantitate regional myocardial TI-201 distribution, redistribution and clearance rate. Significant improvement in TI-201 activity was present in the anterior and septal segments of the left ventricle 1 week after PTCA. This increase in TI-201 uptake was associated with a significant reduction in the amount of TI-201 redistribution between initial and delayed postexercise images in the same regions. TI-201 clearance rate in the segments supplied by the dilated vessel also improved significantly. Abnormal TI-201 lung uptake was seen in 17 patients before and in 4 patients after PTCA. Exercise ejection fraction response and septal wall motion also improved after PTCA of the LAD stenosis in all 17 patients who had exercise radionuclide ventriculography. Improvement in clinical, angiographic and hemodynamic factors as well as in global and regional myocardial perfusion and function occurs after PTCA for 1-vessel LAD coronary artery disease.     

Dual anterior descending coronary artery associated with coronary artery disease

The patient is a male with risk factors for coronary artery disease, who was referred for cardiac catheterization after acute myocardial infarction in the inferior wall. The patient underwent transluminal coronary angioplasty in the right coronary artery with successful stent implantation.     

Left internal mammary artery grafting to left anterior descending coronary artery by minimally invasive direct coronary artery bypass approach

New surgical techniques for the treatment of the isolated lesion of the left anterior descending coronary artery (LAD) include off-pump surgery, minimal access to the heart, and endoscopic or computer enhanced coronary artery bypass surgery. The term minimally invasive direct coronary artery bypass surgery (MIDCAB) is related to a leftside minithoracotomy, the harvest of the left internal mammary artery (IMA) under direct vision, and an anastomosis performed between IMA and LAD under direct vision, using the technique of mechanical local immobilization by a special device. Alternative techniques include endoscopic harvesting of the IMA, or as a new and still experimental approach, the closed-chest total endoscopic coronary artery bypass grafting (TECAB) with the use of a high tech telemanipulator system. The currently reported results demonstrate the safety of MIDCAB surgery (30-day mortality < 0.5%, perioperative myocardial infarction < 2%, early patency rate between 95% and 98%). Mid-term results after 6 months have shown a patency rate between 94% and 97%, and more than 90% of the patients are without any angina symptoms. Due to this promising results MIDCAB is an alternative treatment for high-grade LAD lesions.     

Left anterior descending coronary artery stenosis: in a patient with takotsubo cardiomyopathy

Takotsubo cardiomyopathy is characterized by chest pain, electrocardiographic abnormalities such as ST-segment elevation or depression, and elevated cardiac enzyme levels. Left ventriculography reveals transient akinesis of the involved segment of the myocardial wall (usually the left ventricular apex) and compensatory hyperkinesis of the noninvolved myocardium, which appears as apical ballooning during systole. Existing criteria for the diagnosis of takotsubo cardiomyopathy include the absence of obstructive coronary artery disease. Indeed, previous investigators have found incidental stenosis in only a minority of patients.Herein, we present the unusual case of an 84-year-old woman who sustained 4 episodes of takotsubo cardiomyopathy in 18 years. At the time of the initial episode, coronary angiography revealed no substantial stenosis. Concomitant with the 2nd episode, stenosis in the 1st obtuse marginal branch was treated with stenting. No new lesions were apparent after the patient's 3rd presentation, and the previously placed stent was patent. During the 4th (current) presentation, we detected and percutaneously treated severe stenoses in the patient's left anterior descending coronary artery and 2nd obtuse marginal branch.Although this report is of a single patient only, it definitively illustrates that severe coronary artery disease can occur in patients who have takotsubo cardiomyopathy. We recommend the thorough evaluation of possible coronary artery disease in high-risk patients, even upon the strong clinical suspicion of takotsubo cardiomyopathy.     

Left anterior descending coronary artery myocardial bridging detected by 64-multidetector computed tomography

A 59-year-old female came to the clinic to evaluate an operation risk of knee joint arthritis. She has history of hypertension for 6 years. She complained of dyspnea on exercise before. Radionuclide imaging demonstrated large moderate perfusion defect in anterior, anteroseptal, and anterolateral regions with significant reversibility. ECG gated 64-multidetector computed tomography demonstrated the middle third of the left anterior descending coronary artery myocardial bridging. The length of tunneled artery was 23 mm and the depth of tunneled artery was 3 mm. Coronary angiogram confirmed the middle third of the left anterior descending coronary artery myocardial bridging. Multidetector computed tomography is a reliable and noninvasive tool for diagnosing coronary myocardial bridging.     

