复杂冠状动脉病变的腔内成形术

本文报道5例不同类型复杂冠状动脉病变腔内成形术。对于位于血管分叉处的病变,采用了双导丝技术;对于引起急性心肌梗塞的高度狭窄血管采用自灌注球囊扩张;对于完全闭塞且病变较长的血管,采用较硬的标准直头导引钢丝导入尔后逐段扩张的办法;对于术中出现的内膜剥离,采用了自灌注球囊导管行长时间低压修补。术后血管再通,残余狭窄为0～10％。因此,认为只要针对不同情况,采用不同方法,PTCA成功率可望提高。     

Embolic coronary artery occlusion in percutaneous transfemoral coronary arteriography

A review is presented of 139 selective coronary artery studies during a 25 month period in which 1,112 coronary artery injections were performed using the percutaneous transfemoral artery approach as described by Judkins in 1967.² Six patients (four per cent) developed acute occlusion of the left coronary artery or one of its branches during the procedure, and two of these died with occlusion of the left main coronary artery shortly thereafter.It is felt that since in all cases of this series and most of those of others, embolic occlusion within the left coronary artery system occurred, the complication is related to the thrombogenic properties of the left coronary catheter or to the procedure in which introduction of the second catheter is required.     

Heart rescue in acute left main coronary artery occlusion with CABG using initial retrograde perfusion.

Acute occlusion of the left main coronary artery (LMCA) is a rare and almost invariably fatal condition. Here, we report on heart salvage in two such cases with CABG aided by emergent retrograde reperfusion as the initial operative step. Both cases were extremely unusual. The first patient had twice survived LMCA occlusion; the second also had right coronary artery occlusion. We will also review the literature on acute LMCA occlusion and coronary venous retroperfusion.     

Successful Management of an Iatrogenic Left Main Coronary Artery Occlusion during Coronary Angiography: A Case Report and Brief Review

Abrupt left main coronary artery (LMCA) closure during diagnostic coronary angiography is a rare but catastrophic event with a poor prognosis. Emergency reperfusion of the LMCA with hemodynamic support should be the primary goal in patients with acute LMCA occlusion. Emergency coronary artery bypass graft surgery may be effective but time-consuming, and carries the risk of extensive and irreversible myocardial damage. We describe a case of abrupt closure of the LMCA due to plaque rupture by a diagnostic angiographic catheter without visible dissection following coronary angiography that was successfully treated with bail-out stenting during cardiopulmonary resuscitation.     

Hemodynamics and coronary blood flow during experimental aortic valvuloplasty: comparison of the dual versus the single catheter methods

During thoracotomy 12 anesthetized swine were instrumented and valvuloplasty catheters were positioned at the aortic anulus. Thirty-second occlusions of the left ventricular outflow tract were performed with a single catheter (n = 34) and with simultaneous inflation of dual catheters (n = 47). Left anterior descending coronary artery blood flow fell to minimums of 15% of baseline flow (SD 13.9%) during single balloon occlusion and to 63.8% of baseline flow (SD 22.8%) during dual balloon occlusion. Main pulmonary artery flow fell to minimums of 13.6% of baseline flow (SD 17.3%) during single balloon occlusion and to 66.9% of baseline flow (SD 18.3%) during dual balloon occlusion. Femoral artery systolic pressure dropped to 20.1% of baseline pressure (SD 5.6%) during single balloon occlusion and to 82.6% of baseline pressure (SD 8.1%) during dual balloon occlusion. During single balloon occlusion, 8.5 (SD 3.5) premature ventricular contractions were observed and 2.8 (SD 1.6) premature ventricular contractions occurred during dual balloon occlusion. After deflation of the valvuloplasty catheters, the time to return of baseline flow in the left anterior descending coronary artery was 28.4 second (SD 23.2 seconds) with the single balloon method and 4.8 seconds (SD 3.7 seconds) with the dual balloon method. All of these differences were statistically significant (p less than .001). During occlusion of the left ventricular outflow tract by dual valvuloplasty catheters, there were better hemodynamics, higher coronary blood flows, and fewer premature ventricular contractions than during occlusion by a single catheter. After occlusion by dual catheters, returns to baseline coronary flows were more rapid than after single catheter occlusions. These data may have application to clinical aortic valvuloplasty.     

