A case of type IV dual left anterior descending artery associated with anomalous origin of the left circumflex artery in the presence of coronary atherosclerosis

Double origin of the left anterior descending coronary artery (LAD) from the left and right coronary arteries (type IV dual LAD) is a rare coronary anomaly. We report an unusual case of type IV dual LAD associated with anomalous origin of the left circumflex artery from the right coronary artery in a patient with a recent history of myocardial infarction. The first diagonal branch originating from the short LAD demonstrated 70-80% stenosis and the posterior descending artery was totally occluded. We believe that this unusual variance of the coronary arteries in association with atherosclerosis has not been previously reported.     

非体外循环下多支冠状动脉病变的旁路移植术

目的：探讨非体外循环冠状动脉旁路移植术的手术技巧和术中处理方法。方法：连续57例患接受非体外循环冠状动脉旁路移植术。术中予以适量扩容、小剂量α受体兴奋剂以维持血流动力学平稳，采用心脏稳定器控制局部心肌运动幅度，阻断冠状动脉或在置入血管塞控制冠状动脉出血情况下进行血管吻合。全组吻合前降支57例，对角支21例，右冠状动脉27例，钝缘支42例，后降支20例。结果：术后1例死于并发感染和急性肾功能衰竭，余患痊愈出院。随访所有患心绞痛症状均消失，冠状动脉造影示桥路和吻合口通畅。结论：选择合适的病例进行非体外循环冠状动脉旁路移植术可获得满意的临床效果。术中血流动力学稳定极为重要。弹力线阻断靶血管近远端或腔内置入血管塞法均能有效地控制切开的冠状动脉出血。冠状动脉吻合的顺序应是先行前降支和右冠系统的吻合。     

Anomalous origin of the three major coronary arteries from a single common ostium

The prevalence of coronary anomalies is about 1.3% among patients who undergo coronary angiography. Although the majority of coronary artery anomalies are incidental findings and are not clinically significant, the interarterial course between the great vessels of the aberrant artery may be responsible for syncope, angina, arrhythmias or sudden death. There are only a few case reports in the literature that describe the origin of all coronary arteries from a single ostium. This type of anomaly has been seen in only 0.024-0.044% of the population. This is a first case where not only was there a common ostium of the left anterior descending artery and right coronary artery without a left main, but an absent left circumflex artery with blood supply of its territory by a posterolateral/marginal branch from the right posterior descending artery and conal branch.     

Isolated stenosis of left anterior descending or right coronary artery: Relation between site of stenosis and ventricular dysfunction and therapeutic implications

Indications for coronary arterial bypass surgery in single vessel coronary artery disease are unresolved. To determine the extent of myocardium at risk with stenosis (70 percent or more) of a single coronary artery, left ventricular angiograms of 200 patients with stenosis confined to either the left anterior descending or right coronary artery and of 15 normal control subjects were assessed. Among patients without myocardial infarction, ejection fraction was unchanged (p > 0.05 versus normal values) in (1) those with stenosis of the proximal (above first septal branch, n = 19), mid (between septal and first diagonal branches, n = 14) and distal (within 2 cm distal to diagonal branch, n = 15) left anterior descending coronary artery, and (2) those with stenosis of the proximal (above acute marginal branch, n = 16) and distal (between acute marginal and posterior descending branches, n = 16) right coronary artery. In contrast, ejection fraction was depressed (p < 0.001 versus normal values) In left anterior descending arterial stenosis with anterior myocardial Infarction: proximal (38 ± 10 percent, n = 33), mid (46 ± 12 percent, n = 24; p < 0.01 versus proximal), and distal (56 ± 9 percent, n = 15; p < 0.01 versus mid). Ejection fraction was similar with proximal and distal stenosis of the right coronary artery and inferior Infarction: 54 ± 11 percent versus 55 ± 9 percent, p > 0.05; both p < 0.05 versus normal value. Shortening velocity was assessed in three anterior (I to III, base to apex) and three inferior (IV to VI, apex to base) equidistant hemichords perpendicular to the long axis, 30 ° right anterior oblique view. With anterior Infarction and left anterior descending stenosis, shortening of hemichords I to V, I to IV and II to III with proximal, mid and distal stenosis, respectively, was depressed (p < 0.05 versus normal value). Septal excursion and thickening on M mode echocardiography with proximal left anterior descending stenosis and infarction were depressed (p < 0.05 versus mid and distal stenosis with infarcts). Hemichordal shortening with Inferior infarction was similarly depressed (p > 0.05) with proximal and distal stenoses.In conclusion, stenosis of the left anterior descending coronary artery is a heterogenous disease, the extent of jeopardized myocardium is highly dependent on the site of stenosis, and the criteria for surgery cannot be applied uniformly. When the surgical goal is myocardial preservation, these data provide an objective rationale for bypass of stenosis of the proximal left anterior descending coronary artery. In stenosis confined to the right coronary artery, left ventricular preservation alone should not be considered an indication for coronary bypass grafting.     

