An unusual combination of coronary arterial and systemic venous anomalies-clinical implications

A 57-year-old male underwent coronary angiography for exertional angina which showed two left anterior descending coronary arteries (LAD)--a short LAD from the left coronary sinus terminating in the proximal Anterior Inter-Ventricular Sulcus (AIVS), a long LAD from the proximal right coronary artery entering the distal AIVS and an anomalous left circumflex artery from the right coronary sinus. In addition, he also had absent right superior vena cava and a persistent left superior vena cava entering the coronary sinus.     

Report of a new anomaly of the left anterior descending artery: type VI dual LAD

A 48-year-old man with past medical history of coronary artery disease, previous angioplasty, hyperlipidemia, and generalized anxiety disorder presented with atypical chest pain. Coronary angiography and CT angiography revealed a variant dual left anterior descending (LAD) coronary artery not previously described. Spindola-Franco et al. have categorized dual LAD into four angiographic subtypes based on the origin and course of both a short- and a long branch of the LAD. Additionally, Manchanda et al. have described a novel variant of dual LAD with the short- and long LAD originating directly from the left and right coronary sinuses, respectively (Type V, see Table I). In the case presented, the long LAD arises from the right coronary artery and follows a unique route underneath the right ventricular outflow tract in the interventricular septal area to the anterior interventricular groove. We propose that this anatomy represents a new variant of dual LAD (Type VI).     

Echocardiographic features of false tendons in the left ventricle

M mode and two dimensional echocardiographic features consistent with previously reported autopsy findings of false tendons were seen in 5 of approximately 1,000 consecutive echocardiographic examinations. Later, the presence of false tendon was proved at autopsy in one of the five cases. Examination in three cases revealed heart disease: aortic regurgitation, third degree atrioventricular (A-V) block with aortic regurgitation and invasive thymoma with pericardial effusion; examination in two cases revealed no heart disease.In three cases, M mode echocardiograms revealed in the outflow tract of the left ventricle abnormal linear echoes that strongly mimicked those in other disorders such as discrete subaortic stenosis or flail aortic valve. In two cases, there were abnormal linear echoes in the left ventricle toward the apex. In three cases, two dimensional echocardiograms revealed long string-like echoes stretching from the upper part of the interventricular septum across the ventricular cavity to the lateral wall of the left ventricle in long and short axis views or in four chamber views. In two cases, long slender echoes between the lower parts of the interventricular septum and the left ventricle were seen in apical long axis views. These string-like echoes seem to represent the false tendons previously reported only at autopsy, although actual pathologic confirmation was available in only one of the five cases.It is concluded that (1) M mode and two dimensional echocardiograms can demonstrate the presence of false tendons, and (2) two dimensional echocardiograms are useful in differentiating false tendons from other conditions causing abnormal linear echoes in the outflow tract of the left ventricle on M mode echography.     

三维斑点追踪技术评价冠心病早期患者左室局部收缩功能

目的应用三维斑点追踪技术(3D-STE)观察冠状动脉粥样硬化性心脏病(冠心病)早期患者左心室各节段面积应变峰值及达峰时间,评价其左室局部收缩功能。方法选取2017年7月至2018年6月就诊于青岛市市立医院拟诊断为冠心病患者118例,根据冠脉造影检查选出病例组35例和对照组30例,其中病例组分为三组,左前降狭窄组(LAD)15例,左回旋狭窄组(LCX)11例,右冠脉狭窄组(RCA)9例。经胸采集心尖四腔心切面的左室全容积三维动态图像存储,应用3DT分析软件进行脱机分析,得出左心室16节段的面积应变峰值(PAS)及整体面积应变峰值(PAS-glo),左心室16节段面积应变达峰时间(TAS)及整体面积应变达峰时间(TAS-glo)。比较冠心病患者与正常对照组上述指标之间的差异。结果病例组与正常对照组的面积应变曲线的形态和走形趋势基本一致。与正常组比较,病例组狭窄冠脉所对应支配的节段面积应变峰值明显降低,达峰时间延长,差异有统计学意义(P均<0.05)。LAD组前间隔基底段、前间隔中间段、室间隔中间段的PAS降低,前壁基底段、前间隔基底段、前壁中间段、前间隔中间段、室间隔中间段的TAS延长;LCX组后壁基底段、侧壁基底段、后壁中间段的PAS降低,后壁基底段、下壁基底段、后壁中间段、侧壁中间段的TAS延长;RCA组室间隔基底段、下壁中间段的PAS降低,室间隔基底段、下壁基底段、下壁中间段TAS延长。整体面积应变与正常组相比无明显降低,差异无统计学意义(P>0.05)。结论三维斑点追踪技术可以准确评价冠心病早期患者的左室局部应变的异常,从而评价其左室局部收缩功能。     

