Atresia of left coronary ostium and left main coronary artery

An uncommon coronary anomaly incidentally found at autopsy of a 76-year-old woman is reported. There was no history of cardiovascular symptoms or clinical signs of ischemic heart disease. The autopsy disclosed that the patient had no left coronary ostium and that the left main coronary artery was atretic. However, the rest of the left coronary system, including the left anterior descending coronary artery and the left circumflex coronary artery, were intact in their normal positions. Arterial flow to the left coronary system was supplied by a dilated collateral vessel that originated from the right main coronary artery and coursed between the right ventricular infundibulum and the aorta. Our case suggests that atresia of the left coronary ostium and the left main coronary artery, often associated with death at an early age, may also be compatible with symptom-free longevity. Moreover, attention is focused on the nomenclature of single coronary anomalies.     

Anatomic variant of the posterior interventricular coronary artery: Implications for coronary angioplasty in acute myocardial infarction

Acute thrombotic occlusion of an infarct-related artery is frequently found in patients presenting with myocardial infarction. In a patient with acute inferior wall myocardial infarction complicated by continuous chest pain and hemodynamic instability, emergency diagnostic coronary arteriography demonstrated a patent, infarct-related, “pseudo” right coronary artery while, in fact, this vessel was a rare anatomic variant of the posterior interventricular branch with very early origin from the right coronary artery and the true right coronary artery was completely occluded by a thrombotic obstruction. Accurate anatomic-angiographic interpretation of the angiogram was crucial for successful performance of emergency recanalization and revascularization of the true right coronary artery with laser and balloon angioplasty. Once antegrade flow was restored another rare coronary variant was discovered, i.e., a sinoatrial node artery arising from the middle portion of the newly patent right coronary artery. Clin. Anat. 10:303–306, 1997. © 1997 Wiley-Liss, Inc.     

Dissecting aneurysm of a coronary artery due to percutaneous transluminal balloon angioplasty

Percutaneous transluminal balloon angioplasty (PTCA) is utilized successfully to dilate stenotic coronary arteries. The procedure is a frequent nonsurgical method to restore coronary artery blood flow to ischemic myocardium. In this paper, we report a case of intimal tear and medial dissection of the right coronary artery leading to a dissecting aneurysm and occlusion of the coronary artery. The patient died following coronary artery bypass grafts, and the autopsy demonstrated the dissecting aneurysm of the coronary artery.     

Origin of anterior descending coronary artery from right aortic sinus. Intramyocardial tunneling to left side of heart

We report a rare case of a coronary anomaly. All of the coronary arteries originated from a single ostium located in the right coronary cusp. The single coronary artery had a main branch corresponding to the usually dominant right coronary artery. The left anterior descending coronary artery arose from the right coronary artery and coursed intramyocardially within the right ventricular outflow tract to the anterior interventricular sulcus. The absence of evidence of myocardial ischemia in our patient, both clinically and at autopsy, and in three cases reported previously, suggests that the condition reported here was an unlikely cause of myocardial ischemia.     

Delayed coronary occlusion following primary successful angioplasty: Management and outcome

Summary The treatment of delayed coronary occlusion after primary successful percutaneous transluminal coronary angioplasty (PTCA) is more difficult because surgical standby is often not available. The purpose of this study was to assess the therapeutic approaches and outcome of patients with delayed coronary occlusion from 30 to 180 minutes after successful PTCA. A delayed occlusion occurred in 18 (0.9%) (61±11 years; malen=14, femalen=4) out of 2065 consecutive patients after PTCA. In 11 patients the dilated stenoses were located in the left descending artery, while seven patients had the stenosis in the right coronary artery. Twelve patients had unstable or postinfarction angina. The time interval between completion of PTCA and the onset of chest pain was 64±39 minutes. Immediate i.v. nitroglycerin resulted in no relief of the symptoms in any patient. One patient was operated upon at once, and one was given i.v. thrombolysis resulting in pain relief and reversal of ECG changes. The remaining 16 patients returned initially to the catheterization laboratory, where the occluded vessels were opened by mechanical recanalization. Three of them remained in stable condition. Due to impending reocclusion surgery was necessary in four patients and thrombolysis was performed in nine. After thrombolysis the vessel remained open in four patients. The other five needed bypass surgery on the day of PTCA. Myocardial infarction developed in nine patients (maximal CK 673±488 units/l). In conclusion, delayed occlusion after successful PTCA is a rare complication occurring primarily in patients with unstable angina. Mechanical recanalization opened the occluded vessel in most patients, and myocardial infarction was prevented in 50%.Abbreviations PTCA percutaneous transluminal coronary angioplasty - CK creatine kinase - ECG electrocardiogramm - SD standard deviation     

Effect of angioplasty and grafting on porcine vascular nerves: a potential neurotropic role for endothelin-1

