右冠状动脉缺如左冠状动脉双支病变PCI术1例

冠状动脉解剖变异临床上较为常见,冠状动脉变异特别是起源变异的发生概率为1%~2%,其中右冠状动脉起源变异占80%。右冠状动脉常见变异为开口位置异常,而先天性缺如却少见,有人认为右冠状动脉先天性缺如与胚胎时期冠状动脉异常发育或未发育完全有关。本文就1例右冠状动脉缺如并左冠状动脉双支病变行经皮冠状动脉介入治疗(PCI)术总结分析如下:     

成年人冠状动脉造影先天性变异分析

目的 :探讨成年人先天性冠状动脉变异 (畸形 )的检出频度。　　方法 :回顾性研究总结 4173例患者的冠状动脉造影资料 ,准确判定各种先天性冠状动脉变异。　　结果 :1冠状动脉造影 4173例中检出冠状动脉开口起源异常 5 0例 ,检出率为 1.2 % ,其中各种右冠状动脉起源异常 42例 ,占 84.0 % ,左冠状动脉起源异常 7例 ,占 14.0 % ,左、右冠状动脉开口起源均异常 1例 ,占 2 .0 % ;2检出各种类型冠状动脉分支起源异常 15例 ,检出率为 0 .4% ;3检出各种类型冠状动脉瘘 2 8例 ,检出率为 0 .7% ,其中 18例(6 4.3% )为冠状动脉—肺动脉瘘 ;4其它少见冠状动脉变异 2例。　　结论 :成年人先天性冠状动脉变异的临床症状和体征多不典型或缺如 ,通常在心导管检查中被偶然发现 ,冠状动脉造影是确诊各种类型冠状动脉变异最重要的检查方法。     

冠状动脉造影中冠状动脉先天性变异的分析

目的:分析冠状动脉先天性变异的冠状动脉造影表现,探讨冠状动脉造影的诊断价值。方法:2003年1月～2007年12月在武汉钢铁公司总医院行冠状动脉造影的患者900例,对其结果进行回顾性分析。结果:共检出67例冠状动脉先天性变异,检出率为7.44%。其中检出冠状动脉瘘9例,检出率为1.00%,并以冠状动脉-右心室瘘最为多见。12例为冠状动脉起源和分布异常,占1.33%,并以右冠状动脉的先天性变异为多见。检出冠状动脉心肌桥(壁冠状动脉)46例,检出率为5.11%,并以左前降支心肌桥多见。结论:冠状动脉先天性变异的临床症状和体征多不典型或缺如,冠状动脉造影是确诊各种冠状动脉先天性变异的重要手段。     

先天性左冠状动脉畸形并狭窄性病变行PCI治疗2例

冠状动脉畸形是一种少见的先天性疾病,左单冠状动脉畸形更是非常罕见,发生率为0.025%,可分为L-1型及L-2型,L-1型系先天性右冠状动脉缺如,L-2型系右冠脉开口异常。本文报告2例左单冠状动脉畸形病例系先天性右冠状动脉缺如,均分别对其左冠状动脉狭窄病变行PCI术,报告如下:1例1男,70岁,住院号0224987,因突发急性前壁心肌梗死在外院溶栓治疗后3 d转来我院行冠脉介入治疗。入院后第5天于2010年9月4日行冠状动脉造影示:左主干未见明显狭窄,LAD近段30%狭窄,中段90%狭窄,D1口部     

急性前壁心肌梗死合并完全性房室传导阻滞的冠状动脉造影特点

目的:分析急性前壁心肌梗死合并完全性房室传导阻滞的冠状动脉造影特点.方法:2004-03-2009-03上海交通大学附属第一人民医院心内科共收治急性前壁心肌梗死合并新发完全性房室传导阻滞患者19例,其中14例行冠状动脉造影术,多体位投照观察病变特点,明确梗死相关动脉.并根据主要冠状动脉直径狭窄≥50%的支数,分为左主干病变,单支病变,2支病变,3支病变.结果:14例患者冠状动脉造影均提示冠状动脉严重病变.单支病变1例,2支病变3例,3支病变8例,左主干加3支病变2例.梗死相关动脉12例为左冠状动脉,闭塞部位1例在左主干;9例在左前降支近段,其中4例提供侧支至右冠状动脉远段,2例提供侧支至左回旋支远段;1例在左前降支中段,右冠状动脉变异,开口于闭塞远段;1例在左回旋支近段,提供侧支至右冠状动脉.2例梗死相关动脉为右冠状动脉,闭塞部位1例在近段,为优势型;1例在中段,远段提供侧支至左前降支之第一间隔支.结论:急性前壁心肌梗死合并新发完全性房室传导阻滞患者冠状动脉病变严重,多为多支多处重度狭窄,梗死相关动脉供血范围较广,分别或同时累及第一间隔支动脉、房室结动脉,间接提示临床预后较差.     

