Left main coronary artery atresia diagnosed by multidetector computed tomography

Left main coronary artery atresia is an extremely rare disease. Differential diagnosis of left main coronary artery atresia from atherosclerotic occlusion of left main coronary artery is difficult even if performing invasive coronary angiography. We present a case of a 48-year-old male with left main coronary artery atresia. Echocardiography showed left ventricular dysfunction. Invasive coronary angiography showed absence of left main coronary artery. A multidetector computed tomography showed a string-like structure at the site of left main coronary artery. A diagnosis of left main coronary artery atresia was made, and he underwent coronary artery bypass grafting. At the operation, a thin and not-sclerotic left main coronary artery was observed. Echocardiography, performed after the surgery, showed normalization of the left ventricular systolic function. Multidetector computed tomography might be a useful method to diagnose left main coronary artery atresia.     

Pancreatoduodenectomy after coronary artery bypass grafting using the right gastroepiploic artery: a case report

We herein report the case of an advanced ampullary cancer developed 80 months after coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA) and successfully treated by pancreaticoduodenectomy (PD) with revascularization using the great saphenous vein. A 69-year-old Japanese male was admitted for examination with one-month history of nausea and appetite loss. He underwent three vessel CABG, involving bypassing between the right coronary artery and RGEA about 80 months before. The preoperative diagnosis with CT scan and gastric endoscope was carcinoma of the papilla of Vater. Preoperative abdominal angiography showed the RGEA graft remained well patent. He underwent PD with regional lymph node dissection after revascularization of the RGEA. The postoperative clinical course was uneventful. The histopathological examinations of the resected specimen revealed adenocarcinoma of the ampulla, pT2, pN0, M0 stage IB. The patient is currently alive without any further signs of ischemic heart disease several months after his operation. This case report demonstrates that the radical PD with revascularization using other vein graft can be safely performed after CABG using the RGEA.     

Ventricular tachycardia in a man with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute ischemic coronary events. It is more prevalent in young women, particularly in the peripartum period. In men it is an extremely rare cause. We described the clinical course of a patient, man, presenting pain chest and ventricular malignant arrhythmias. Four days after admission the patient underwent coronary angiography, showing a large SCAD. After this, he had undergone coronary artery bypass surgery. He presented an angiography and clinical resolution and he was still asymptomatic at a 6-month clinical follow up. Pathophysiologic aspects and treatment options of spontaneous coronary artery dissection are discussed.     

Myocardial revascularization in a patient with situs inversus totalis

We report the case of a patient with dextrocardia and situs inversus totalis associated with obstructive coronariopathy in the anterior and posterior descending arteries, right coronary artery, first diagonal branch and left marginal branch. The patient underwent coronary artery bypass grafting surgery. This surgery has been rarely reported in literature and we found only one similar case in the national medical literature. The myocardial revascularization was carried out with the right mammary artery for the anterior descending artery. The saphenous vein anastomosed the aorta to the right coronary artery, left marginal branch, fist diagonal branch and posterior descending artery. The surgery was performed with extracorporeal circulation.     

Recurrent acute coronary events in a young adult

Acute myocardial infarction (MI) in young adults is rare. Clinicopathological conditions such as nephrotic syndrome, antiphospholipid syndrome, spontaneous coronary artery spasms or embolism can be attributed to such events. In this case report, we present a 30-year-old male who had his first MI at the age of 20 years. He received percutaneous intervention as initial treatment. Despite aggressive risk factor management, he continued to have acute coronary events and was later diagnosed with antiphospholipid syndrome (APS). At the same time, he was diagnosed with severe chronic thromboembolic pulmonary hypertension and severe tricuspid regurgitation. He underwent pulmonary endartererectomy, tricuspid annuloplasty and radial artery bypass graft to the first obtuse marginal artery. Warfarin therapy was initiated upon the diagnosis of APS. Despite being therapeutic on warfarin and aggressive risk factor management, he had yet another MI. Coronary angiogram at this time showed fresh occlusion of the right coronary artery at the mid-segment, and the patient received two overlapping stents that achieved a good effect. This case emphasizes the importance of awareness, early recognition and aggressive management of patients with APS presenting chest pain or acute coronary events. Despite appropriate treatment, such as risk factor management and percutaneous interventions, recurrence of an acute coronary event is high. The presentation of younger patients with recurrent coronary events but no significant risk factors of atherosclerosis should evoke the suspicion of APS-related coronary artery disease, and all risk factors should be aggressively managed.     

