Calcified bicuspid aortic valve mass prolapsing into the left main coronary artery

We report a case of a mobile calcific mass on the aortic valve that prolapsed into the left main coronary artery of a 51-year-old man. This case and a review of the literature suggest that calcific embolization to coronary arteries is a rare but possibly underrecognized complication of calcified degenerative or bicuspid aortic valves. This potentially catastrophic complication of calcified aortic valves needs to be suspected and recognized in clinical practice.     

Acute aortic dissection mimicking an acute coronary syndrome through occlusion of the right coronary artery

Occlusion of the right coronary artery (RCA) is an uncommon complication of type A aortic dissection. Aortic dissection and acute coronary syndrome (ACS) share a similar pathogenesis in atherosclerosis and hypertension. Consequently a patient with ischaemic risk factors presenting with chest pain and dynamic ECG change may well be incorrectly treated for ACS if careful attention is not paid to the presenting symptoms and signs. This case report describes a 59-year-old man who presented with chest pain, confusion and an ischaemic ECG and was initially treated for ACS. He subsequently deteriorated clinically and imaging confirmed type A aortic dissection complicated by RCA occlusion. Following emergent surgery with aortic root replacement and coronary artery bypass grafting he later made a good recovery.     

Spontaneous aortic dissection limited to sinus of Valsalva and involving the left main coronary artery

Aortic dissection limited to one sinus of Valsalva has been described exclusively as an iatrogenic complication during catheterization interventions. This life-threatening subtype had a very small area of dissection, when coronary ostia are frequently involved. We report a 43-year-old man with dissection limited to left sinus of Valsalva, involving the left main coronary artery and causing non-ST-myocardial infarction, including severe reversible ST-depression, maximum of 9 mm in V₅ lead. Dissection was suggested by cineangiography, transesophageal echocardiogram, and contrast-enhanced multidetector computed tomography. Surgical treatment was successful. There were not any associated diseases in the sinuses of Valsalsa, aortic valve or coronary arteries. Unlike previous reported cases of aortic dissection with such limited localization, the present case was spontaneous, and not iatrogenic.     

Spontaneous dissection in the left main coronary artery

We present two cases of spontaneous left main stem coronary artery dissection. One was underdiagnosed with suboptimal percutaneous coronary artery intervention followed by acute vessel occlusion again during the hospitalization. The other one was identified and confirmed by intravascular ultrasound, followed by conservative medical treatment, with completed healing of SCAD during two-month follow up.     

Angiographic retrograde filling of all left coronary arterial branches in a patient with chronic total occlusion of left main coronary artery

A 81‐year‐old female patient was referred in our hospital with episodes of pulmonary edema and had an isolated chronic total occlusion of the left main coronary artery. Coronary angiogram showed total occlusion the left main and filling the left coronary system by collaterals from the right coronary artery.     

Percutaneous coronary intervention for left main coronary artery disease

Coronary artery bypass surgery is the currently accepted treatment for unprotected left main coronary artery disease. Currently, the data supporting the safety and efficacy of stents for unprotected left main coronary disease are derived mostly from nonrandomized, single-center studies or registries. These results appear promising but large randomized trials are needed to guide therapy of this potentially lethal disease.     

Angiographically undetected plaque in the left main coronary artery

The absence of angiographic findings despite significant coronary artery disease has been previously described. Possible explanations for the limitation of plaque detection by angiography include compensatory vessel enlargement in face of intracoronary plaque formation, the lack of reference segments in diffuse atherosclerosis as well as technical limitations. Intracoronary ultrasound (ICUS) imaging provides the possibility of direct plaque visualization. We studied angiographically normal left main coronary arteries (LMCA) in 72 patients prior to diagnostic angiography or therapeutic interventions using ICUS (30 MHz). ICUS images were continuously recorded and recalled from memory for morphometric analysis. Lumen area, plaque area and the total vessel area were determined by computer software. ICUS imaging revealed atherosclerotic plaque in 55 of the 72 patients with angiographically normal LMCA (76%). The average plaque area stenosis was 22±12% (range 3–44%). Total vessel area showed a significant direct correlation with plaque area, indicating compensation of coronary plaque formation. The average percent change in plaque area (difference between maximal and minimal plaque area within the LMCA) was 11±19%, indicating a diffuse pattern. Measurement of change in lumen area (difference between maximal and minimal lumen area within the LMCA) revealed an average value of 6±7%. Lumen area of the LMCA was 15.9±3.2 mm² in patients with and 17.2±1.9 mm² without atherosclerotic plaque (n.s.). Thus, the lack of angiographic changes despite advanced plaque formation in the LMCA could be explained by compensatory vessel enlargement and by diffuse distribution of plaque in the vessel; true lumen narrowings overlooked by angiography seem not to account for the failure of angiography to detect plaque.     