左冠状动脉主干狭窄195例临床分析

目的　探讨左冠状动脉主干 (左主干 )狭窄的临床特点、诊断及治疗方法。方法　按冠状动脉造影 (CAG)结果将冠状动脉管径狭窄程度分为轻、中、重及完全闭塞 4组 ,并按其他冠状动脉受累情况分为孤立左主干组 9例 (4 6 2 % )、左主干 +1支组 15例 (7 6 9% )、左主干 +2支组 5 3例(2 7 18% )、左主干 +3支组 118例 (6 0 5 1% )。结果　经CAG确诊的 2 892例冠心病患者中左主干狭窄 195例 (6 74 % ) ,检出率低。临床主要表现为不稳定心绞痛 16 4例 (84 1% ) ,心肌梗死 (MI) 12 5例(6 4 1% )。冠状动脉旁路移植术 (CABG) 5 7例 ,术后 4 7例 (84 2 % )患者心绞痛消失。 5例行无保护性左主干病变直接支架术 ,术后无心绞痛再发。结论　左主干狭窄临床症状严重。CAG是确诊的唯一手段。CABG为最佳治疗方法。无保护性左主干病变直接支架术可用于有适应症患者。     

先天性右冠状动脉缺如运动平板试验阳性1例

先天性右冠状动脉缺如即胚胎时期右冠状动脉未发育或先天性右冠状动脉闭塞,也就是只有单支左冠状动脉。山东省日照市人民医院心内科于2009年2月10日收治1例先天性右冠状动脉缺如患者,报道如下。     

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。     

先天性冠状动脉瘘的DSA造影研究

目的 对6例冠状动脉瘘的冠状动脉造影或升主动脉造影表现进行分析,以提高对该病的认识.方法 收集6例冠状动脉瘘病例,男性2例,女性4例,年龄23～69岁;平均53岁.经DSA冠状动脉造影或升主动脉造影证实.结果 本组冠状动脉瘘起源于左冠状动脉6例,右冠状动脉1例.临床上无特征性症状,其中5例因分流量较小,听诊未闻及连续性杂音.1例分流量较大,左冠状动脉右室瘘伴冠状静脉瘘而行手术治疗.结论 先天性冠状动脉瘘为少见病,选择性冠状动脉造影及升主动脉造影具有重要诊断价值.     

急性心肌梗死经皮冠状动脉介入术中心律失常及处理

目的比较分析因急性心肌梗死接受经皮冠状动脉介入术病人的心律失常特点以及处理策略。方法观察209例急性心肌梗死病人在直接经皮冠状动脉介入术中心律失常的类型以及在不同的干预血管：右冠状动脉、左前降支和左回旋支中的发生机会。结果209例急性心肌梗死患中共出现86例心律失常，其中右冠状动脉病变27例，左前降支病变44例，左回旋支病变18例，共出现窦性心动过缓14例，共出现室性心律失常51例。结论右冠状动脉病变的病人术中发生的窦性心动过缓比其他血管病变多；室性心律失常在接受直接经皮冠状动脉介入术治疗的急性心肌梗死病人中多见：应积极防治在急性心肌梗死直接经皮冠状动脉介入术中出现的各种严重心律失常。     

少见冠状动脉畸形18例

目的 :探讨 18例少见冠状动脉 (冠脉 )畸形特征及评价选择性冠脉造影在其诊断中的作用。方法 :对17例患者进行冠脉造影 ,13例患者进行手术纠正治疗。另 1例二维超声心动图误诊为动脉导管未闭 ,术中证实为右冠脉 -右室瘘。结果 :18例患者中共发现有 9种冠脉畸形 ,包括冠脉起源异常 2例 ;左冠脉回旋支缺如 1例 ;左、右冠脉 -肺动脉瘘 3例 ;左冠脉 -肺动脉瘘 3例 ;右冠脉 -右心房瘘 3例 ;右冠脉 -右室瘘 2例 ;右冠脉 -静脉瘘 1例 ;左冠脉 -右室瘘 1例 ;左冠脉 -左心室瘘 2例。其中 13例患者经手术治疗得到再证实。结论 :冠脉畸形是少见的先天性血管畸形 ,选择性冠脉造影是确诊的重要手段 ,需与先天性心脏病和冠心病心绞痛鉴别 ,术后效果良好。     