先天性心脏病冠状动脉瘘的介入治疗

收集近年来国内外先天性冠状动脉瘘100例介入文献与85例手术文献,分析冠状动脉瘘的类型,治疗方法及预后。冠状动脉瘘起源于左冠状动脉多见,出口多在右心。单一冠状动脉瘘可以考虑以经导管介入封堵治疗,这是创伤小,相对安全有效的治疗手段且预后良好,适宜推广。合并其他先天性畸形者或冠状动脉病变者以及介入治疗失败者考虑手术治疗。     

Coronary collateral circulation

The occurrence and influence of coronary collateral circulation and obstruction of the supplying coronary arteries on left ventricular contractility, prevalence of myocardial infarction, and bicycle exercise ergometer test were studied in a random sample of 286 patients with angiographically documented coronary artery disease. Collaterals appeared increasingly in all three main coronary arteries with grade of obstruction. The highest prevalence of collaterals occurred in stenosis of the right coronary artery (60%), followed by the left descending artery (45%); they occurred least in the left circumflex artery (21%) (p less than 0.001). The frequency of intra-arterial collateral circulation was 42%, 11%, and 12%, respectively (p less than 0.001). With total occlusion of the left anterior descending coronary artery, 22% of the patients had normokinetic anterior and apical left ventricular wall when collaterals were present. More often, the inferior wall showed normal contraction with total occlusion of the right coronary artery and collaterals [52%, p less than 0.001 compared with left anterior descending artery (LAD)]. The prevalence of inferior myocardial infarction was 39%, with collateral circulation to the totally occluded right coronary artery. The respective prevalence of anterior infarction and total occlusion in the left coronary artery was 58% (p less than 0.02). The presence or absence of collaterals had no obvious influence on ST-segment response during bicycle ergometer test. In triple-vessel disease, peak work capacity was better when collaterals to LAD were not jeopardized (427 kpm) than when jeopardized (321 kpm) (p less than 0.02).     

Left main coronary artery embolization in an 11‐year‐old girl due to inflammatory myofibroblastic tumor of the mitral valve

This report describes a rare case of a subtotal left main coronary artery occlusion from mitral valve tumor embolization in an 11‐year‐old African American girl. This case is the first to report isolated ST segment elevation in lead aVR as a sign of a subtotal left main coronary artery occlusion in the pediatric population. In our case, we report a rare case of inflammatory myofibroblastic tumor of the mitral valve presenting with acute myocardial infarction due to embolization into the left main coronary artery. Coronary intervention was successfully performed using an aspiration catheter. Inflammatory myofibroblastic tumor usually presents as a solitary pulmonary nodule. Intracardiac involvement has been rarely reported. Despite the benign nature of the tumor, fatal presentations can occur. Early recognition and rapid intervention can be lifesaving in these patients. © 2015 Wiley Periodicals, Inc.     

Intracoronary Imaging‒Guided Percutaneous Coronary Intervention for Woven Coronary Artery Disease With Chronic Total Occlusion

Woven coronary artery disease is a relatively rare congenital anomaly with unexplained etiology. Herein we presented the first unusual woven case involving all coronary arteries with chronic total occlusion lesion of the left anterior descending artery; describe intracoronary imaging‒guided percutaneous coronary intervention for woven coronary artery disease with chronic total occlusion lesion of the left anterior descending artery; and discuss the complexities involved in intervening with such lesions.     

