Clinical and angiographic findings in a patient with vasospasm in an anomalous coronary artery

We report the case of a 58-year-old man with coronary vasospasm that occurred within an anomalous coronary artery. The rapidly progressive clinical course and the dramatic treadmill test result preceeded the diagnostic cardiac catheterization. Combination therapy with isosorbide, beta blocker, and nifedipine resulted in complete resolution of symptoms.     

Late intervention in an asymptomatic pediatric patient with anomalous left coronary artery

Anomalous left coronary artery from the pulmonary artery(ALCAPA) is most commonly diagnosed within the first year of life with congestive heart failure symptomatology reflecting left ventricle(LV) dysfunction. The late diagnosis of ALCAPA is presented in a 5-yearold without significant LV dysfunction, mild LV dilatation and only mild mitral regurgitation that did not change significantly after surgery. The timing of surgical intervention in the late diagnosis of ALCAPA remains unclear despite risks of significant ongoing myocardial injury secondary to coronary artery hypoperfusion and progressive mitral valve dysfunction. Intervention in this case allows for revascularization which may reverse ventricular and valvular dysfunction.     

Percutaneous revascularization in a patient with anomalous origin of left main coronary artery

Anomalous origin of the coronary artery from opposite coronary sinus is infrequently observed during coronary angiography. Percutaneous coronary intervention (PCI) of anomalous coronary artery is technically difficult and challenging. It requires appropriate selection of guide catheters for adequate stability, coaxial alignment and backup support during the intervention. We hereby report a rare case of anomalous origin of left main coronary artery (LM) from the right coronary sinus, having a retro-aortic course to the left side before its bifurcation into left anterior descending (LAD) and circumflex artery. The 59-year-old man had successful PCI of atherosclerotic LAD lesions. A 64-slice Multi-Detector Computed Tomography (MDCT) performed at 4 years of follow-up demonstrated patency of coronary stents and also delineated the origin and course of the anomalous LM. The case illustrates the rarity of anomalous LM, and describes technical issues during PCI and the role of MDCT in coronary anomaly imaging.     

Myocardial contrast echocardiography for assessment of myocardial perfusion at rest in a patient with left main coronary artery stenosis

The present case will focus on the potential of hypoperfusion detection with myocardial contrast echocardiography (MCE) using power Doppler harmonic imaging (PDHI). PDHI is normally performed in a triggered mode. Microbubbles were destroyed by the ultrasound energy in the myocardium, and myocardium has to be refilled with microbubbles within the time interval between the ultrasound pulses to obtain repetitive information about perfusion. Using the contrast agent Levovist, however, real-time PDHI also results in myocardial opacification presumably due to perfusion signals of the arteriolar microbubble passage. A 45-year-old woman with typical stress-induced angina was admitted to our department for cardiac catheterization. Prior to the angiography a conventional echocardiogram showed normal left ventricular function. Tissue Doppler, however, demonstrated postsystolic longitudinal shortening of the septal, anterior, and lateral wall regions. Myocardial contrast echocardiography with triggered PDHI showed complete opacification of the myocardium at rest. Using real-time PDHI with Levovist, the septum could not be opacified. The consecutive angiography documented a severe unprotected main coronary artery stenosis. After angioplasty and stent implantation, MCE measurements were repeated. Repetitive intravenous bolus injections of Optison during triggered PDHI showed no differences to the investigation prior to the angioplasty. Using real-time PDHI with Levovist, however, there was a marked difference in comparison to the pre-interventional analysis. A complete opacification of the apical septum was observed. The present case suggests that different MCE techniques can analyze different compartments of the myocardial vasculature in clinical practice. This methodological comparison between triggered and real-time PDHI shows obviously differences in the DI signal detection due to the different microbubble behavior. Clinicians should be aware of the potentials of MCE to improve noninvasive diagnostic procedures in patients with ischemic heart disease.     

Acute myocardial infarction in a patient with anomalous left coronary artery origin and primary antiphospholipid syndrome

Anomalous left main coronary artery (LMCA) originating from the right coronary sinus and running between the aorta and pulmonary trunk is a rare congenital condition. Although this disease is known to be associated with myocardial infarction and sudden death, the precise mechanism is uncertain. A 14-year-old male with this anomaly developed myocardial infarction during exercise complicated by primary antiphospholipid syndrome. He was admitted to hospital with persistent chest pain and sudden cardiac collapse that occurred while he was running. Cardiac catheterization demonstrated a narrowed segment in the LMCA and impaired blood flow, prompting a diagnosis of extensive anterior myocardial infarction. Emergency bypass surgery was performed using a single saphenous vein graft to the left anterior descending artery. Postoperative angiography showed the presence of an anomalous LMCA arising from the right sinus of Valsalva and running between the great vessels. The aortic samples were pathologically normal. He was discovered to also have primary antiphospholipid syndrome and was discharged without symptoms after warfarin therapy. Complicated primary antiphospholipid syndrome may trigger myocardial infarction in asymptomatic patients with this type of coronary anomaly.     

