Isolated coronary ostial stenosis associated with coronary vasospasm

A 50-year-old woman was brought to the emergency room in a preshock condition. An emergency coronary angiogram revealed 90% ostial stenosis of the left coronary artery with delayed distal filling. After intracoronary nitrate, the degree of stenosis was reduced to 75%; no other coronary lesions were evident. The patient was found to have hyperthyroidism and she became euthyroid after a 2-month regimen of methimazole. A follow-up coronary angiogram showed that the left coronary artery had 50% ostial stenosis without delayed distal filling. At the same time, an aortogram showed complete occlusion of the right subclavian artery in its proximal site, a slight dilatation of the truncus brachiocephalic artery, and a diffuse wall irregularity of the abdominal aorta, suggestive of Takayasu's arteritis.     

Primary coronary artery dissection: its incidence, mode of the onset and prognostic evaluation

The incidence, mode of the onset and prognosis of primary coronary artery dissection in 1,445 consecutive patients with myocardial infarction undergoing coronary angiography were elucidated in the present study. Primary coronary artery dissection was observed in four patients (0.28%). The first case was a 28-year-old man, who developed angina at rest, followed by inferior myocardial infarction. His coronary angiogram showed dual lumina in the proximal to distal segments of the right coronary artery, which were separated by a flap. A left ventriculogram showed severe impairment of contraction (akinesis) in its inferior segment. Six years later, he was classified as New York Heart Association (NYHA) functional class I. The second case, a 54-year-old man, developed vasospastic angina followed by inferior myocardial infarction. His coronary angiogram showed a similar dissection from the proximal to distal segments of the right coronary artery. A left ventriculogram showed akinesis of the inferior segment and a coronary angiogram five years later showed marked resolution of the dissection. Twelve years after the infarction, he was classified as NYHA functional class I. The third case, a 46-year-old woman, experienced sudden onset of inferior myocardial infarction. Her coronary angiogram showed dissection from the middle to distal segments, and the posterior descending branch of the right coronary artery. A left ventriculogram showed akinesis of the inferior segment, and three years later, she was asymptomatic. The fourth case, a 28-year-old woman, developed anterior myocardial infarction following delivery. Her coronary angiogram revealed dissection from the proximal to middle segments of the left anterior descending artery. A left ventriculogram showed akinesis in the anteroseptal segment and dyskinesis in the apical segment. She died suddenly four years after her myocardial infarction. Thus, primary coronary artery dissection is not extremely rare and it may have been associated with coronary vasospasm in at least two of these four cases.     

Coronary artery fistulae from single coronary artery in a patient with rheumatic mitral stenosis.

Here we report coronary artery fistulae (CAF) arising from a single coronary artery in a patient with rheumatic mitral stenosis. A 62-year-old woman underwent a coronary angiogram prior to mitral valve replacement (MVR). The left coronary artery angiogram showed the right coronary artery arising from the left anterior descending coronary artery. From the distal left circumflex artery, two CAF were seen draining into left atrium. The haemodynamically insignificant fistulae were left alone and patient underwent MVR. Such an association has not been reported so far.     

Congenital atresia of left main coronary artery

We report a rare case of congenital atresia of left main coronary artery in an elderly male presenting with angina and positive stress thallium test. Coronary angiogram showed absence of left main coronary artery in the left aortic sinus. Collaterals from right coronary artery supplied left anterior descending artery and left circumflex artery territories. Despite collaterals, the left anterior descending and left circumflex arteries were rudimentary. Poor size of left-sided arteries precluded any surgical revascularization which is the treatment of choice in this rare entity.     

Unusual ST-t changes in Ebstein's anomaly with occlusion of a nondominant coronary artery

We present a case report of a patient of Ebstein's anomaly presenting with unusual ECG changes during acute coronary syndrome. The patient had undergone radiofrequency ablation of right posteroseptal accessory pathway. Two years later, he presented with acute chest pain. His ECG revealed ST elevation of 6-7 mm in leads III, aVF. V3R and V1-V4 with atrioventricular dissociation. He was thrombolysed for the same. He subsequently underwent an angiogram for continuing angina. His angiogram showed a nondominant right coronary artery with a 95% stenosis. The left circumflex artery was dominant but without any stenosis. The left anterior descending artery was also normal. Angiogplasty and stenting were done for the right coronary artery lesion and the patient did well on follow-up. The ST segment elevation in the anterior precordial leads resulting from occlusion of a nondominant right coronary artery is unusual. The possible reason for this is the isolated right ventricular infarction in the absence of any left ventricular infarction. Thus the electrical current of injury resulting from the right ventricular infarction was unopposed by any counterbalancing current of injury from the inferior surface of the left ventricle.     