Coronary angiography in cardiac myxomas: Findings in 19 consecutive cases and review of the literature

We reviewed the coronary angiographic findings of 19 patients with a cardiac myxoma, who underwent cardiac catheterization before surgery. Seventeen myxomas were localized in the left atrium and seven had angiographically visible tumor vascularity emerging from atrial branches of the right coronary artery in four patients and the circumflex coronary artery in three. In one patient, we found significant coronary artery disease of the circumflex coronary artery and in another we saw a thrombus-like lesion in the proximal third of the left anterior descending coronary artery. Our results are compared with the findings in two smaller groups of patients with cardiac myxoma who underwent coronary angiography preoperatively. We conclude that the major importance of coronary angiography in patients with cardiac myxomas is to exclude concomitant coronary artery disease before surgery. In a very small minority of patients, a selective coronary angiography is the clue to the diagnosis of cardiac myxoma. © 1993 Wiley-Liss, Inc.     

Right coronary artery to left ventricle fistula associated with three-vessel coronary artery disease: a case report

Right coronary artery to left ventricle fistula is a rare type of coronary artery fistula among congenital coronary artery anomalies. Most patients exhibit no symptoms and some experience chest pain. Coronary angiography sometimes detects the presence of coronary artery fistula, but not coronary arteriosclerosis. A 76-year-old man with unstable angina was admitted because he did not respond to drug therapy. Coronary angiography showed three-vessel coronary artery disease and the contrast agent entered the left ventricle from the terminal of the right coronary artery during diastole. Multidetector-row computer tomography showed similar findings. The patient subsequently underwent coronary artery bypass grafting and obliteration of the coronary artery fistula. The chest pain was relieved and he is now in good condition.     

Cirurgia de revascularização coronária após doença de Kawasaki

Kawasaki disease (KD) is a systemic vasculitis of unknown etiology, which is the main cause of acquired heart disease in children in developed countries. The main complications result from the development of coronary aneurysms which can lead to ischemic heart disease.We present the case of a teenage boy with a diagnosis of KD at the age of seven. He was treated with gammaglobulin and aspirin and echocardiographic evaluation in the acute phase was apparently normal. At the age of eleven, he developed chest pain and exertional dyspnea. Nuclear perfusion scans with exercise revealed hypoperfusion of the left anterior descending (LAD) and right coronary (RC) artery territories. Cardiac catheterization showed occlusion of the proximal segments of both arteries. He underwent coronary artery bypass graft surgery (internal mammary artery bypass graft to the LAD artery and saphenous vein graft to the RC artery), with a good clinical result.This case report highlights the importance of early diagnosis and treatment of KD and regular cardiological follow-up, bearing in mind the potential late complications of this pediatric disease.     

Learning on the Web. Case 1: syncope and palpitation in a patient following aortic valve replacement

A usually very fit man aged 90 presented with syncope and angina of effort. He was found to have severe calcific aortic stenosis and associated coronary disease restricted to the left anterior descending (LAD) coronary artery. He underwent an aortic valve replacement with tissue prosthesis and a single coronary graft to the LAD. He came off bypass without difficulty but on the third postoperative period, when he had left the intensive care unit and was making excellent progress mobilising, he had further episodes of syncope and also developed palpitations. The significance of these symptoms and the diagnosis and treatment of these postoperative problems is discussed in an interactive case presentation.     

Clinical characteristics and long-term prognosis of patients with variant angina. A comparative study between western and Japanese populations

To determine the factors influencing the prognosis of variant angina, the clinical characteristics and long-term prognosis of 158 consecutive Japanese patients were examined and compared with those in previous major western studies (Pisa, Montreal, and Duke studies). The Japanese patients were characterized by relatively low prevalences of coronary risk factors, significant coronary stenoses and previous myocardial infarction. Survival and survival without myocardial infarction for the entire group or for the subpopulation with significant coronary artery disease were significantly better in the Japanese population than in the western populations; however, in the subpopulation without significant coronary artery disease, the prognosis was excellent in all four studies. If the prevalence of coronary artery disease was corrected for the Japanese population, there would be no difference in the prognosis between the Japanese and the western populations. It is concluded: (1) the overall prognosis of variant angina may be better in Japanese patients, and (2) coronary artery disease appears to be the strongest prognostic factor for assessing the differences in the prognosis between the Japanese and the western populations.     