结节性多动脉炎合并心肌梗死8例临床分析

目的总结结节性多动脉炎累及冠状动脉导致心肌梗死患者的临床表现及冠状动脉受累特点。方法对北京协和医院有病案记录的结节性多动脉炎合并心肌梗死的8例患者的临床症状、系统受累、实验室检查、冠状动脉及其他血管造影、超声心动图和病理检查等进行回顾性分析。结果 8例患者中男性5例,女性3例,年龄21～52岁,平均(37.6±11.7)岁。胸痛6例,心力衰竭1例。心电图缺血性ST-T改变5例,除窦性心动过速、房性期前收缩外,未见其他恶性心律失常。左心室射血分数降低(≤50%)3例,节段性室壁运动异常6例,室壁瘤形成2例,心肌病变2例,肺高压1例。4例有冠状动脉影像学检查资料,均累及右冠状动脉,3例为三支病变,1例为两支病变,其造影结果描述为冠状动脉弥漫性病变、冠状动脉扩张、多发动脉瘤以及节段性狭窄、闭塞。这些患者均有其他多部位血管受累的表现和动脉造影检查的异常。结论结节性多动脉炎可累及冠状动脉导致心肌梗死,其冠状动脉受累常为多支病变、多有右冠状动脉受累,动脉瘤伴血栓形成和节段性狭窄。对冠心病低危心肌梗死的患者,需要完善血管检查,警惕结节性多动脉炎累及冠状动脉的情况。     

Congenital absence of the left circumflex coronary artery

We report a rare case of congenital coronary artery anomaly with recurrent chest pain. A 44-year-old Taiwanese female patient presented with exertional chest pain that had lasted for 2 years. An electrocardiogram showed right axis deviation and an rS pattern in leads I and aVL, and an exercise stress test was inconclusive. A thallium-201 myocardial perfusion study revealed perfusion defects in the septal and inferior walls which normalized in the delayed imaging. Coronary angiography revealed the absence of a left circumflex coronary artery and a superdominant right coronary artery with terminal branches supplying the left ventricular inferior and posterolateral walls. An aortogram revealed no evidence of the existence of a left circumflex coronary artery. Administration of nitrates and calcium antagonists could not ameliorate her symptoms, but she remained stable during ordinary activity. In young premenopausal female patients who present with symptoms suggestive of angina pectoris and a positive stress test, congenital anomaly of the coronary artery should be considered and an angiographic study should be performed.     

Congenital anomalies of coronary artery origin: a diagnostic challenge

From a series of 4,313 consecutive patients who underwent a diagnostic coronary angiogram, 16 (0.37%) presented a congenital anomalous origin of the coronary arteries. None of these patients had other congenital cardiac anomalies associated. Age was 57 +/- 9 years and 13 (81%) were male. The diagnostic catheterization was performed for unstable angina in 8 patients (50%), for stable angina in five (32%), for dyspnea in two and for atypical chest pain in the remaining patient. A previous myocardial infarction was present in 6 patients (37%) whereas one patient had apical hypertrophic cardiomyopathy. We observed absence of coronary lesions in 4 patients and severe coronary stenosis lesions in 12 patients (75%), five of those with lesions located in the anomalous vessel. The most frequent abnormality found was an anomalous origin of left circumflex coronary artery in 8 cases (50%), followed by an abnormal origin of the right coronary artery in 5 cases (31%), and an abnormal origin of the left coronary tree in 3 cases (19%) (left anterior descending coronary artery arising from the right coronary artery, a single coronary artery which originated in the left coronary sinus, and a left main coronary artery which originated in the noncoronary sinus). The relationship of the anomalous coronary artery to the great vessels was the following: A retro-aortic course in 11 patient (69%), by the anterior free wall in two (12.5%), interarterial in two (12.5%), and septal in one (6%). Finally, as an index of the difficulty to visualize the anomalous coronary artery, an unusual catheter was needed in six (37%) of the diagnostic procedures to reach the target vessel.(ABSTRACT TRUNCATED AT 250 WORDS)     

Non-atherosclerotic coronary artery disease and sudden death in the young.