Bypass to the left coronary artery system may accelerate left main coronary artery negative remodeling and calcification

Aims

This study aimed to use intravascular ultrasound (IVUS) data to reveal the mechanism of lesion progression in the native coronary circulation proximal to bypass grafts after coronary artery bypass grafting (CABG).

Methods and results

We reviewed IVUS images in 86 patients with an angiographically significant left main coronary artery (LMCA) stenosis. Overall, 41 patients underwent CABG more than 6 months (mean 8.2 ± 6.1 years) previously and had at least one patent graft to the left coronary artery system. The number of patent grafts to the left coronary artery was 1.4 ± 0.7. Comparing patent graft vs. non-CABG groups, external elastic membrane and lumen areas and remodeling index at the minimum lumen area (MLA) site trended smaller with no difference in the plaque & media area. In addition, patients in the patent graft group had more LMCA calcium whether defined by cross-sectional (arc at the MLA site of 141 ± 109° vs. 88 ± 108°, P = 0.025) or longitudinal measurements (calcium length index, calculated as LMCA calcium length divided by total LMCA length, 0.69 ± 0.38 vs. 0.50 ± 0.42, P = 0.035).

Conclusions

Negative remodeling may be the main mechanism of lesion progression proximal to a patent bypass graft, and more calcium was found in LMCA after CABG compared with non-CABG patients.     

Successful resuscitation with extracorporeal membrane oxygenation support for refractory ventricular fibrillation caused by left main coronary artery occlusion

Refractory ventricular fibrillation with cardiac arrest caused by occlusion of the left main coronary artery may rapidly become fatal. In this report, we describe the case of a 70-year-old male who presented to emergency department with chest pain. Electrocardiogram showed ST-segment elevation in leads aVR and aVL and ST-segment depression in leads v3, v4, v5, v6, 2, 3, and aVF. Occlusion of the left main coronary artery was suspected. While waiting for percutaneous coronary intervention, the patient experienced sudden refractory ventricular fibrillation with cardiac arrest. In the emergency department, resuscitation of a patient with refractory ventricular fibrillation caused by occlusion of the left main coronary artery and ongoing cardiopulmonary resuscitation is a clinical challenge. Resuscitation with extracorporeal membrane oxygenation support was initiated approximately 35?min after prolonged conventional cardiopulmonary resuscitation. Emergency coronary angiography showed almost total occlusion of the left main coronary artery. Percutaneous coronary intervention with a stent restored coronary perfusion. The patient was discharged on day 6 without serious sequelae or neurological deficits.     

A case of giant left main coronary artery aneurysm in an elderly man

Aneurysms of the left main coronary artery are rare and their optimal treatments remain unknown. A 64-year-old man without any symptoms was referred to our department for suspected coronary aneurysm. Transthoracic echocardiography demonstrated an aneurysm of the left main coronary artery. On transesophageal echocardiography, the thrombus was suspected inside and severe ostial stenosis of the left coronary artery was highly suspected due to the accelerated flow velocity. Multidetector computed tomography demonstrated the aneurysm as being 37 mm in diameter with significant stenosis at both left coronary arteries, more clearly than coronary angiography. Because of its size and coexisting coronary artery disease, surgical closure of the aneurysm and coronary artery bypasses were performed. Echocardiography and coronary computed tomography could help in the diagnosis and the therapeutic decision in the case of left main coronary artery aneurysm before coronary angiography.     