Coronary perfusion catheter: its effectiveness in an experimental model of acute coronary occlusion

The effectiveness of a coronary perfusion catheter was studied in an animal model of acute coronary occlusion. Systemic hemodynamic variables, regional myocardial blood flow (RMBF) in the subepicardium and subendocardium, and regional systolic function (systolic segmental shortening) of the area perfused by the circumflex coronary artery (CX) were measured in eight anesthetized dogs. After baseline measurements, the CX coronary artery was occluded with a silk snare and measurements were repeated after 5 minutes of ischemia (occlusion No. 1). The snare was released and 1 hour later the snare occlusion was repeated after placement of a perfusion catheter in the CX coronary artery. After 5 minutes, measurements were repeated (occlusion No. 2). To determine the long-term effectiveness of the catheter, hemodynamic variables and regional function measurements were then obtained every 15 minutes for a total of 60 minutes. During occlusion No. 1, RMBF decreased from 1.30 +/- 0.20 to 0.41 +/- 0.13 ml.min-1.gm-1 (p less than 0.01), and subendocardial RMBF decreased from 1.44 +/- .24 to 0.34 +/- 0.15 ml.min-1.gm-1 (p less than 0.01). After insertion of the perfusion catheter (occlusion No. 2), subepicardial RMBF was maintained at 0.97 +/- 0.16 and subendocardial RMBF was maintained at 0.78 +/- 0.13 ml.min-1.gm-1; during occlusion No. 2 subepicardial RMBF was greater (p less than 0.05) than occlusion No. 1 and was not different from baseline.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reopening of Chronic Coronary Artery Occlusions by Low Speed Rotational Angioplasty

Following successful application in chronic peripheral artery occlusions, rotational angioplasty was refined and miniaturized for application in patients with chronic coronary artery occlusions. The new catheter system comprises a motor-driven rotating inner steel catheter made up of several steel coils providing maximum elasticity and complete torque control with an olive-like rounded tip (1.0–1.7 mm). The catheter has a lumen for contrast injection and a shielding plastic tube. It is introduced through a conventional 8 Fr guiding catheter. The slowly rotating (200 RPM) catheter passes nontraumatically through the occlusions, thus creating a new channel with smooth contours in a "remodeling" fashion. Once the channel (diameter 1–1.5 mm) is confirmed angiographically, balloon angioplasty is performed over an exchange wire in conventional technique. The new technique was applied to patients with chronic coronary occlusions. Reopening was first attempted with conventional guidewire technique. If the occlusion could be probed with the guidewire, patients were excluded from the study. Twenty patients in whom the occlusion could not be probed with a wire were studied: 1 ACVB, 2 LAD, and 17 RCA. Average duration of occlusion was 7.4 months; it exceeded 3 months in 15/20 and 6 months in 12/20 patients. Successful reopening was achieved in 9/20 (3 from the first 10, 6 from the second 10 patients). No vessel wall perforation or any other severe complication was encountered. Residual stenosis diameter ranged from 30%–70%. Duration of occlusion was similar among patients from the successful and unsuccessful group. It is concluded that with low speed rotational angioplasty reopening of chronic coronary artery occlusions can be achieved in a considerable part of patients in whom conventional technique is unsuccessful. (J Interven Cardiol 1989:2:3)     

Chronic Total Left Main Coronary Artery Occlusion— A Case Report

We report on the clinical and angiographic data of a patient suffering from total chronic occlusion of the left main coronary artery. For many years the patient’s only complaint was of mild stable angina (CCS I). He had a history of a previous acute myocardial infarction 20 years ago, possibly caused by the occlusion of the left main coronary artery. The anatomic and clinical findings of chronic total occlusion of the left main coronary artery during his life are discussed.     

Coronary artery dissection following radiofrequency ablation for atrial fibrillation: Case report and review of the literature

Coronary artery injury following catheter ablation for cardiac arrhythmias is very rare. We present a case of left circumflex (LCx) coronary artery dissection causing inferoposterior ST-elevation myocardial infarction following radiofrequency (RF) ablation for atrial fibrillation (AF) in a 39-year-old male with no cardiovascular risk factors. This was confirmed on coronary angiography and intracoronary vascular ultrasound (IVUS). The likely etiology is thermal injury during RF ablation for AF, due to the close proximity of the left atrial appendage and left pulmonary veins to the LCx. He was successfully treated with primary percutaneous coronary intervention with good outcome. This is, to our knowledge, the first reported case of proven acute coronary dissection secondary to RF ablation for AF reported in the literature, and highlights the importance of considering this as a mechanism for coronary occlusion in these patients.     