OBJECTIVE--To assess prevalence and type of non-atherosclerotic coronary artery disease in young people (< or = 35 years) who died suddenly. DESIGN--A necropsy study of 150 consecutive cases of sudden death (that is, within 6 h of the onset of symptoms). RESULTS--Death was attributed to coronary artery disease in 48 cases: in 16 (33%) of them the disease was non-atherosclerotic. Twelve subjects (eight males and four females, age range 2-35 years, mean 24.2) had congenital anomalies: a deep intramyocardial course in six, origin from the wrong sinus in three, and ostial obstructions in three. Sudden death was the first manifestation of disease in six cases. The other six had a history of palpitation or syncope or both. An electrocardiogram was available in five cases and showed ventricular arrhythmias in four; none had angina pectoris. Stress testing was available in two cases: neither showed any effort-dependent ST-T abnormalities. In six cases sudden death was related to physical exercise. Acquired non-atherosclerotic coronary artery disease was found in four cases: spontaneous coronary dissection in three previously symptom free patients and Kawasaki coronary arteritis in one child who had had acute myocardial infarction. CONCLUSION--One third of the cases of fatal coronary artery disease were non-atherosclerotic with coronary artery anomalies being the most frequent form. Coronary artery anomalies should be suspected in young patients who have symptoms of ventricular arrhythmias without any overt signs and symptoms of ischaemia.     

经导管封堵主动脉窦瘤破口的临床评价

目的 探讨经导管封堵主动脉窦瘤破裂的临床效果.方法 8例患者,年龄17～44岁.其中5例为主动脉右冠状动脉窦瘤破裂入右心室,破口直径2.5～13 mm;2例为主动脉右冠状动脉窦瘤破裂入右心房,破口直径4～8 mm;1例为主动脉无冠状动脉窦瘤破裂入右心室,破口直径6 mm.7例为先天性,1例为获得性（医源性）.通过建立股动脉-主动脉窦瘤破口-右心室（或右心房）-右心房-股静脉的轨道,透视下经股静脉置入合适的动脉导管未闭封堵器,所选择的封堵器直径较破口大（2～5 mm）.结果 5例患者封堵成功,无并发症发生.随访2～4年,5例患者症状和体征均消失,超声证实封堵器形态位置良好,无残余分流、栓塞、细菌性心内膜炎、主动脉瓣反流等发生.1例封堵后1周封堵器脱落,脱入右下肺动脉,转外科手术取出封堵器同时行主动脉窦瘤修补.1例因破口大置入封堵器后影响右冠状动脉开口,放弃介入治疗转外科手术治疗.1例置入封堵器后因主动脉瓣反流,放弃封堵治疗继续观察.结论 术前选择合适的患者,经导管主动脉窦瘤破口封堵术为一种微创、安全和有效的治疗方法.其中、远期疗效良好,临床应用前景较好.     

Value of lead V4R in exercise testing to predict proximal stenosis of the right coronary artery

To assess the value of lead V4R during exercise testing for predicting proximal stenosis of the right coronary artery, 107 patients were studied. In all patients, a Bruce exercise test with the simultaneous recording of leads I, II, V4R, V1, V4 and V6 was followed by coronary angiography. Apart from registering ST segment changes in the conventional leads, all patients were classified according to absence or presence of an ST segment deviation of 1 mm or greater in lead V4R. Seventy-nine of the 107 patients were studied because of inadequate control of angina pectoris. Seven patients had had myocardial infarction before 40 years of age. Twenty-one patients were analyzed because of severe cardiac arrhythmias. In the 46 patients who had a previous myocardial infarction, the infarct location was inferior in 28 and anterior in 18. Seven of the 14 patients without myocardial infarction and significant proximal stenosis in the right coronary artery showed an ST segment deviation of 1 mm or greater in lead V4R during exercise. This was also observed in 11 of 18 patients with an old inferior wall infarction and proximal occlusion of the right coronary artery. None of the 53 patients without significant proximal stenosis in the right coronary artery showed exercise-related ST segment changes in lead V4R. Exercise-related ST segment deviation in lead V4R had a sensitivity of 56%, a specificity of 96% and a predictive accuracy of 84% in recognizing proximal stenosis in the right coronary artery. These observations indicate that the recording of lead V4R is of value for predicting or excluding proximal stenosis in the right coronary artery.     