Interventricular septal wall motion abnormality in left bundle branch block

An experimental study was performed to clarify the mechanism of perfusion defects in the interventricular septum on T1-201 scintigraphy, as seen in patients with left bundle branch block (LBBB) having normal coronary arteries. In anesthetized open-chest dogs, the following parameters were assessed during right atrial pacing as a control, left ventricular pacing to produce right bundle branch block (RBBB), and right ventricular pacing for LBBB; 1. intramuscular pressure in the interventricular septum, 2. blood flow of the left anterior descending coronary artery (LAD) measured by an electromagnetic flowmeter; 3. regional myocardial blood flow (MBF) determined at three sites, including the interventricular septum, LAD area, and left circumflex coronary artery (LCx) area using the H2-washout method. Aortic pressure, left ventricular pressure, and M-mode echocardiograms were recorded during the procedures. During right ventricular pacing, LAD flow remained unchanged; whereas MBF at the interventricular septum decreased from 99.6 +/- 23.4 to 79.2 +/- 17.6 ml/min/100 g, but MBF at the LCx area increased from 103.2 +/- 19.8 to 122 +/- 18.4 ml/min/100 g. In contrast, there were no significant changes in regional flow in any sites during left ventricular pacing. During right ventricular pacing, an early systolic dip was observed in the septal wall concomitantly with the onset of rise in intramuscular pressure in the interventricular septum. However, the beginning of the rise in left ventricular pressure was delayed 33 +/- 4 msec after that of the septal intramuscular pressure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Is it possible to rule out extensive anterior myocardial infarction in the absence of abnormal Q waves in lead I and aVL? Effect of infero-apical extension of infarction over apex

To determine whether abnormal Q wave in lead I or aVL may be of use to estimate the size of an extensive anterior myocardial infarction, electrocardiographic and left ventriculographic findings were analyzed in 45 patients with old extensive anterior infarction. All 45 patients had a significant narrowing in the proximal segment of left anterior descending coronary artery (LAD) and severe asynergy in anterolateral segment. The patients were divided into two groups; Group I consisted of 35 cases with less involvement of the inferoapical segment and Group II of 10 cases with remarkable extension of the anterolateral infarction into the inferoapical segment due to occlusion of very long LAD supplying the anterior half of posterior interventricular groove. There were no statistical differences in the extent of anterolateral asynergy, number of abnormal Q waves in precordial leads and left ventricular ejection fraction between the two groups. While abnormal Q wave in lead I or aVL was present in 28 cases (80%) of Group I, it was observed in only 3 cases (30%) of Group II (p less than 0.01). Thus, we can't rule out extensive anterior myocardial infarction even if abnormal Q waves are absent in lead I or aVL, in which abnormal Q waves may be cancelled by loss of electromotive force of inferoapical segment due to extension of the anterior infarction over the apex in cases with extraordinarily long LAD.     