Dysfunction of aortocoronary bypass. Prognosis]

From 1978 to 1988, 108 patients with at least one occluded or stenosed aorto-coronary bypass graft (over 75% stenosis) underwent coronary angiography on average 31 months after the initial coronary bypass surgery. The occluded or stenosed coronary graft was either a saphenous vein (n = 126 including 9 sequentials) or internal mammary artery (n = 5). The bypassed artery was the left anterior descending (n = 66), right coronary (n = 40), left marginal (n = 25) or diagonal (n = 9). The number of occluded or stenosed grafts by patient was 1.2. The left ventricular ejection fraction was 55% (range 25 to 77%). During a mean follow-up period of 60 months after coronary angiography, there were 14 cardiac deaths and 15 non-lethal myocardial infarctions. Treatment comprised 12 angioplasties, 26 new bypass grafts and 3 cardiac transplantations. The 8 year actuarial survival was 84%. The survival without infarction at 8 years was 69%. Survival was significantly decreased to 72% when the occluded or stenosed graft was located on the left anterior descending artery. The survival without infarction at 8 years was 52% in the patients with dysfunction of left anterior descending artery grafts and 89% when the diseased graft was located on another artery (right coronary, left marginal, diagonal). Therefore, the data of this retrospective study show that coronary graft dysfunction on the right coronary, left marginal or diagonal arteries do not greatly influence life expectancy in the medium term after coronary bypass surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

A quantitative study of the anatomy and distribution of coronary arteries in swine in comparison with other animals and man

The coronary circulation of swine was studied to establish adequate baseline information for using swine in cardiovascular research. Of 65 hearts from domestic and miniature pigs, 45 were injected with a methacrylate plastic and prepared as coronary artery casts whose branches were described and measured, and 20 were injected with different coloured dyes in the right, left anterior descending, and circumflex coronary arteries so that horizontal sections of the heart showed the distribution of each artery and the source of blood supply to particular areas or structures of the heart. Like man, the swine had a left coronary artery that was larger in diameter and longer than the right coronary artery. The right coronary artery was almost always dominant (78%), supplying the posterior septum and atrioventricular node via the posterior descending coronary artery. Eight (17%) of the hearts possessed a balanced blood supply. Two (5%) hearts had a left dominant supply. The intracoronary artery dye injections showed that 72.4% of the right ventricular mass was supplied by the right coronary artery and 27.6% by the left anterior descending coronary artery. In the left ventricle 49% of the mass was supplied by the left anterior descending coronary artery, 25.5% by the right coronary artery, and 25.5% by the circumflex coronary artery. The left anterior descending coronary artery supplied 58% of the interventricular septal mass, while the posterior descending coronary artery supplied 42%. The distribution of the left anterior descending coronary artery branches to the ventricular wall varied inversely in number and size of its diagonal branches (2-9) with the obtuse marginal branches of the circumflex coronary artery which were occasionally more numerous or extended to the apex. The blood supply to the sinoatrial node was always by a branch of the right coronary artery. This analysis shows that not only the coronary anatomy but also the distribution of blood supply to particular areas or structures of the swine heart are very similar to that of humans.     

Site and severity of coronary narrowing and infarct size in man.