Transient Ischemia Does Not Limit Subsequent Ischemic Regional Dysfunction in Humans: A Transesophageal Echocardiographic Study During Minimally Invasive Coronary Artery Bypass Surgery

Objectives. This study sought to assess the effects of sequential coronary artery occlusion during minimally invasive coronary artery bypass graft surgery (CABG) on hemodynamic variables and left ventricular systolic function by means of transesophageal echocardiography (TEE).Background. Clinical and experimental studies suggest a protective effect of ischemic preconditioning in patients with acute coronary syndromes. However, the effect of repetitive myocardial ischemia on myocardial mechanical function in humans is not completely understood.Methods. Seventeen patients with left anterior descending coronary artery (LAD) stenosis ≥70% and normal rest left ventricular systolic function referred for minimally invasive CABG underwent intraoperative TEE for assessment of regional left ventricular wall motion and measurement of hemodynamic variables at baseline (baseline 1), during a 5-min coronary occlusion (occlusion 1), after a 5-min reperfusion period (baseline 2) and a during a second coronary occlusion during bypass anastomosis (occlusion 2).Results. Left ventricular wall motion score (LVWMS) increased significantly from baseline (16.0) to occlusion 1 (21.4 ± 3.1 [mean ± SD], p < 0.05) and occlusion 2 (21.8 ± 3.1, p < 0.05). No difference in LVWMS was noted between occlusions 1 and 2. Pulmonary artery systolic pressure increased significantly from baseline (25 ± 6 mm Hg) to occlusion 1 (32 ± 7 mm Hg, p < 0.05) and occlusion 2 (33 ± 6 mm Hg, p < 0.05). Pulmonary artery diastolic pressure also increased significantly from baseline (12 ± 4 mm Hg) to occlusion 1 (16 ± 4 mm Hg, p < 0.05) and occlusion 2 (16 ± 4 mm Hg, p < 0.05). No significant differences in pulmonary artery pressures were noted between occlusions 1 and 2.Conclusions. Ischemic dysfunction was precipitated by the 5-min LAD occlusion, as shown by the increase in LVWMS and pulmonary artery pressure. However, a 5-min coronary occlusion and the resulting ischemia do not alter regional left ventricular systolic function during subsequent ischemia in humans.     

Coronary Thrombo-Aspiration

Persistence of a thrombus after coronary angioplasty can be treated by transcatheter aspiration. This technique has been used in the right coronary artery of three patients. Coronary arteriography showed the occlusion of the proximal segment in two patients and a stenosis in one. In the two patients with an occlusion, there was no residual stenosis after balloon angioplasty, but a long thrombus remained: in the third patient, the thrombosis of the mid-segment of the right coronary artery was secondary to a spasm of the proximal and mid-segments. In all patients, the guiding catheter was gently advanced up to the thrombus that was aspirated with a syringe. The immediate result was excellent, and the control angiogram performed after a delay of 1 to 15 months showed the patency of the artery and the absence of residual stenosis.     