冠心病伴束支传导阻滞患者冠状动脉病变特点研究

目的 :探讨冠心病伴束支传导阻滞患者冠状动脉血管病变特点。方法 :回顾性分析冠心病伴束支传导阻滞患者 (束支阻滞组 ,39例 )及无束支阻滞的冠心病患者 (对照组 ,35 1例 )心电图束支阻滞有无与冠状动脉病变的对应关系。结果 :与对照组比较 ,束支阻滞组左主干、左回旋支 (LCX)及三支血管 [左前降支 (LAD)、LCX、右冠状动脉 (RCA)同时存在病变 ]发生病变比率增加 (P <0 .0 1,P <0 .0 5 ,P <0 .0 5 )。右束支传导阻滞(RBBB)者LAD及RCA发病率高 ,RBBB并发左前分支阻滞 (LAFB)者三支血管病变发生率增高 ,左束支传导阻滞 (LBBB)者LAD、LCX病变发生率高 ,LAFB者LAD病变发生率高 ,房室传导阻滞伴束支阻滞患者多为三支血管病变。结论 :冠心病伴束支阻滞预示冠状动脉病变广泛而严重 ,LBBB提示冠状动脉血管病变以左冠状动脉为主 ,RBBB提示冠状动脉血管病变多累及RCA及LAD ,如存在 2种以上阻滞 ,特别是并发有左前分支或房室阻滞时 ,多提示存在三支血管病变及左主干病变     

Anomalous origin of posterior descending artery from left anterior descending in the presence of a diminutive right coronary artery: diagnosed by ECG gated multi-detector CT

Coronary anomalies are easily detected on ECG gated multi-detector CT which has shown to be superior to conventional angiography is demonstrating their origin and course. We present an unusual case of posterior descending artery arising as the continuation of the left anterior descending artery (LAD) in the presence of a diminutive right coronary artery (RCA). The LAD crossed over the apex and continued its course to the base of the heart in the posterior interventricular groove as PDA. The RCA, although normal in origin, was diminutive and terminated on the lateral wall of the right ventricle. This anomaly has been rarely reported and the previous cases have all been conventional angiographic findings.     

Coronary artery fistulas emptying into left heart chambers

We present three cases of coronary artery fistulas entering into the left heart chambers. Coronary arteriography in one showed aneurysmal dilatation of the main left coronary artery and a fistulous communication with a large left atrium. Exploration during repair revealed an anomalous branch of the left circumflex emptying into the left atrium. In the second case the proximal left circumflex gave rise to a branch supplying a hemangioma which emptied into the left atrium. Coronary arteriograms of the third patient showed an enlarged left anterior descending artery with an anomalous branch emptying into the left ventricle. Shunt flow was estimated with hydrogen as a tracer in the last two cases and was two thirds and one third of the left coronary inflow, respectively. Review of the literature shows 32 previously reported cases of a fistula draining into the left side of the heart.     

组织多普勒技术评价扩张型心肌病左室心功能的临床价值

目的探讨组织多普勒技术(TDI)检测扩张型心肌病(DCM)左室心功能的临床价值。方法选择DCM病人和正常健康者各40例,用TDI于胸骨旁长轴检测室间隔及左室后壁中间段短轴方向心肌运动速度(MV),并计算心肌运动速度阶差(MVG);经心尖窗检测左室前壁、后壁、下壁、侧壁和前壁、后壁室间隔中间段长轴方向MV。结果DCM组病人出现4种MV频谱形态异常,长轴、短轴方向MV均明显低于正常对照组(P<0.05或P<0.01);DCM组MVG也明显低于正常对照组(P<0.05或P<0.01)。结论TDI可定量评价DCM病人左室心肌功能,丰富了DCM的超声诊断手段。     

Single coronary artery Left (SCA L)-Right coronary artery arising from mid-left anterior descending coronary artery: New variant of Lipton classification (SCA L-II) diagnosed by computed tomographic angiography

Isolated single coronary artery (SCA) is a rare anomaly. Current classification of left and right is further classified based on the course of the anomalous vessel. We report two SCA L cases where right coronary artery (RCA) arose from mid-left anterior descending coronary artery (LAD). Our observation is a variation from the current Lipton classification SCA L Type II where RCA arose from left coronary artery before the LAD, in our cases the RCA arose from mid LAD after the first septal perforator. We believe that this variant should be described as SCA L Type II variant 2 (V2) while the original Lipton classification should be described as SCA L Type II variant 1 (V1).     