The most commonly performed procedure for treating coronary artery stenosis is percutaneous transluminal coronary angioplasty (PTCA) and, where the vessel lumen is severely narrowed, coronary artery bypass grafting (CABG). In PTCA, regions of atherosclerotic plaques are disrupted, and the vessel lumen increased by inflating a balloon catheter. In CABG an autologous saphenous vein into coronary artery interposition graft is performed in order to bypass occluded regions of epicardial coronary arteries. Both interventions cause varying degrees of vascular damage and the long-term efficacy of these procedures is limited by a high incidence of neointimal formation and subsequent vascular restenosis (Bach et al. 1994; Bryan & Angelini, 1994).
The endothelium-derived constrictor peptide, endothelin-1 (ET-1) (Yanagisawa et al. 1988), also possesses mitogenic activity on vascular smooth muscle cells (Hirata et al. 1989) and has been suggested as playing a role in atherosclerosis (Dashwood et al. 1993; Zeiher et al. 1994) and intimal hyperplasia (Dashwood et al. 1993; Douglas et al. 1994).     

The aorticopulmonary artery of the cat — its location and postnatal closure

This paper describes the position and time of postnatal closure of a vessel from the pulmonary artery to the aorticopulmonary glomus (carotid body-like) tissue. Nine prenatal and eight postnatal kittens (killed at 12 hours, and 8, 12, 16, 30, 42, 60 and 90 days) and 50 adult cats were examined. The vessel arose from the root of the right pulmonary artery and had ascending and descending branches. The latter supplied the aorticopulmonary glomus tissue and mingled with vessels arising from the root of the coronary arteries — usually the left. In two prenatal cats an actual anastomosis was demonstrated. There was no change in the intramural part of the branch of the pulmonary artery in kittens less than 16 days old. The vessel was partly closed by cellular proliferation by the sixteenth day and was almost certainly occluded by the forty-second day. It was not patent in any animal more than 42 days of age. In the adult cat, the aorticopulmonary glomus tissue was less cellular than in the fetus. It is suggested that the communication between the branch from the right pulmonary artery and the coronary arteries through chemoreceptor tissue may have functional significance.     

Morphology of coronary vessels in coronary heart disease. An analysis of 930 coronary angiograms

Coronary anatomy was analyzed in 930 patients who underwent coronary arteriography because of coronary artery disease. There was a slight predominance of single vessel disease, whereas double and triple vessel disease were equally distributed. A left main (LM) lesion was found in 5.2%, with an additional right coronary artery lesion in 3.3%. The left anterior descending (LAD) artery was involved most frequently, followed by the right coronary artery (RCA) and left circumflex (Cx). The LAD demonstrated more often a proximal stenosis than the RCA and Cx. If the LM is associated with a RCA-stenosis then the LAD and Cx are involved more commonly, suggesting a more advanced disease in all major vessels. The analysis of ventricular function revealed a significant deterioration according to the number of diseased vessels. If the LM is associated with a RCA lesion, then the hemodynamics are similar to a 3-vessel disease, whereas isolated LM lesions are associated with good ventricular function according to the lesser degree of coronary sclerosis. The deterioration of the hemodynamics in correlation with coronary vessel involvement is significant, however due to the large standard deviations conclusions for the individual patient can not be drawn.     

Unusual autopsy finding in a case of metastatic teratocarcinoma

An unusual autopsy finding was seen in a young case of metastatic teratocarcinoma of the right testis. The patient presented with features of myocardial ischemia and died of sudden cardiac arrest. At autopsy, the lungs were studded with variably sized metastatic nodules composed of glistening hyaline cartilage. Examination of the coronary arteries revealed complete occlusion of the left anterior descending and left circumflex artery lumina by tumor emboli composed of glistening white chondromyxoid material. Histopathology confirmed the presence of mature hyaline cartilage and chondromyxoid material in tumor emboli. The individual died due to severe coronary insufficiency and sudden cardiac arrest secondary to complete luminal occlusion of the left anterior descending and left circumflex artery lumina by tumor emboli composed of hyaline cartilage.     

Evidence at autopsy of spasm in the distal right coronary artery in persons with coronary heart disease dying suddenly

The aim of this study was to examine whether there are morphological signs in spasm in the coronary arteries at autopsy in persons with coronary artery disease dying suddenly. From a forensic autopsy service, 48 cases of sudden and unexpected deaths were selected: 24 cases with a preliminary diagnosis of coronary heart disease and 24 cases involving persons dying of noncoronary causes. A complete autopsy according to a preset protocol was followed with particular emphasis on the heart examination. The myocardium and the coronary arteries were sampled and examined without knowledge to which group the case belonged. The degree of folding of the internal elastic lamina of the proximal and distal parts of the coronary arteries was measured by picture analysis of elastin-stained cross sections of the arteries. The degree of folding was significantly greater in the distal section of the right coronary artery in cases of the coronary group compared to the folding in the same section in cases of the noncoronary group. In the proximal part of the right coronary artery and in the left coronary artery with its two branches, there were no differences in the folding of the internal elastic membrane between the groups.

