Surgical angioplasty of ruptured left anterior descending coronary artery without cardiopulmonary bypass.

We report a case of successful off-pump surgical angioplasty in the left anterior descending coronary artery using a saphenous vein patch. A 49-year-old male with left main disease and severe cerebrovascular stenosis underwent off-pump bypass to the left anterior descending artery. Postoperative angiography showed anastomotic stenosis where balloon angioplasty was performed. However, it resulted in coronary perforation complicated with epicardial tamponade, and emergency off-pump surgical angioplasty was performed. This case demonstrated that coronary arterial rupture could be managed by surgical angioplasty without cardiopulmonary bypass when coronary artery perforation occurred.     

前降支肌桥合并后降支肌桥1例

患者，男，50岁，阵发性胸闷、胸痛、心悸两年，血压：190／140mmHg。胸片：主动脉结增宽，左室增大，心胸比0．58；超声：左室壁增厚，左室前壁运动减低；心电图：ST段Ⅰ、Ⅱ、aVL、V5、V6下移〉0．05mV。T波Ⅰ、Ⅱ、aVL、V4～V6双向倒置；实验室检查：心肌酶学正常；诊断：①高血压3级，极高危组。②冠心病：不稳定性心绞痛。收治入院行冠状动脉造影检查：冠脉呈右优势型，前降支近-中段弥漫性狭窄最窄约80％，中段可见肌桥形成（图1A、B）。第1对角支近段约70％管状狭窄；回旋支近段弥漫性狭窄最窄约60％。右冠状动脉左室后支中段约60％管状狭窄，后降支可见肌桥形成（图1C、D）。在前降支近－中段狭窄处置入支架，患者状况良好，一周后出院。     

Tetralogy of Fallot with anomalous origin of left anterior descending coronary artery. Surgical options

Anomalous origin of the left anterior descending coronary artery from the right coronary artery can interfere with the location of the usual ventriculotomy during repair of tetralogy of Fallot. The purpose of this study was to compare the results of two operative techniques: (1) a "tailored" right ventricular incision and outflow patch reconstruction and (2) placement of a conduit from the right ventricle to the main pulmonary artery. We reviewed the records of 416 patients who had complete repair of tetralogy of Fallot at the Mayo Clinic from 1973 through 1984. Twenty (5%) (median age 6.5 years) had anomalous origin of the left anterior descending coronary artery from the right coronary artery. Twelve of these patients had right ventricular outflow patch reconstruction, and eight had placement of a conduit from the right ventricle to the pulmonary artery. Three deaths occurred, all during hospitalization, two in the patch reconstruction group and one in the conduit group. The average reduction in right ventricular pressure postoperatively was slightly but not significantly greater for the conduit group. These data indicate that correction of tetralogy of Fallot with anomalous origin of the left anterior descending coronary artery can be done with either patch reconstruction or conduit placement. Selection of the more appropriate procedure depends on the exact location and degree of tortuosity of the anomalous artery and the level and severity of right ventricular outflow obstruction.     

Surgical treatment of a left anterior descending artery to the main pulmonary artery fistula

We report a case of surgical treatment of a 58-year-old symptomatic patient with large coronary artery fistula, which drained from the left anterior descending artery into the main pulmonary artery (PA), and concomitant large patent foramen ovale. The surgery was performed through a median sternotomy with aortobicaval total cardiopulmonary bypass. The PA was incised. The fistula was identified 5 mm above the anterior leaflet of the pulmonary valve and was closed off using a prolene suture. Afterward, the atrium septum defect was closed with a Dacron patch via the standard right atrium access. There were no postoperative complications.     

Right coronary artery originating from left anterior descending artery: a case report

Right Coronary Artery (RCA) originating from left anterior descending artery is a very rare congenital coronary artery anomaly. A 66-year-old man presented with hypertension and complaints of exertional chest pain. The angiography was performed. Aortic root angiography showed no coronary ostium orginating from the right sinus of valsalva. Right coronary artery was vizualized as anomalously originating from the midportion of left anterior descending artery. Severe stenosis were seen in ostium of anomalous right coronary artery, in midportion of left anterior descending and in midportion of circumflex artery. The patient was referred for coronary artery bypass grafting. The patient underwent coronary artery bypass surgery for three vessels. He was discharged home on postoperative day 7 without any complication. His echocardiogram on follow-up visit revealed good biventricular function.     