A rare type of dual left anterior descending artery distribution demonstrated by multislice cardiac computerized tomography in a patient with anterior wall infarction

Dual left anterior descending coronary artery (LAD) distribution with either of the vessels originating from the left main coronary artery (LMCA) and the right aortic sinus of Valsalva is an extremely rare coronary artery anomaly. Here we discuss a 45-year-old male who presented with non-ST-elevation anterior wall myocardial infarction due to near-total occlusion of the LAD immediately after its origin from the LMCA. The distal interventricular septum was supplied by an additional LAD arising from the right aortic sinus with a long septal course. The anomalous origin and septal course of the latter vessel were confirmed with multislice cardiac computerized tomography. The binary distribution of the LAD limited the extent of ischemic insult to the anterior wall in this case.     

Comparison of angiographic findings in patients with acute anteroseptal versus anterior wall ST-elevation myocardial infarction

Anteroseptal ST elevation myocardial infarction (AS-STEMI), in which ST elevation is limited to leads V(1) to V(3), is considered confined to the basal and mid anterior and septal segments, sparing the apex. In contrast, extensive anterior STEMI (EA-STEMI), in which ST elevation extends to leads V(4) to V(6), is considered to involve more apical segments. However, it has been reported that AS-STEMI affects mainly the apex. Others have suggested that AS-STEMI may occur in patients with extensive anterior involvement if proximal occlusion of a wrapping left anterior descending coronary artery (LAD) results in cancelation of the basal-anterior and apical injury vectors. Therefore, the aim of this study was to identify, in 97 consecutive patients with STEMI, distinct coronary angiographic characteristics that could differentiate between cases of AS-STEMI (n = 39) and EA-STEMI (n = 58). Angiography was used to determine the length of the LAD, its site of occlusion, and whether there was an alternative blood supply to the apex. Patients with AS-STEMI were more likely than those with EA-STEMI to have ≥1 branches that reached the apex (p = 0.0015) and to have proximal LAD occlusion combined with either a short LAD or >1 large side branch (35.9% vs 12.1%, p = 0.011). However, patients with AS-STEMI were also more likely to have proximal occlusion before the first septal branch of a long LAD (35.9% vs 10.3%, p = 0.005). In conclusion, AS-STEMI can occur when only the basal and mid portions of the anterior wall are infarcted, but it can also arise when the infarction extensively involves the basal anterior and the distal inferior and apical segments.     

Quantitation of variations in regional left ventricular function in isolated disease of the left anterior descending coronary artery

The pattern of contraction of the endocardial wall of the left ventricle in the right anterior oblique cineangiogram was studied by using a frame by frame radial technique and a fixed centroid without correction for rotation and translation motion during the cardiac cycle. Spatial defects of contraction were quantitated by measuring the shortening fraction of each radius and temporospatial defects by using a time-contraction integral. Twelve normal subjects were used as a basis for comparison. Thirty-two patients with isolated disease of the left anterior descending (LAD) coronary artery were divided into seven arbitrary clinicopathological subsets. Five subsets showed significant quantitative differences in contraction from the normal subjects but there was no significant difference between the subsets. They had a typical defect of contraction in the distal two thirds of the anterior wall, the apex and distal quarter of the inferior wall of the left ventricle. The subsets included: (1) patients who had undergone an anterior myocardial infarction and who had total occlusion of the LAD artery and a large anterior infarction on ECG; (2) patients with a previous classical myocardial infarction but with only 95% residual narrowing of the LAD; (3) patients with an anterior infarction and total occlusion of the LAD with return of the R waves in the anterior precordial leads; (4) patients with anterior infarction, LAD obstruction and left bundle branch block and (5) patients with anterior infarction but with early successful reperfusion with intracoronary streptokinase. Two other subsets, (1) patients with total obstruction of the LAD without a clinical myocardial infarction or (2) subtotal occlusion of the LAD without infarction, had mild left ventricular dysfunction at rest and did not differ significantly from normal.     