Multiple Left Internal Mammary Artery-to-Pulmonary Artery Fistulae 15 Years after Coronary Artery Bypass Grafting

Left internal mammary artery (LIMA)-to-pulmonary artery fistulae rarely develop after coronary artery bypass grafting. Fewer than 30 cases of these fistulae have been reported since 1947. Nevertheless, this entity should be considered as a cause of recurrent angina after bypass surgery, in the absence of other causes. We present the case of a 67-year-old man with cardiac symptoms in whom multiple LIMA-to-pulmonary artery fistulae were found, 15 years after he had undergone coronary artery bypass grafting. The diagnosis was confirmed by means of coronary angiography with selective catheterization of the LIMA and by computed tomographic angiography of the heart. The patient underwent reoperative 2-vessel coronary artery bypass grafting and ligation of multiple fistulae; 16 months postoperatively, he was asymptomatic and doing well. In addition to reporting this case, we discuss relevant diagnostic and treatment considerations.Key words: Arteriovenous malformations/physiopathology, coronary artery bypass/adverse effects, fistula/etiology, internal mammary-coronary artery anastomosis/adverse effects, mammary arteries/surgery, myocardial ischemia/etiology, pulmonary artery/surgery, vascular fistula/complications/etiology/surgeryAs a bypass-graft conduit to the left anterior descending coronary artery (LAD), the left internal mammary artery (LIMA) is the vessel of choice because of its proven longevity and long-term patency. The formation of a LIMA-to-pulmonary artery (PA) fistula after coronary artery bypass grafting (CABG) is a rare complication: fewer than 30 reports have appeared in the medical literature.¹ We report a case of multiple LIMA-to-PA fistulae that we found 15 years after a patient had undergone CABG.     

Single coronary artery anomaly: branching of left coronary artery from right coronary artery with 2 distinct patterns

Normal coronary vasculature has a left coronary artery arising from the left coronary cusp and a right coronary artery arising from the right coronary cusp. In about 0.024% of cases in the general population, there is no left main coronary artery. In fact, there is a single coronary artery, which arises from the right coronary cusp. We encountered 2 such cases with distinct patterns. The first case was a patient with angina who had an abnormal stress test for which he underwent coronary angiography. This revealed a single coronary artery arising from the right coronary cusp. This vessel gave rise to the right coronary artery, which had a varicose anatomy, with a critical lesion in the posterior descending artery. The left coronary artery passed anteriorly to the pulmonary artery with a critical lesion in the circumflex artery. In the second case, the patient also had angina with a normal noninvasive work-up but due to his persistent symptoms, coronary angiography was performed. This revealed a single coronary artery arising from the right coronary cusp. Subsequent CT angiography revealed that the left coronary artery coursed in between the aorta and pulmonary artery without critical lesions. In both cases, the patients underwent coronary artery bypass grafting.     

The whole nine yards: multiple cardiac surgical and percutaneous interventions in a patient during 30 years of care

A 38-year-old man underwent coronary artery bypass graft surgery for angina pectoris following myocardial infarction. During the following 28 years, he required two repeat coronary artery bypass graft surgical procedures, nine percutaneous coronary interventions and 17 coronary angiograms. His treatment included saphenous vein, left internal mammary artery and gastroepiploic artery grafting, percutaneous transluminal coronary angioplasty and intragraft thrombolytic therapy, directional coronary atherectomy, cutting balloon angioplasty, intracoronary stenting with bare-metal and drug-eluting stents, treatment for in-stent restenosis, stenting of the left main and circumflex coronary arteries and saphenous vein graft as well as intracoronary pressure wire diagnostics. In addition to his statin therapy, antiplatelets and angiotensin-converting enzyme inhibitors, he also underwent biventricular automatic implantable cardioverter-defibrillator implantation and atrioventricular node radiofrequency ablation for his impaired left ventricular function, ventricular tachycardia and rapid atrial fibrillation. The present unusual case represents almost 'the whole nine yards' of treatment that has become available to patients with coronary artery disease during the past 30 years of technological development.     

Anomalous origin of the right coronary artery from the pulmonary artery associated with tetralogy of Fallot: description of the pre-surgical diagnosis and surgical repair

Anomalous origin of the right coronary artery from the pulmonary artery is a rare congenital defect. We describe the case of an infant with anomalous origin of the right coronary artery from the pulmonary artery in association with tetralogy of Fallot. This patient had a pre-operative echocardiographic diagnosis, which was confirmed by angiography, and later underwent a successful surgical repair.     

Takayasu arteritis with coronary aneurysms causing acute myocardial infarction in a young man

Takayasu arteritis is an inflammatory condition that involves the large cardiac vessels, predominantly the aorta and its main branches. It typically affects young women (age, ≤40 yr), most often Asians and Latin Americans. Herein, we describe a rare manifestation of Takayasu arteritis in a 19-year-old black Tunisian man who presented with acute inferior myocardial infarction and complete atrioventricular block after occlusion from a giant aneurysm in the right coronary artery. The coronary artery disease was associated with aneurysmal dilations in the carotid, vertebral, and right renal arteries. Medical therapy improved Thrombolysis in Myocardial Infarction flow in the area of the giant aneurysm from grade 1 to grade 3. Upon the diagnosis of Takayasu arteritis, intravenous methylprednisolone and oral prednisone therapy was started. After 10 days of hospitalization, the patient was discharged on a medical regimen. Renovascular hypertension due to renal artery stenosis was suspected, so he underwent successful percutaneous transluminal angioplasty of the inferior segmental artery of the right renal artery. During 12 months of close postprocedural monitoring, he experienced lower blood pressure, no chest pain, and no cardiovascular complications.This association of conditions has not been previously reported. Besides presenting this very rare combination of findings, we discuss the differential diagnosis of Takayasu arteritis in our patient.     