Left main disease associated with an anomalous left anterior descending artery

Abstract Background: Coronary artery anomalies are very rare. Recognizing these anomalies are clinically relevant as they can mimic symptoms of coronary artery disease, and sporadic cases of sudden death have been described in these patients. Method: This report describes a 55‐year‐old patient with left main disease and an anomalous left anterior descending artery arising from anterior coronary sinus who presented with palpitations. Result: Patient underwent coronary artery bypass grafting with left internal mammary artery to the ramus intermedius with cardiopulmonary bypass using antegrade blood cardioplegia. The anomalous left anterior descending artery was crossing the right ventricular outflow tract and running on the interventricular groove. Conclusion: The diagnosis and management of coronary artery anomalies is the subject of this review.     

Complete revascularization of the left anterior descending coronary artery.

OBJECTIVE: To assess the efficacy of complete revascularization of the left anterior descending coronary artery. METHODS: To obtain such revascularization, 81 patients required the use of such complex techniques as the onlay patch technique or double bypasses during bypass grafting. RESULTS: The onlay patch technique was used in 39 (48%) and double bypasses in 42 (52%). The wall motion in all anterior segments of the left ventricle showed an improving trend postoperatively. The patency rate was 99% overall, and the bypass grafts to the left anterior descending coronary artery were all patent with flow in all left anterior descending coronary artery areas. Perioperative myocardial infarction occurred in only 1 patient (1.2%), and hospital mortality was 2.5% (2/81). Long-term results of 79 hospital survivors were as follows: the mean follow-up time was 77 months (3 to 236); the actuarial survival rate including all deaths and estimated by cardiac death was 90% and 95% at the eighth postoperative year respectively; the cardiac event free rate at the fifth and eighth postoperative year was 90% and 63% respectively. A total of 8 cardiac events were observed. Excluding 3 cardiac deaths, no cardiac events were clearly attributable to the left anterior descending coronary artery. CONCLUSIONS: Complete revascularization of the left anterior descending coronary artery using these techniques improved the anterior wall motion in the left ventricle and cardiac performance at low risk, and provided excellent long-term results.     

Saphenous vein patch angioplasty for a discrete saccular aneurysm of left anterior descending coronary artery.

We present here a case of discrete saccular coronary artery aneurysm located astride bifurcation between the left anterior descending artery and first diagonal branch in the absence of severe coronary artery occlusive disease. The patient underwent surgery where complete resection of the aneurysm and patch angioplasty using saphenous vein graft were performed. Postoperative coronary angiography revealed disappearance of the aneurysm and no stenosis of the repaired coronary artery. The patient is now leading a normal life without any symptoms one year after the operation.     

Surgical treatment in an adult with coronary artery aneurysm at proximal site of left anterior descending artery; report of a case

A 52-year-old man was admitted to our hospital with complaint of chest pain and abnormal electrocardiogram (ECG) findings showing ST depression in V2-V6. Coronary computed tomography (CT) and coronary arteriography (CAG) showed coronary artery aneurysm at #5 [left main trunk (LMT)] 20 mm, #11 [circumflex artery (Cx)] 8.3 mm, RV branch 4 mm, and severe stenosis at #5 and #11. Therefore, his chest pain was due to thromboembolism from coronary artery aneurysm. In the present case, Kawasaki disease was not diagnosed in childhood. Coronary artery aneurysms were rare in the elderly and were usually found in association with Kawasaki disease. Morphological evaluation findings strongly suggested that the coronary artery aneurysm were related to Kawasaki disease. Resection of coronary artery aneurysm and coronary artery bypass grafting [left internal thoracic artery (LITA) to #8 and saphenous vein graft (SVG): aorta (Ao) to #14] were successfully performed. We report a case of coronary artery aneurysms presumed to be due to childhood Kawasaki disease in an elderly man.     

Extensive endarterectomy of the left anterior descending artery

Diffuse obstructive disease of the left anterior descending coronary artery presents a new challenge to the surgeon especially if the heart and septal muscle supplied by this vessel is ischaemic but viable. Venous skips were utilized in the past to overcome this problem, but recently extensive endarterectomy of this system has been advocated. The case studies of 5 patients are presented who have undergone extensive endarterectomy of the left anterior descending artery and coronary bypass grafting.     

Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.     