Blood supply of the human interventricular septum in north-west Indians

The blood supply of the human interventricular septum was studied in hearts obtained from 500 (300 males and 200 females) medicolegal autopsy subjects aged 18 to 75 years. In 350 specimens the coronary arteries were injected with 20 per cent solution of cellulose acetate butyrate and branches supplying the septum were displayed by dissection while in the remaining hearts the arteries were injected with a solution of barium sulphate and X-rays taken. The anterior two-thirds of the septum is supplied by 4 to 10 perforators and one or two long septal arteries (in 94 per cent instances) which arise from the anterior interventricular artery; the latter turns round the inferior border of the heart and extends for a variable distance in the caudal part of the interventricular sulcus and supplies perforators to the posterior one-third of the septum. The cephalic part of the posterior one-third of the septum gets its blood supply from the posterior interventricular artery; some variations in this arrangement have been encountered. In about 85 per cent instances the right coronary artery or its conus branch gives an interventricular septal branch which pierces the anterior wall of the right ventricle and runs subendocardially on the supraventricular crest to reach the interventricular septum where it anastomoses with the anterior perforators; about 15 per cent subjects who do not have this septal branch are likely to sustain a larger infarction in case the anterior interventricular artery gets blocked.     

Anomalous origin of the left anterior descending coronary artery from the right sinus of Valsalva associated with effort angina pectoris

A 54-year-old man suffering from effort angina pectoris hadan anomalous origin of the left anterior descending coronaryartery (LAD) from the right sinus of Valsalva (RSV). The anomalousLAD with a small ostium and without other significant narrowinginitially ran into the interventricular septum and subsequentlythe anterior interventricular groove. Coronary angiography duringthe anginal attack induced by ergometer exercise testing revealedneither an enhanced narrowing of the LAD ostium, nor myocardialsqueezing of the LAD at the interventricular septum level, norcoronary vasospasm. Myocardial ischaemia associated with ananomalous aortic origin of the LAD from the RSV is extremelyrare, especially when the vessel runs a septal course. In thepresent case, the ostial stenosis of the anomalous LAD, probablydue to developed atherosclerosis, seemed to be the most likelycause of the exertional angina.     

Tandem pedicled internal thoracic artery conduit for sequential grafting of multiple left anterior descending coronary artery lesions

A patient presented with severe triple-vessel coronary artery disease, including multiple lesions on the left anterior descending coronary artery (LAD), which supplied a well-contracting myocardium. In approaching our patient, we judged that a pedicled left internal thoracic artery (LITA) would not provide enough length for sequential grafting of the multisegment-diseased LAD. We also considered that a pedicled right internal thoracic artery (RITA) conduit would not be long enough to provide a free segment that would form a tandem graft with a LITA and then arrive at the marginal branch, unless it was detached at its origin. Consequently, we decided to form a composite graft that would connect a free, short segment (6-7 cm) of pedicled LITA to the in situ pedicled RITA, in an end-to-end fashion. This new composite conduit enabled us to perform sequential grafting (3 sequential anastomoses, 2 with the LITA segment) of the multisegment-diseased LAD, following the route anterior to the aorta. The in situ remnant of the LITA was grafted to the marginal branch. Although many large series have reported resourceful solutions, to the best of our knowledge, tandem arterial sequential grafting (an in situ pedicled RITA plus a free, short segment of a pedicled LITA) has not heretofore been reported in application to the multisegmented-diseased LAD artery. We strongly believe that this technique is an attractive variation on bilateral pedicled ITA left-sided revascularization in cases of multivessel coronary artery disease, including LADs with multiple lesions.     