Paradoxical embolism in the left main coronary artery: diagnosis by transesophageal echocardiography

We describe a patient with a paradoxical coronary embolism diagnosed by transesophageal echocardiography. The patient developed a stroke followed by a myocardial infarction. Coronary angiography showed an obstruction of the left main coronary artery. Transesophageal echocardiography showed the mechanism of the neurologic and cardiac events to be a paradoxical embolism. Emergency surgical retrieval of the thrombus lodged in the left main coronary ostium and of a separate thrombus traversing a patent foramen ovale was performed. To our knowledge, direct visualization of the paradoxical coronary embolism by echocardiography has not been reported previously. We discuss mechanisms responsible for paradoxical coronary embolism and review the literature pertaining to this condition.     

急性左主干闭塞所致急性心肌梗死的临床特点

目的 回顾性分析急性左主干（LM）闭塞所致急性心肌梗死（AMI）患者的临床表现,总结此类患者的临床特点。方法 从1995年1月至2006年5月,首都医科大学附属北京朝阳医院共完成1793例AMI患者的急诊经皮介入治疗（PCI）,其中共有15例患者的梗死相关血管为左主干。15例患者均为男性,年龄（43—85）（60．6±10．4）岁。回顾性分析这15位患者的临床资料、造影和介入治疗情况、以及临床随访结果。结果 1例患者表现为aVR导联以外的广泛导联ST段压低,其余14例均表现为急性广泛前壁心肌梗死。10例（66．7％）患者术前存在严重心源性休克,所有患者均在主动脉内球囊反搏（IABP）支持下接受急诊PCI治疗。急性期死亡9例（60．0％）,存活的6例患者均完成3个月随访,其中1例于术后4年猝死。对比分析的结果,提示术前存在良好的侧支循环可能是影响此类患者近期预后的影响因素。结论 LM急性闭塞所致的AMI患者病情凶险,心源性休克发生率及急性期死亡率高。IABP支持下急诊PCI治疗可以挽救部分病人的生命和改善预后。     

Right coronary artery chronic total occlusion in presence of anomalous origin of left coronary artery

Right sinus origin of left coronary artery is a very uncommon congenital coronary anomaly. The presence of an associated totally occluded right coronary artery represents an exceedingly rare picture. An accurate morphologic identification of anomalous arteries, by multi-detector computed tomography, is mandatory before planning any therapeutic intervention. We report an interesting case of chronic total occlusion of the right coronary artery in a young patient with anomalous left coronary artery.     

Drug-eluting stents in unprotected left main coronary artery disease

Though coronary bypass graft surgery (CABG) has traditionally been the cornerstone of therapy in patients with unprotected left main coronary artery (ULMCA) disease, recent evidence supports the use of percutaneous coronary intervention in appropriate patients. Indeed in patients with ULMCA disease, drug-eluting stents (DES) have shown similar incidence of hard end points, fewer periprocedural complications and lower stroke rates compared with CABG, though at the cost of increased revascularization with time. Furthermore, the availability of newer efficacious and safer DES as well as improvements in diagnostic tools, percutaneous techniques and, importantly, a better patient selection, allowed percutaneous coronary intervention a viable alternative to CABG of left main-patients with low disease complexity; however, even in this interventional era characterized by efficacious DES, patients with ULMCA disease remain a challenging high-risk population where outcomes strongly depend on clinical characteristics, anatomical disease complexity and extension and operator’s experience. This review summarizes the role of DES in ULMCA disease patients.     

Successful stenting of a left main coronary artery occlusion as a complication of RF ablation for Wolff-Parkinson-White syndrome

Wolff-Parkinson-White (WPW) syndrome is a disorder characterized by presence of an accessory pathway that predisposes patients to tachyarrhythmias and sudden death. Radiofrequency ablation (RFA) is both effective and safe for patients with symptomatic tachyarrhythmias mediated by accessory atrioventricular pathways. During the procedure, fatal complications may occur but it is considered low in relation to the morbidity associated with the WPW syndrome. Coronary artery occlusion, as a complication of an RF catheter ablation, is quite rare. In this report, we present a 56-year-old male patient with a left main coronary artery (LMCA) occlusion during the ablation of left anterolateral wall accessory pathway. It should be kept in mind if the patient complains of new onset of severe chest pain, an immediate angiography should be performed.