The relation between the site and severity of coronary artery lesion and infarct size was investigated in 59 patients with acute myocardial infarction. All patients had no prior myocardial infarction and had at least one significant coronary narrowing (greater than or equal to 75%) in one of the major coronary arteries or in the first diagonal branch. Left ventriculography and selective coronary arteriography were performed on average 2.2 months after the onset of infarction to identify the site and severity of coronary narrowing and to assess the extent of the non-contracting segment (akinetic, dyskinetic, or aneurysmal). Thirty-four of 59 patients were studied enzymatically and total CK released was taken as an indication of infarct size. Non-contracting segment and total CK released in group L-I (narrowing proximal to the first diagonal branch) were significantly larger than those in group L-II (a coronary lesion distal to the branch). The data also indicate that the perfusion area of the first diagonal branch is as large as that of the left anterior descending artery below the first diagonal branch. In contrast to left anterior descending artery disease, the involvement of the right ventricular branch did not significantly influence the infarct size. However, infarct size was significantly larger in eight patients with the left ventricular branch of the right coronary artery supplying the predominantly large area of posterior wall of the left ventricle than in nine patients with small left ventricular branches. It was also shown that the severity of coronary narrowing does not correlate with the infarct size in either left anterior descending or right coronary artery disease.     

Left atrial myxoma associated with obstructive coronary artery disease

We describe a case of a 67 year-old patient with obstructive coronary artery disease that, in the preoperative survey for inguinal herniorraphy surgery, discovered, by a two-dimensional echocardiogram, a tumor in left atrium, mobile, non-obstructive. The patient underwent a cineangiocoronariography showing severe stenosis in the left anterior descending artery, moderate stenosis in the left circumflex artery, near the origin of the first marginal branch, and a non-obstructive plaque in the right coronary artery. There was also moderate left ventricular dysfunction. After that, the patient has gone coronary artery bypass surgery and resection of the left atrial tumor. The histological exam revealed that the tumor was, in fact, a myxoma.     

Pullback atherectomy (PAC) for the treatment of complex bifurcation coronary artery disease

We report initial successful results using a novel retrograde cutting (pullback) atherectomy catheter (PAC) to treat complex bifurcation coronary artery disease, in 2 patients. In one case a bifurcation lesion involving the left anterior descending and a large diagonal branch was treated without the need for two-wire or kissing-balloon technique. In the second case a high-grade eccentric lesion of the right coronary artery at the site of a right ventricular marginal branch was treated successfully. This report describes the first clinical application of pullback atherectomy in human coronary circulation, and suggests that this device may play a useful role in the treatment of complex bifurcation coronary artery disease. © 1996 Wiley-Liss, Inc.     

Supernumerary right coronary artery

A rare case of a patient with supernumerary right coronary artery in whom the two vessels arose from the right coronary sinus from two separate ostia adjacent to each other is presented. The smaller vessel gave off the sinoatrial nodal branch and the posterior descending artery whereas the larger one gave off the conus branch, the right ventricular branches, and continued as acute marginal branch. This is the first case report in the English literature.     

Complete proximal occlusion of all three main coronary arteries complicated with a left main coronary aneurysm: a case report

A 68-year-old woman with recurrent chest pain was referred to our institution. Coronary angiography showed 100% obstruction of the left main trunk, the proximal right coronary artery with good collaterals to the left anterior descending artery and left circumflex artery along the conus artery. Emergency surgical revascularization was undertaken with two saphenous vein grafts. The saphenous vein grafts were placed in the left anterior descending artery, obtuse marginal branch and the posterolateral and posterior descending coronary arteries with excellent flow. The postoperative course was uneventful and follow-up angiography was obtained 20 days after the surgery. Coronary angiography demonstrated a saccular aneurysm (10 x 9 mm) originating at the distal segment of the left main coronary artery with 90% stenosis, and excellent patency of both saphenous vein grafts. Follow-up angiography was performed 1 and 3 years after the surgery. The size of the left main coronary aneurysm remained unchanged at both examinations. The patient did well with no further cardiac symptoms after 5 years.     

Robotically assisted multivessel minimally invasive direct coronary artery bypass grafting with the use of bilateral internal thoracic arteries.

This case report presents the robotically assisted multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB) technique using the bilateral internal thoracic arteries. A 54-year-old man with multivessel coronary artery disease was considered eligible for a robotically assisted myocardial revascularization. The bilateral internal thoracic arteries were harvested completely in a totally skeletonized fashion through three 1-2-cm-long incisions on the left thoracic wall. A small left anterior thoracotomy was then performed. The left internal thoracic artery was anastomosed to the left anterior descending coronary artery, and the composite radial artery graft from the right internal thoracic artery was sequentially anastomosed to the first diagonal branch, the obtuse marginal branch, and the distal right coronary artery on the beating heart without cardiopulmonary bypass. The harvesting time of the grafts was 66 min, and the total operative time was 5 h 58 min. Postoperative angiography revealed that all grafts were widely patent. The postoperative course was uneventful, and the patient was discharged 10 days after the operation. Robotically assisted MIDCAB using the bilateral thoracic arteries is a safe and effective means of myocardial revascularization for patients with multivesssel disease.     