Activation of the human fetal heart

Epicardial activation of atrial and ventricles, endocardial activation of the ventricles, and intramural activation of the interventricular septum, were studied in 11 isolated, revived, and perfused human fetal hearts. No evidence was found for specialized pathways in the atria. Earliest epicardial breakthrough in the ventricles occurred in the area pretrabecularis of the right ventricle; sometimes an early area was found on the posterior aspect of the right ventricle. Latest activated areas were the diaphragmatic and basal aspects of the right ventricle; on occasion, the latest region was the posterolateral part of the left ventricle. On the endocardial surface three regions of early activity were found; the central part of the middle third of the left part of the septum, an area located near the base of the left anterior free wall, and a region near the middle lower part of the left posterior paraseptal region. Septal activation occurred in a left-to-right direction only; nowhere was a right-to-left spread of excitation found. The intramural spread of excitation was perpendicular to the endocardial surface in the central part of the interventricular septum and in the free wall of the left ventricle. In the basal and apical parts of the interventricular septum and in the free wall of the right ventricle, excitation spreads in a tangential fashion.     

Left anterior descending artery length in left and right coronary artery dominance

BACKGROUND: Coronary stenosis of the left anterior descending artery (LAD) is respected by cardiologists because of its negative influence on morbidity and mortality. An important anatomical consideration is the length of the LAD. OBJECTIVE: To investigate the relationship between length of LAD and coronary dominance. DESIGN: Retrospective comparison of 100 consecutive angiograms with left coronary dominance with 100 consecutive angiograms with right coronary dominance. The relationship between the length of the LAD and coronary dominance was analyzed. METHODS: We retrospectively compared 100 consecutive angiograms with left coronary dominance (the posterior descending artery being supplied by the circumflex artery) with 100 consecutive angiograms with right coronary dominance (the posterior descending artery being supplied by the right coronary artery). LADs were categorized into three types: type A, LAD terminating before the cardiac apex; type B, LAD reaching the apex but not supplying the inferoapical segment of the left ventricle; and type C, LAD wrapping around the apex and supplying the inferoapical segment. LAD typing was also analyzed in relation to gender. RESULTS: It was found that the LAD wrapped around the apex in 87% of cases of left coronary dominance but only in 47% of patients with right coronary dominance, and that the long LADs were more frequently seen in women than in men, irrespective of coronary dominance. CONCLUSIONS: We found that the LAD in left coronary dominance is usually long and wraps around the apex, and believe that angiographic interventions in such cases have important clinical significance.     

Coronary angioplasty at the time of initial diagnostic coronary angiography in patients with unstable angina

Of the last 200 consecutive patients undergoing PTCA procedures at our institution, 29 (15%) had unstable angina; and angioplasty was performed at the time of diagnostic coronary arteriography. There were 26 males and three females with an age range of 31-82 (mean 57) years. Factors favoring PTCA at the time of initial coronary arteriography included clinical indications for revascularization, appropriate anatomy based on high-quality fluoroscopy, and availability of emergency surgery if required. Of 34 coronary lesions in 29 patients, 19 involved the anterior branch of the left anterior descending coronary artery (LAD), eight the circumflex branch (Cx); and seven the right coronary artery (RCA). Five patients had two vessels dilated (one LAD + RCA, two LAD + Cx, and two RCA + Cx). Of the coronary artery lesions, 19 were concentric, seven were eccentric, 20 were single and discrete, six were long or multiple in the same vessel; eight vessels were totally occluded, and in nine patients there was good collateral circulation. Twenty-nine (85%) arteries were successfully dilated. Of the unsuccessful cases, one was from failure to cross a totally occluded lesion, and three residual lesions and/or postdilatation pressure gradients remained significant. One patient required emergency aortocoronary bypass surgery because of total occlusion of the LAD immediately post-PTCA. There were no postprocedural myocardial infarcts or deaths. It is concluded that, in selected patients with unstable angina, PTCA can be performed successfully and with low risk at the time of initial diagnostic coronary arteriography. This approach offers certain clinical financial advantages.