Our findings indicate that a spasmic contracture of an artery may be diagnosed postmortem. The spasm of the distal part of the right coronary artery may have caused focal ischemia in the central parts of the cardiac conducting system, precipitating a lethal arrhythmia.     

Analog Electrical Model of the Coronary Circulation in Case of Multiple Revascularizations

In this work, we propose an analog electrical model of the coronary circulation for patients with obstructive disease undergoing revascularization. In this clinical situation, the collateral circulation to the occluded artery is difficult to ascertain via preoperative measurements and well-developed collaterals might induce long-term restenosis of the revascularized artery due to flow competition mechanisms. The proposed model allows an original biomechanical analysis of per-operative hemodynamic data in order to assess quantitative evaluation of pressures and flows inside the native stenosed arteries, the collateral network and the bypass grafts. Average cardiac cycle values are analysed. In the case of 3-vessel disease and chronic occlusion of the right coronary artery, the quantitative results confirm the protective effects of the collateral flows in the pathological situation, but also show that the revascularization of the occluded right artery is fully justified since the collateral flows remain low, even when the left territory is revascularized. The model thus provides a computational tool to evaluate therapeutic strategies for each patient.     

心肌桥的形态特点与冠状动脉粥样硬化关系

目的　探讨心肌桥（MB）存在及与冠状动脉粥样硬化（AS）的关系。 方法　回顾性分析在法医尸解中发现的87例心肌桥的形态特点与AS的关系。 结果　MB检出率34.7％,并随年龄呈阶梯样增加,心肌桥主要出现在左冠状动脉前降支及右主干, 单个MB最多,占90.8％（79例）。MB桥前段发生AS有43.7％（38例）,管腔狭窄程度大多在Ⅲ级以上占86.8％（33例）;桥后段有8％（7例）发生AS,管腔狭窄程度均在Ⅱ级以下,二者有统计学意义（P<0.05）,桥下段无AS;存在AS的MB长度大多2.0cm以上。 结论　大多数MB是解剖变异,随着年龄增加可导致桥前段和桥后段AS,桥前段更易发生AS。     

Coronary ectasia in familial hypercholesterolemia: histopathologic study regarding matrix metalloproteinases.

A 39-year-old male heterozygous familial hypercholesterolemia patient with marked ectasia over the entire coronary artery tree had been treated with several kinds of lipid-lowering single or combined drug therapies using clofibrate, compactin, cholestyramine, probucol, and pravastatin, and LDL-apheresis. During the 19-year follow-up, he suffered myocardial infarction three times and some of the ectatic coronary segments became enlarged, others narrowed, and one of them occluded in spite of the treatment. At the age of 58, he died after a fourth cardiac attack and subsequent cardiogenic shock. The autopsy indicated that his three coronary arteries showed diffuse ectatic changes and the largest lumen diameter of the left anterior descending artery was 25 mm, of the circumflex artery 12 mm, and of the right coronary artery 13 mm. The ectatic artery wall was not thick and the major part of the lumen was occupied by organized thrombi. Microscopic examinations showed that the larger the diameter of the lumen, the more severe the structural damage of the intima and tunica media and the larger the number of infiltrated cells, including lymphocytes, macrophages, and plasma cells. Immunoreactivity against matrix metalloproteinase (MMP)-1, and MMP-2 was observed in smooth muscle cells, macrophages, lymphocytes, and endothelial cells of the vasa vasorum or neovasculature. MMP-9 immunoreactivity was also localized in intimal foamy macrophages and round cells (macrophages and lymphocytes) of the media and adventitia. MMP-1 increased with the lumen diameter of the ectatic arteries. The ratio of immunoreactivity against both MMP-2 and MMP-9 to that against tissue inhibitor of metalloproteinase (TIMP)-2 also increased with the lumen diameter, but it no longer increased when the diameter was over 10 mm. These observations suggest that the MMP-TIMP system appears to play a significant role in the development of coronary ectasia     

Giant right coronary artery aneurysm presenting as a paracardiac mass.

Coronary artery aneurysms, commonly atherosclerotic, are usually asymptomatic and can be diagnosed incidentally during investigation for ischemic heart disease or on autopsy. An asymptomatic giant right coronary artery aneurysm presenting as a paracardiac mass discovered on autopsy is reported here. Even though there was great concern due to its large size, complex atherosclerotic lesions, and potential obstruction of blood flow, it had no direct link to the cause of death. We also review the literature on giant right coronary artery aneurysms exceeding 5 cm in the last 10 years.     