Apport du scanner multibarrettes dans la détection des anomalies de naissance des artères coronaires avec trajet inter-aortopulmonaire : à propos de deux cas et revue de la littérature

Coronary anomalies are a rare entity. The gold standard remains the coronary angiogram. However, the identification of the origin and the course of aberrant coronary arteries using angiography may be difficult. We report two cases regarding two patients who underwent coronary angiography in order to evaluate coronary heart disease. In the first case, angiography has shown a left anterior descending artery (LAD) originating from the right anterior sinus. A multidetector CT scan (MDCT) showed an inter-aortopulmonary course of the LAD. In the second case, selective catheterization of the right coronary artery could not be done. A MDCT scan was performed. An abnormal origin of the right coronary artery was detected. It originates from the left sinus with a separate ostium of the left main coronary artery. This artery had an inter-aortopulmonary course. The 64 MDCT scan can be useful as a complementary tool for the diagnosis of coronary artery anomalies. Detection of the inter-aortopulmonary course is essential, since this situation will require surgical treatment to avoid sudden cardiac death.     

Ultra Long Stent in an Aberrant Right Coronary Artery

The prevalence of anomalous origin of right coronary artery from the left sinus is about 0.92%. A percutaneous coronary intervention (PCI) in such a vessel is challenging especially when maneuvering long stents. We report a case of 75-year old female patient with recent acute coronary syndrome. The angiogram showed significant lesions in the left anterior descending coronary artery and the left circumflex coronary artery with an aberrant RCA originating from the left sinus close to the origin of LMCA with multiple tight lesions. The aberrant RCA was stented with a 50 mm long stent. To the best of our knowledge, the placement of such a long stent in an aberrant coronary artery has hitherto never been reported in the literature.     

Intercoronary communication with unidirectional blood flow

Intercoronary communication is a rare condition in which there is an open-ended circulation with bidirectional blood flow between two coronary arteries. This report highlights a case of an intercoronary connection between the right coronary and circumflex arteries with unidirectional flow. Selective injection of the right coronary artery showed retrograde filling only of the circumflex artery, but left coronary injection did not fill the right coronary artery.     

Factors affecting early graft patency after coronary grafts

From June 1984 to December 1987, an early postoperative angiographic study was performed in 247 patients who underwent isolated coronary artery bypass surgery. The average age of these patients was 58.6 years, range 31 to 75 years. Preoperatively 50.8% of patients had myocardial infarction and 43.2% of them had unstable angina before surgery. Early coronary artery bypass angiogram was performed in 683 grafts (2.76 grafts per patient): 74 internal mammary artery grafts and 609 saphenous vein grafts. The distribution, location and type of the stenosis, distal coronary artery diameter, segmental myocardial contractility, and distal angiographic coronary filling are analyzed with a matching statistical method. Multivariate analysis showed significant predictors of early graft occlusion to be right coronary and circumflex artery, poor or non visible distal angiographic filling, coronary arteries smaller than 1.5 mm. The univariate analysis associates as risk factors hypokinetic or akinetic territories and multiple stenosis coronary arteries. It can be concluded that the early angiographic study demonstrate that coronary arteries with multiple stenosis, poor distal angiographic filling, smaller than 1.5 mm in diameter, coronary arteries perfusing hypokinetic or akinetic territories and the right coronary and left circumflex artery grafts have significantly lower early cumulative patency rates.     

Effect of stenosed and occluded coronary arteries on immediate and late myocardial uptake of thallium-201.

Exercise and redistribution myocardial scintigraphy using thallium-201 was compared with the left ventricular angiogram and with the presence of stenosis or occlusion of coronary arteries on angiography. Irreversible scintigraphic defects representing areas of myocardial infarction were found in all patients with occlusion of the left anterior descending artery but nearly one-third of patients with stenosis of that artery also showed evidence of infarction. For the right coronary or circumflex arteries the incidence of infarction was 82% with vessel occlusion and 57% with vessel stenosis. Of abnormally contracting segments on the left ventricular angiogram, 95% showed irreversible scintigraphic defects but 33% of normally contracting segments supplied by a diseased artery also showed this. Myocardial infarction is not uncommon in patients with angina even in the absence of coronary occlusion. The incidence is underestimated by the left ventricular angiogram. These findings are of importance in the assessment of patients with coronary disease and their evaluation before coronary artery surgery.     

Spontaneous acquired left descending coronary artery to left ventricle fistula in a patient with an apical saddle thrombus.

Coronary artery fistulas are a rare anomaly. The majority are congenital in origin, although they may be acquired due to invasive cardiac procedures or trauma. The most common course is between the right coronary artery and the right ventricle. The authors describe the case of an acquired left anterior descending coronary artery to left ventricle fistula, associated with a saddle thrombus, in a patient with a previously normal coronary angiogram and none of the predisposing factors mentioned above. Spontaneous formation of acquired coronary fistulas is reported as a very rare event in the literature.     