Left main coronary artery disease: radionuclide angiographic function versus anatomic correlates with visual and quantitative angiographic methods

The results of exercise radionuclide angiography in 29 patients with significant left main coronary artery stenosis were examined to correlate functional left ventricular performance with anatomic severity of left main coronary artery stenosis. Change in ejection fraction, regional wall motion, and peak ejection fraction were widely variable; none of these parameters correlated with severity of left main stenosis as assessed by visual or quantitative angiographic methods. Twenty-five patients (86%) had two or more of the following indicators of ischemia with exercise: chest pain, significant ST-segment depression, systolic hypotension, definite decrease in ejection fraction, or definite decline in regional wall motion. However, four patients (14%) had only mild abnormalities in ejection fraction and regional wall motion, although they did have hemodynamic and electrocardiographic evidence of severe ischemia. Exercise radionuclide angiography yields heterogeneous results in patients with significant left main coronary artery stenosis. Anatomically severe left main coronary artery stenosis is not always associated with mechanical evidence of severe ischemia.     

An angiographic and intravascular ultrasound study of the left anterior descending coronary artery in takotsubo cardiomyopathy

The precise cause of takotsubo cardiomyopathy (TC) remains controversial. Plaque rupture with transient thrombotic occlusion of a transapical left anterior descending coronary artery (LAD) has been advanced as a potential mechanism. To explore this hypothesis, the investigators analyzed data from 11 patients prospectively enrolled in the Rhode Island Takotsubo Cardiomyopathy Registry who underwent coronary angiography and intravascular ultrasound evaluation of the LAD during their initial presentation. Despite the presence of nonobstructive coronary artery disease, no culprit lesion was identified in any patient. Similarly, the course of the LAD failed to account for the characteristic left ventricular apical ballooning seen in TC. In conclusion, an atherosclerotic coronary lesion in the LAD causing an aborted myocardial infarction may not be the primary underlying cause of TC, and nonobstructive coronary artery disease and TC may coexist without a direct causal association.     

Assessment of left ventricular function in patients with isolated severe disease of the left anterior descending artery: Clinical,electrocardiographic, hemodynamic,and angiographic correlations

The purpose of this study was to define the spectrum of left ventriculographic (LV) abnormalities in 60 patients with isolated ≥90% diameter narrowing of the left anterior descending artery (LAD). The patients were divided into three groups: Group I (26 patients) had normal left ventricular (LV) function with ejection fraction (EF) of >60% and no akinetic-dyskinetic segment representing abnormal contracting segments (ACS) of the left ventricular wall; Group II (15 patients) had mild to moderate LV dysfunction with EF of 40–60% and an akinetic-dyskinetic segment of < 30% of the end diastolic perimeter (0–30%; mean, 11.6%) and Group III (19 patients) had severe LV dysfunction with EF <40%, or an akinetic-dyskinetic segment of ≥30 % (30–81%; mean, 41.5%) or both. The data obtained from the history, physical examination, electrocardiogram (ECG), chest x-ray studies, hemodynamic studies, left ventriculography, and coronary arteriography were entered and filed on a memory disc in an IBM 370-168 computer. Analysis of the results showed: (1) more severe LV dysfunction is associated with increased incidence of large hearts, gallops, decreased cardiac output, and occlusion of the LAD. (2) ECG evidence of infarction is also associated with higher incidence of the abnormalities of the indices of LV dysfunction. (3) LAD occlusion (versus stenosis) has a higher incidence of severe LV dysfunction and prior infarction. (4) The site of LAD disease did not predict the extent of left ventricular dysfunction. (5) Collaterals did not protect against severe LV dysfunction.     

Giant left anterior descending coronary artery aneurysm

Small atherosclerotic coronary artery aneurysms are a relatively frequent incidental finding at angiography. We report an unusual case in that the aneurysm found was extremely large and therefore potentially at risk of rupture.     

Single coronary artery, anomalous origin of the right coronary artery from the left anterior descending artery.

We present a patient with an abnormal origin of the right coronary artery from the left anterior descending artery. The patient had chest pain probably related to myocardial ischaemia. This anomaly is very rare and has previously been reported in only three cases. The abnormal vessel travelled rightwards and remained anterior to the main pulmonary artery, it was free of significant stenosis. The mechanism of anterior myocardial ischaemia remains unexplained.