Giant right coronary artery aneurysm secondary to Kawasaki disease in child: a case report

Coronary artery aneurysm or ectasia was reported in approximately 15% to 25% of the affected children, particularly in the proximal end of the main blood vessel and the left anterior descending part. Rare patients have been reported with aneurysm in the distal end of the right coronary artery. In this case report, we present a rare case with aneurysm in the distal end of the right coronary artery. Multi-slice computed tomography was performed for the coronary angiography. Aspirin (10 mg/kg body weight per day) and gamma globulin (2 kg/kg body weight) was administrated via intravenous injection. The patient is currently in a healthy status with a 12-month follow up.     

Replacement of circumflex branch of left coronary artery originating from the right aortic sinus

Abstract: Replacement of the circumflex branch of the left coronary artery is extremely rare. We conducted a retrospective study to determine the incidence of this anomaly of circumflex branch of the left coronary artery. Two such patients were identified from 850 adults undergoing cardiac catheterization procedures. The circumflex branch of the left coronary artery was replaced by a vessel arising from the right aortic sinus. The course of this vessel was retroaortic. A knowledge of this anomaly is important for coronary artery bypass surgery.     

A very rare anatomic variation of the right ventricular branch: right ventricular descending branch from the anterior interventricular branch

The anterior interventricular branch of the left coronary artery has the most constant distribution in the human heart and rarely gives off right ventricular branches. Here we report a case with a right ventricular branch which diverged from the anterior interventricular branch and descended on the anterior right ventricular wall parallel to the anterior interventricular sulcus; we termed it the right ventricular descending branch. This artery gave a collateral artery to the occluded anterior interventricular branch at the apex, and had prevented anterior myocardial infarction. The right ventricular descending branch should be precisely identified in order to perform successful myocardial revascularization procedures such as coronary artery bypass grafting and percutaneous coronary intervention, especially in a patient with anterior interventricular branch occlusion.     

Rapid progression of nonculprit coronary lesions six weeks after successful primary PCI in culprit artery： a case report

We report a case of a 49-year-old man who was admitted with a 3-hour history of sudden onset of substemal chest pain. Coronary angiography revealed that the left circumflex artery （LCX） was acutely and totally occluded at the mid-portion. In addition, the proximal and mid-portion of the right coronary artery （RCA） had a 60% occlusion. We inferred that the LCX was the culprit artery and primary PCI was successfully performed. Six weeks later, the patient had an eventful course with recurrence of chest pain. Coronary angiography showed no significant ste- nosis in the previous LCX lesion, while the proximal and middle potion of the RCA had a 90% occlusion. Our case demonstrates the systemic nature of acute coronary syndromes and highlights the inherent instability of coronary artery disease.     

Total anomalous origin of the coronary circulation from the right pulmonary artery

Origin of both coronary arteries from a branch of the pulmonary artery is rare and has not been reported as a cause of sudden unexpected death. We report autopsy findings of a 14-day male infant in previously good health who died suddenly. From the proximal right pulmonary artery arose a single coronary artery, which branched into the right and left main coronary arteries. The right proximal coronary artery coursed between the aorta and pulmonary trunk, and the left main traveled along the anterior proximal aorta. The distal course of the coronary circulation was normal. There was concentric subendocardial healing myocardial infarction. No other congenital anomalies were identified. Total anomalous origin of the coronary arteries from the pulmonary trunk or artery should be considered in cases of sudden unexpected death in infants.     

Prevalence of left and balanced coronary arterial dominance decreases with increasing age of patients at autopsy. A postmortem coronary angiograms study

BackgroundIn patients presenting with an acute coronary syndrome, left over right coronary dominance appears to be independently associated with increased long-term mortality. This could lead to decreasing numbers of patients with a left dominant coronary artery system in older age groups.MethodsWe assessed the type of coronary dominance in different age groups in postmortem angiograms that were routinely performed at autopsy between 1993 and 2007. Coronary dominance was determined by identifying the origin of the posterior descending artery and posterolateral branches on postmortem angiography. Age, gender, and cause of death were recorded from the autopsy database. The prevalence of left dominant, right dominant, and codominant systems was determined in three increasing age categories, with cutoffs based on tertiles.ResultsA total 1620 coronary angiograms were assessed; 167 were excluded because it was not possible to determine coronary dominance. The median age of all patients was 71 years; 56% were male. Of all deaths, 40% were classified as cardiac. Regarding coronary dominance, 81.2% was right, 9.1% was left, and 9.7% was codominant. Overall, a decrease in prevalence of left and codominant coronary systems was observed with increasing age in the three age cohorts (≤63years, 64–75 years, and ≥76 years) (P=.001 for overall comparison).ConclusionsIn this large autopsy cohort, the prevalence of a left dominant or codominant coronary system decreased with increasing age. These findings could relate to a slightly higher risk of mortality in case of left versus right coronary artery occlusion.