Surgical management of a left anterior descending pseudoaneurysm related to Behcet's disease

A 22-year-old woman suffering from Behcet's disease and severe angina was diagnosed with a left anterior descending coronary artery giant pseudoaneurysm. Preoperative investigations, surgical management, and its principles, as well as specific postoperative follow-up considerations are described.     

Adjunct endarterectomy of the left anterior descending coronary artery

During a three-year period, complete revascularization of diffusely diseased left anterior descending (LAD) coronary arteries was accomplished by extensive endarterectomy in conjunction with bypass grafting in 37 patients in whom conventional bypass was not feasible. This group constituted 7.0% of all patients undergoing nonemergency coronary revascularization during this period. The left internal mammary artery was used to bypass the endarterectomized LAD artery in 22 patients. There was 1 (2.7%) operative death and 1 perioperative myocardial infarction. At follow-up, which was 100% with a mean of 41.4 months, all endarterectomy patients were in New York Heart Association Functional Class I or II. Twenty-four endarterectomy patients underwent first-pass radionuclide angiographic stress testing 20 months after operation. Twenty patients (83%) had excellent postoperative exercise tolerance, achieving 5 to 7 mets on treadmill testing. Left ventricular functional reserve was preserved, as evidenced by an increase of global ejection fraction from 48 +/- 15% at rest to 59 +/- 18% (p less than 0.005) with exercise. A similar increase was measured in the proximal and distal anterior wall segmental ejection fractions. No difference in response to exercise was found between the internal mammary artery and the vein graft groups. Thus, complete revascularization of the diffusely diseased LAD artery can be accomplished by adjunct endarterectomy without added morbidity or mortality and with excellent functional results.     

不同手术方式重建左前降支血运的效果

目的 比较使用非体外循环心脏不停跳冠状动脉旁路移植术(OPCAB)、微创小切口直视下心脏不停跳冠状动脉旁路移植术(MIDCAB)和机器人辅助冠状动脉旁路移植术(RA-CAB)3种不同方式行左前降支(LAD)血运重建的围手术期效果.方法 2009年2月至2012年5月,接受单纯LAD血运重建患者102例,其中OPCAB组31例,MIDCAB组45例,RA-CAB组26例.MIDCAB手术方式为左胸小切口心脏不停跳冠状动脉旁路移植术,RA-CAB手术方式为da Vinci机器人辅助左乳内动脉(LI-MA)获取,左胸小切口心脏不停跳冠状动脉旁路移植术.结果 3组患者在术中旁路血管流量、搏动指数和围手术期死亡、心肌梗死、脑血管意外、再次血运重建、严重心脑血管不良事件(MACCE事件)、肾功能衰竭、再次开胸止血、新发心房颤动、纵隔感染以及术后并发症率上均无显著差异.相比OPCAB,MIDCAB和RA-CAB能显著减少输血率(4.4％对32.3％,P＜0.05;7.7％对32.3％,P＜0.05),其中RA-CAB更能显著缩短术后住院天数[(8.8±3.2)天对(12.4±7.7)天,P＜0.05)].MIDCAB与RACAB两组之间围手术期结果差异无统计学意义.结论 MIDCAB和RA-CAB治疗左前降支血管病变安全、有效、可行,围手术期效果满意,比OPCAB能显著减少血制品的使用,RA-CAB更能大大缩短术后住院天数,具有创伤更小、恢复更快的优势.     

Fifteen-year results of coronary artery bypass for isolated left anterior descending coronary artery disease

During 1971 through 1975, 266 patients underwent primary coronary artery bypass grafting for occlusive disease confined to the left anterior descending coronary artery. Actuarial survival at 15 years was 72.7% with 60% of survivors being free from angina. Although the cause of death was cardiac related in 50% of the patients who died, survival was comparable with that of an age-matched and sex-matched general population. During follow-up, 48 secondary or tertiary repeat coronary artery bypass as well as 44 percutaneous transluminal coronary angioplasty procedures were performed. Acute event-free status (freedom from acute myocardial infarction, repeat coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, or death) persisted at 15 years in 43.2% of patients. The differences in survival when patients were segregated according to age, sex, number of grafts performed, or graft conduit (internal mammary artery versus vein) were not significant. However, comparison of graft conduits revealed a significantly better (p = 0.02) overall acute event-free survival when the internal mammary artery was used.