Localization of lesions in the coronary circulation

The location of coronary artery narrowings in coronary disease (CAD) is of considerable importance in assessing the mass of myocardium at risk as well as patient prognosis. The detailed distribution of coronary lesions was mapped in 302 patients with CAD who had coronary angiography for chest pain. All identifiable coronary lesions were measured manually and the site and degree of narrowing were stored in a computer-based multisegmental model of the coronary tree. A high prevalence of CAD was found in proximal vessels and especially at, or adjacent to, proximal points of branching. In the left anterior descending coronary artery, the lesions were most prevalent immediately after the first diagonal branch and at the origin of this branch. In the right coronary artery, there was a high prevalence of narrowing between the infundibular and acute marginal branches and specifically around the origin of the right ventricular branch. In the left circumflex coronary artery, there was a predilection for narrowing in and around the origin of the first marginal branch. When a ramus intermedius was present, its origin was frequently the site of narrowing.     

经心外膜下侧支循环逆向介入治疗冠状动脉慢性完全闭塞病变

目的 探讨应用我国市场已有器械,经心外膜下侧支循环血管,对慢性完全闭塞(CTO)病变行逆向经皮冠状动脉介入治疗(PCI)的可行性.方法 5例CTO病变均在常规正向PCI失败后,行逆向PCI.将7 F强支撑逆向指引导管送至供体血管,超滑导丝通过心外膜下侧支循环血管到达CTO病变远端,在微导管支持下交换较硬的导丝,逆向通过CTO病变,逆向导丝继续进入6 F正向指引导管,并在正向指引导管内球囊扩张锚定.逆向扩张病变后,正向导丝通过病变,用常规PCI方法完成手术.其中应用捕获逆向导丝技术和反向CART技术各1例.结果 在逆向导丝通过侧支循环的路径中,经左前降支至右冠状动脉远端3例,经左回旋支至右冠状动脉1例,经钝缘支至左前降支1例.其中4例成功开通CTO病变,完成支架置入术.另外1例虽然导丝及微导管到达CTO病变远端,但无法逆向通过闭塞病变.所有患者介入术中均未发生并发症.结论 在我国没有专门逆向PCI工具的情况下,如果室间隔支不适合作为逆向通道,心外膜下侧支循环在符合一定条件时也可作为逆向通道,进行CTO病变的逆向PCI.     

Vascular anomaly - left anterior descending artery originating from right coronary sinus

A case of a patient with congenital anomaly of coronary blood vessels with left anterior descending artery starting from right coronary sinus is presented. The patient was operated on due to symptoms of myocardial ischaemia by carrying out an off-pump coronary artery bypass graft to left anterior descending artery and obtuse marginal artery, with a very good outcome.     

冠状动脉管径与分叉角度的CT冠状动脉成像研究

目的 在冠状动脉CT图像上分析测量成人血管直径与血管分叉的生体信息,进一步加深对冠状动脉应用解剖的认识.方法 选择64排螺旋CT冠状动脉扫描图像质量优秀、血管完全正常的526例成人为观察对象,测量左主干及前降支、回旋支、右冠状动脉自开口至直径2 mm处每间隔1 cm处的管腔直径,计算管腔渐变率;测量大的对角支、钝缘支、锐缘支、后降支、左室后支(直径大于2 mm)开口直径,与同平面交角的主支血管直径和其上方1 cm处主干血管的直径以及分叉的角度.结果 前降支管径从开口的平均3.92 mm经过13 cm后移行为2.10 mm,呈逐渐变细的趋势,所有管腔的平均变化率为7.7％(男性7.0％,女性8.4％),管腔在距开口3 ～5 cm处变化率最大,达8.0％～10.0％;回旋支管径从开口平均的3.57 mm经过13 cm后移行为2.10 mm,呈逐渐变细的趋势,所有管腔的平均变化率为9.7％(男性9.6％,女性9.7％),开口至近端3 cm处管径变化率约3.0％,其后各点变化在8.3％～10.7％;右冠状动脉管径从开口平均的3.97 mm经过18 cm后移行为2.15 mm,呈逐渐变细的趋势,所有管腔的平均变化率为5.1％(男性4.9％,女性5.3％),开口至10 cm处管径变化率＜4.0％,其后变化率加大,在6.1％～15.2％之间.前降支与对角支、回旋支与钝缘支、右冠状动脉与后降支(左室后支)、右冠状动脉与锐缘支的夹角分别约为50°、55°、66°和76°.结论 64排螺旋CT冠状动脉成像可在生体上测量冠状动脉,获取三支主干血管的渐变率与最大渐变部位以及冠状动脉血管分叉的数据,进一步加深对冠状动脉应用解剖的认识.     