A change in the pattern of vasospasm after stenting in a patient with vasospastic angina

We report an unusual case of a male patient with vasospastic angina in whom the pattern of coronary artery spasm changed after coronary stenting. The patient was admitted to our hospital with an acute coronary syndrome. Coronary angiography revealed an intermediate grade stenosis in the right coronary artery, and focal coronary spasm was provoked by intracoronary acetylcholine. A diagnosis of vasospastic angina was made, and the patient was followed medically. He subsequently was readmitted with refractory vasospastic angina and underwent coronary stenting. He was pain-free after stent implantation. Repeat angiography 6 months later showed no restenosis in the stented segment; however, coronary spasm was provoked in all areas except the stented segment by intracoronary acetylcholine injection.     

Symptomatic bradycardia due to total occlusion of left circumflex artery without electrocardiographic evidence of myocardial infarction at initial presentation

We present the case of a 72-year-old man who was admitted due to low blood pressure and acute-onset dizziness with sinus bradyarrhythmia on electrocardiography. He had no obvious anginal symptoms, and there was no marked evidence of myocardial infarction. He was ultimately diagnosed with coronary artery disease with total occlusion of the left circumflex coronary artery, and he underwent successful coronary angioplasty after primary conduction disorders were ruled out.     

Giant tumorous lesions (correction of legions) surrounding the right coronary artery associated with immunoglobulin-G4-related systemic disease

Immunoglobulin G4 (IgG4)-related systemic disease was first recognized as a clinicopathological entity about 10 years ago, and since then, it has attracted growing attention. It is an autoimmune disease which affects multiple organs including the pancreas, bile duct, salivary glands and retroperitoneum. Further, it was recently reported that it can be manifested as periarteritis, often as inflammatory abdominal aortic aneurysm. We describe the case of a 75-year-old man with autoimmune pancreatitis and parotitis who presented with angina. The serum concentration of IgG4 was significantly increased at 2,510 mg/dl. Coronary angiography showed multiple stenotic lesions and pronounced dilatation of the right coronary artery. Cardiac computed tomography disclosed increased wall thickness of the coronary arteries and focal tumorous lesions surrounding the right coronary artery. Treatment with steroids proved only marginally effective and he underwent surgical resection of the aneurysm and coronary artery bypass grafting. The diagnosis of IgG4-related systemic disease was confirmed by histological examination of the resected mass, which showed a massive infiltration of IgG4-positive plasma cells. This case emphasizes the importance of considering the diagnosis in any patient with abnormally increased wall thickness or ectatic lesions in the coronary arteries.     

Pericardial fat accumulation in men as a risk factor for coronary artery disease.

An increment of abdominal visceral fat accumulation has been reported to be a coronary risk factor. We determined the predictive power of pericardial fat (Pfat) accumulation as intra-thoracic visceral fat, in the diagnosis of coronary artery disease (CAD). Among 251 (181 non-obese [body mass index<25], 70 obese [body mass index> or =25]) Japanese male patients who underwent computed tomography (CT), 128 (90 non-obese, 38 obese) patients were suffering from CAD. Pfat volume was determined by the sum of cross-sectional images 1cm thick from the atrial appendage to the apex over the diaphragm. Abdominal visceral fat (Vfat) and subcutaneous fat (Sfat) areas were measured by a single scan at the L4-L5 region. Pfat was most associated with Vfat in body fat distribution. In non-obese patients, Pfat was most associated with CAD among the various risk factors including body fat distribution. Moreover, Pfat was the strongest independent variable for the severity of CAD, determined by coronary angiogram. This result showed that pericardial fat accumulation was a stronger coronary risk factor than the other body fat distributions in non-obese men.     

Intravascular ultrasound for angiographically indeterminant left main coronary artery disease

The precise diagnosis of the presence of significant left main coronary artery disease has profound prognostic and therapeutic implications. Coronary cineangiography has shown to be imprecise and inaccurate to determine the percent stenosis of the left main coronary artery. We report a case with significant left main coronary artery disease in whom coronary cineangiography was in discordance with the clinical data and intravascular ultrasonography. Based on the intravascular ultrasound findings, the patient underwent coronary artery bypass graft surgery. Therefore, the intravascular ultrasonography may be the procedure of choice for assessing indeterminant left main coronary artery lesions by coronary angiography.