Cerebral ischemia due to congenital malformations of brachiocephalic arteries--case reports.

Seven cases of congenital anomalies of brachiocephalic arteries are presented; malformations include unilateral absence of the internal carotid artery (ICA) (n = 3), unilateral hypoplasia of the ICA (n = 2), agenesis of the innominate artery (n = 1), and atresia of the subclavian artery (n = 1). All patients but 1 exhibited symptoms of cerebrovascular insufficiency at the time of radiologic investigation; they were not affected by other cardiovascular malformations, except right aortic arch in 2 cases and left cervical arch in another case. Two patients suffering from congenital subclavian steal syndrome underwent surgery to correct the vascular malformations. Embryogenesis and natural history of such malformations are briefly discussed.     

Coronary Artery Complications after Right Ventricular Outflow Tract Reconstruction Surgery

Background: Mechanisms and clinical manifestations of coronary artery complications after right ventricular outflow tract reconstruction surgery are not well known. Methods: Patients who had coronary artery complications after pulmonary valve replacement or the Rastelli procedure at a single tertiary centre were retrospectively analysed. Results: Coronary artery complications were identified in 20 patients who underwent right ventricular outflow tract reconstruction surgery. The median age at diagnosis of coronary artery complication was 21 years (interquartile range: 13–25 years). Mechanisms of coronary artery complications were compression by adjacent materials in 12 patients, dynamic compression of intramural course of coronary artery in two patients, and intraoperative injury in six patients. Congenital coronary artery anomalies were identified in 50% (10/20) of patients. Four patients presented with early postoperative haemodynamic instability. Fourteen patients showed late onset symptoms or signs of coronary insufficiency, including chest pain, ventricular dysfunction, or ventricular arrhythmias. Coronary artery stenosis was incidentally found on cardiac computed tomography angiography in two asymptomatic patients. Four patients underwent surgical interventions, and one patient underwent percutaneous coronary intervention for coronary stenosis. One patient with recurrent ventricular tachycardia required an implantable cardioverter-defibrillator. There were two deaths in patients with intraoperative coronary injury. Conclusion: Preoperative coronary evaluation and long-term follow-up for the development of coronary artery complications are required in patients undergoing right ventricular outflow tract reconstruction surgery to prevent ventricular dysfunction, arrhythmias, and death, especially among those with congenital coronary anomalies.     

Coronary artery disease in congenital single coronary artery in adults:A Dutch case series

AIM:To assess the current diagnostic and therapeutic management and the clinical implications of congenital single coronary artery(SCA) in adults.METHODS:We identified 15 patients with a SCA detected from four Dutch angiography centers in the period between 2010 and 2013.Symptomatic patients who underwent routine diagnostic coronary angiography(CAG) for suspected coronary artery disease and who incidentally were found to have isolated SCA were analyzed.RESULTS:Fifteen(7 females) with a mean age of 58.5 ± 13.78 years(range 43-86) had a SCA.ConventionalCAG demonstrated congenital isolated SCA originating as a single ostium from the right sinus of Valsalva in 6 patients and originating from the left in 9 patients.Minimal to moderate coronary atherosclerotic changes were found in 4,and severe stenotic lesions in another 4 patients.Seven patients were free of coronary atherosclerosis.Runs of non-sustained ventricular tachycardia were documented in 2 patients,one of whom demonstrated transmural ischemic changes on presentation.Myocardial perfusion scintigraphic evidence of transmural myocardial ischemia was found in 1 patient due to kinking and squeezing of the SCA with an interarterial course between the aorta and pulmonary artery.Multi-slice computed tomography(MSCT) was helpful to delineate the course of the anomalous artery relative to the aorta and pulmonary artery.Percutaneous coronary intervention was successfully performed in 3 patients.Eight patients were managed medically.Arterial bypass graft was performed in 4 patients with the squeezed SCA.CONCLUSION:SCA may be associated with transient transmural myocardial ischemia and aborted sudden death in the absence of coronary atherosclerosis.The availability and sophistication of MSCT facilitates the delineation of the course of a SCA.We present a Dutch case series and review of the literature.