国产雷帕霉素药物洗脱支架在冠状动脉分叉病变介入治疗中的应用

目的探讨国产雷帕霉素药物洗脱支架[DE(SFirebirdTM)]在冠状动脉分叉病变介入治疗中应用的安全性和有效性。方法对47例冠心病患者的53处冠状动脉分叉病变行介入治疗,共置入FirebirdTM68枚。结果46例介入治疗成功,失败1例。分叉病变部位:左主干远端前降支和回旋支分叉病变2处,前降支和对角支分叉病变23处,回旋支和钝缘支分叉病变17处,左心室后侧支和后降支11处。术中发生边支血管闭塞4例,边支血管狭窄加重6例,边支血管发生慢血流3例。住院期间发生急性非ST段抬高型心肌梗死3例,ST段抬高型心肌梗死1例,心绞痛5例,1例于术后2天死于心源性休克。随访6个月,7例复发心绞痛而再次住院治疗,无其余主要不良心脏事件发生。结论DE(SFirebirdTM)在冠状动脉分叉病变介入治疗中应用是可行、安全有效的。     

Advantage of the cranial-right anterior oblique view in diagnosing mid left anterior descending and distal right coronary artery disease

The value of the cranial-right anterior oblique view in uncovering or improving the arteriographic visualization of lesions in the mid left anterior descending coronary artery, the origin of its diagonal and septal branches and of the distal branches of the right coronary artery was analyzed in 300 consecutive patients. The cranial-right anterior oblique view was compared with standard and other angled views. In the mid left anterior descending artery the view provided improved visualization over the other views in 80 percent of cases and uncovered lesions in 7 percent. In the septal arteries, the view improved visualization in more than 90 percent of cases and uncovered lesions in 26 percent. In the diagonal branches, the view improved visualization in nearly 75 percent of cases. In the distal right coronary artery there was improved visualization of the posterior descending and posterolateral branch arteries in more than 80 percent of cases. The cranial-right anterior oblique view was also the most advantageous view from a technical standpoint, yielding satisfactory exposure factors in obese and extremely heavy patients.     

Congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery: An interesting case report

Intercoronary communication is a very rare coronary artery anomaly. It is defined as an open-ended circulation with bidirectional blood flow between two coronary arteries. Coronary artery fistulas are abnormal communications between a coronary artery and a cardiac chamber or major vessel. A 62-year-old man was admitted to our hospital with sudden development of general weakness, dizziness and a sensation of compression in his chest. At presentation his blood pressure was 80/40 mmHg and heart rate was 65 beats/min. The ECG revealed sinus rhythm and 1–2 mm ST elevation in the anterior leads. The patient was taken to the catheterization laboratory for percutaneous coronary intervention. The left main and left circumflex coronary arteries were normal. Coronary angiography showed a communication between the left main and the diagonal branch of the left anterior descending and a fistula between the intercoronary connection and the left atrium. The other coronary arteries were normal. Laboratory test results, including cardiac troponin I and creatine kinase–MB levels, were normal. The angina symptoms disappeared and the ST elevation resolved within four hours. We report an interesting case of congenital coronary artery fistula in an intercoronary communication between the left main and the diagonal branch of the left anterior descending coronary artery presenting as an acute coronary syndrome. To the best of our knowledge, this is the first case in the literature involving a coronary artery fistula in an intercoronary communication.     

Concomitant left anterior descending coronary artery and right coronary artery occlusion with typical anterior ST depression and inferior ST elevation

We report the case of a 41-year-old man with acute myocardial infarction showing first ST elevation in V1-V6-DI-aVL leads followed by a typical V2-V4 ST depression (concomitant occlusion of proximal diagonal branch with an incomplete left anterior descending occlusion) and DII-DIII-aVF ST elevation. At coronary angiography, a proximal left anterior descending coronary stenosis with right coronary artery thrombosis was found.