Pilsicainide-induced coronary vasospasm in a patient with Brugada-type electrocardiogram.

A 65-year-old man with Brugada-type electrocardiogram (ECG) was admitted to our hospital for chest pain, palpitation and faintness. In the cardiac electrophysiological study, no ventricular tachyarrthymia was induced either at baseline or after pilsicainide (50 mg) infusion. Intravenous administration of pilsicainide exaggerated ST-segment elevation in V(1-4) and converted it to the coved type in V(1), accompanied by severe chest pain. Coronary angiography revealed the vasospasm of the right coronary artery was induced by pilsicainide, not by ergonovine. This is the first case report of coronary vasospasm induced by a pure sodium channel blocker in a patient with Brugada-type ECG.     

Accessory pathway associated with an anomalous coronary vein in a patient with Wolff-Parkinson-White syndrome

We report a case of Wolff-Parkinson-White syndrome coexistent with atresia of the coronary sinus (CS) ostium and persistence of the left superior vena cava. The accessory pathway was located at the blind end of the CS, which was bumped with mechanical loss of preexcitation during mapping by a catheter from within the CS. The accessory pathway was successfully ablated with radiofrequency energy applied to this site from the right atrium. This unique combination of anatomically matched anomalies may be important in suggesting a potential embryologic link between the accessory pathway and the coronary vein.     

Rota-stenting of a calcified anomalous left coronary artery via the arm in a multi-vasculopathic patient

Anomalous origins of the coronary arteries pose a challenge to the interventionalist. Diagnostic testing must take into account the possibility that perfusion patterns may be unusual but not pathologic, resulting in false-positive perfusion scanning. Treatment strategies must be customized to allow unusual access and passage of devices around angulations not commonly encountered. In this report, we describe a patient with severe peripheral arterial disease requiring the use of a 7 French multipurpose guide via the brachial approach for rotational atherectomy and stenting of a calcified and angulated anomalous left coronary.     

Angina at rest without significant changes in the per-critical ECG in coronary insufficiency

In coronary patients angina pectoris at rest is usually attended by clear changes in repolarization, and in the absence of such changes clinicians are justifiably reluctant to assert that the constrictive chest pain is due to ischaemia. However, a number of concordant data indicates that in some cases myocardial ischaemia--whether spontaneous or induced by the ergonovine test or by coronary angioplasty--may cause an anginal pain that proceeds without significant alterations in repolarization and indeed, without any changes in ECG tracings. Prior to making a firm diagnosis of this type of angina, several causes of error must be excluded, the main one being that repolarization disorders are labile and may have disappeared whilst the anginal pain persists. But above all, the ischaemic episode that accompanies angina must be documented by haemodynamic, angiographic, scintigraphic or echocardiographic data. The pathogenesis of angina at rest occurring in coronary patients and without changes in per-critical ECG is still imperfectly known and probably complex. The authors review several possible mechanisms: the pain perception threshold may be lowered, the collateral circulation may be highly developed, and the ischaemic episode may be so discreet and/or controlled by treatment, or so evenly distributed between two opposite territories that no electric gradient is generated.     

Acute inferior myocardial infarction and coronary spasm in a patient with an anomalous origin of the right coronary artery from the left sinus of valsalva

A 56-year-old Japanese woman with an acute inferior myocardial infarction was admitted to hospital. Emergency coronary angiography revealed an anomalous origin of the right coronary artery from the left sinus of Valsalva, but there was no stenosis or thrombus in either the right or left coronary artery. Coronary spasm was provoked at the site of the proximal portion of the anomalous coronary artery, which was located between the aorta and pulmonary trunk. This was thought to be the cause of the myocardial infarction.     

Dobutamine-induced ST segment elevation in a patient with angina at rest and critical coronary lesions.

A case of dobutamine-induced ST-segment elevation in a patient with angina at rest and severe two-vessel disease is described. Coronary angiography performed during the ischaemic episode showed patency of coronary arteries; ST-segment elevation and chest pain regressed after propranolol administration. This case suggests that in the presence of severe coronary lesions dobutamine may produce transmural myocardial ischaemia by increasing myocardial oxygen demand and inducing myocardial blood flow maldistribution.     

Bentall operation in a patient with an anomalous left circumflex artery: Case report and review

Anomalous origin of a left circumflex artery from the right coronary sinus represents a technical challenge in patients who require aortic valve/root procedures. This case report describes a patient who presented with bicuspid aortic valve, anomalous origin of the circumflex artery, severe aortic regurgitation, and aneurysm of the ascending aorta as well as aortic root that was safely managed following the Bentall procedure with the combined button technique.     

Aortic valve replacement in a patient with an aberrant left coronary artery

A 22-year-old male undergoing aortic valve replacement was found to have the left coronary ostium arising from the noncoronary cusp area in close proximity to the annulus. He could not be weaned off cardiopulmonary bypass after the operation, even after removal of a Teflon pledget thought to obstruct the left coronary ostium. He underwent bypass grafting to the left coronary system and was then easily weaned off cardiopulmonary bypass.