Importance of myocardial ischemia for coronary collateral development in conscious dogs

The purpose of this study was to evaluate the effects of myocardial ischemia on the development of collateral circulation. Thirteen conscious dogs were instrumented for serial measurements of subendocardial segment length in the area perfused by the left circumflex coronary artery, left circumflex coronary artery flow and left ventricular pressure. In 6 dogs (group A), 1 min left circumflex coronary artery occlusions were carried out at 30 min intervals. When the 442nd 1 min left circumflex coronary artery occlusion produced a reduction in segment shortening and a significant reactive hyperemia, the occlusion time was increased to 2 min. In the remaining 7 dogs (group B), 2 min left circumflex coronary artery occlusions were conducted hourly. In group A, following 451 +/- 201 (SD) min of total occlusion time with the mixture of 1 and 2 min left circumflex coronary artery occlusions (43 +/- 18 days) a left circumflex coronary artery occlusion produced no reduction in segment shortening and negligible reactive hyperemia. By contrast, in group B, 218 +/- 99 min of total occlusion time (18 +/- 8 days) was required to develop adequate collateral circulation. The relative contribution of the first and second 1 min of left circumflex coronary artery occlusion to the collateral development was mathematically evaluated. This analysis indicated that the second 1 min of left circumflex coronary artery occlusion is 4.43-fold more effective than the first 1 min of occlusion in terms of the collateral induction. We concluded that severe myocardial ischemia plays an important role in the development of collateral circulation.     

Coronary artery pseudo-occlusion associated with the use of an active hemoperfusion system during PTCA

We describe the phenomenon of coronary artery "pseudo-occlusion," which may occur when active hemoperfusion devices are utilized during percutaneous transluminal coronary angioplasty (PTCA). In such cases, contrast injected via the guiding catheter fails to opacify the coronary artery distal to the tip of the dilating catheter, thereby giving the angiographic appearance of coronary occlusion. When active hemoperfusion is terminated, contrast opacifies the vessel in a normal fashion. The cause of this observation is likely multifactorial and includes obstruction to flow by the dilating catheter, high distal pressure delivered by the dilating catheter during hemoperfusion competing with the flow of contrast injected via the guiding catheter, and wash-out of contrast at the tip of the dilating catheter by non-contrast containing blood being pumped through the system. This phenomenon must be recognized if potentially deleterious repeat dilatations are to be avoided.     

Coronary occlusion after failed closure of coronaro-pulmonary fistula with detachable balloon

An attempt to occlude a fistula between the right coronary artery and the pulmonary trunk with a detachable balloon resulted in balloon dislodgment and occlusion of the right coronary artery. The dislodged balloon could be retrieved by suction with the help of a guiding catheter for coronary angioplasty.     

Contrast perfusion echocardiography: identification of area at risk of dyskinesis during percutaneous transluminal coronary angioplasty

Two-dimensional contrast perfusion echocardiography was performed in 14 patients who underwent percutaneous transluminal coronary angioplasty to test the efficacy of this new technique for defining the area at risk of dyskinesis during acute coronary occlusion. In nine patients (group A) selective coronary injection of echocontrast medium through the central lumen of the angioplasty catheter was performed immediately before balloon inflation. This produced regional myocardial enhancement that defined the area of dyskinesis after balloon inflation. In five patients (group B) who underwent left coronary angioplasty, echocontrast medium was injected through the introducer catheter positioned in the left main coronary artery during balloon inflation. In each case this produced regional myocardial enhancement remote from the area of dyskinesis. There were no complications related to the intracoronary echocontrast injections, which produced no discernible exacerbation of chest pain or left ventricular contractile dysfunction. These data indicate that selective coronary injection of echocontrast medium defines the perfusion territory of the artery injected and also provides a means of identifying the area at risk of dyskinesis after balloon occlusion of the artery.     

Acute left main coronary artery occlusion--a case report and review of the literature

Acute left main coronary artery (LMCA) occlusion is rare and typically fatal. According to the recent literature, only three cases have been reported surviving emergent coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) caused by total LMCA occlusion. We report the case of a 52-year-old man presenting with total occlusion of the LMCA associated with acute anterolateral myocardial infarction and cardiogenic shock. The patient's dominant right coronary artery did not supply the collaterals to the left coronary system. After ineffective thrombolysis the patient underwent successful emergent CABG for the management of uncontrollable cardiogenic shock. Emergent CABG, though controversial, appears to be a feasible approach for patients with AMI in life-threatening situations, when other attempts at reperfusion have been unsuccessful.