Spasm in a single coronary artery

A 52 year old man presented with effort and resting angina with positive exercise stress testing and myocardial scintigraphy. The initial coronary angiogram showed a single coronary vessel arising from the right coronary ostium dividing into a right coronary artery with a normal trajectory lined with a few non stenotic atheromatous plaques and a left coronary artery which passed between the aorta and pulmonary artery to reach the left atrioventricular groove. At first, it was suggested that the angina was due to compression of the left coronary vessel by the great arteries during effort, but this mechanism could not explain attacks of resting angina and the failure of betablocker therapy. An ergometrine test performed during repeat coronary angiography induced almost complete occlusion of the right coronary vessel and Prinzmetal diaphragmatic ischaemia. The anginal attacks were completely suppressed by Calcium antagonist drugs. The association of coronary spasm and a single coronary artery is rare; only one case has been previously reported. We do not believe that there was a relationship between the two phenomena in our case: the spasm occurred at a distance from the aberrant course of the vessel. The authors emphasise the diagnostic problems and the potential danger of this association.     

Surgical angioplasty of the left main coronary artery. Evaluation and postoperative follow-up with intravascular ultrasound

We report the case of a 45 year old man presenting to our emergency ward with acute onset of typical chest pain. The ECG showed ST-segment depression in the postero-lateral leads without elevation of any cardiac enzymes. The coronary angiogram showed a three-vessel disease with a subtotal, short stenosis of the right coronary artery and a severe ostial stenosis of the left main coronary artery. An operative revascularization with a venous graft to the right coronary artery and a angioplasty with an autologous vein patch of the left main coronary artery were performed. No peri- or postoperative complications occurred. Because of the importance of the left main coronary artery, the patient underwent an early post-operative coronary angiogram with intravascular ultrasound (IVUS) to confirm the patency of the patch angioplasty. We discuss the historical development, the indications and the main advantages of the patch angioplasty in comparison to conventional CABG procedures. The main issue of the presentation is the special value of IVUS in the pre- and postoperative assessment of the left main coronary artery. Within the last few years, IVUS has emerged from a pure research tool to the gold standard of coronary imaging. It is playing a more and more important role in the assessment of angiographically unclear lesions, mainly in the left main stem and its bifurcation. In addition, IVUS has a large influence in clinical decision making, e.g., reverral to CABG or PCI. It is also a powerful tool for optimizing the operative setting and provides the best possible postoperative control.     

Aneurysms of the coronary arteries: one case report

True aneurysms of the coronary arteries are very uncommon. In our institution, from December 1982 to April 1987, in more than 2500 coronarographies, we observed only one case whose angiographic findings revealed a real fusiform aneurysm (at least 3 times the diameter of the original vessel) of the right coronary artery. The same patient exhibited a left anterior descending artery ectasia too, as we already noted in other cases not included in the present report. The other coronary arteries showed no associated lesions. Clinical findings included a previous myocardial inferior infarction and typical precordial effort pain with a basal and stress ECG showing non specific ST-T wave abnormalities. The patient underwent right coronary endoaneurysmectomy with interposition of a saphenous vein graft. Postoperative course was uneventful and 8 months after surgery the patient was asymptomatic, and basal and effort ECG showed no ischemic modification. Control angiogram revealed an optimal anatomical reconstruction with no further evolution of the left anterior descending artery dilatation. The distinction between vessel dilation and an aneurysm is discussed.     

Voluminous fistula between the right coronary artery and a branch of the pulmonary artery causing myocardial ischemia

A 76-year-old female patient was referred to our institution because of typical chest pain. A continuous murmur was audible at the lower sternal border. A transthoracic echocardiogram showed non-dilated right and left ventricles with mild left ventricular inferior wall hypokinesia and an exercise stress test was positive for myocardial ischemia. A coronary angiogram showed no signs of atherosclerotic coronary artery disease, but it revealed a voluminous fistula between the proximal segment of the right coronary artery and a branch of the pulmonary artery, which was percutaneously closed using 3 embolization coils. Such late presentation of a voluminous coronary fistula is extremely rare and, to the best of our knowledge, very few case reports like this have been published.     

Coronary artery ectasia in a patient with myocardial infarction

We report on a case of triple-vessel coronary artery ectasia (CAE) in a young patient. This patient presented with anterior wall myocardial infarction (MI) with post-infarct angina. His coronary angiogram revealed coronary artery ectasia involving the left anterior descending, circumflex and right coronary arteries.     

A rare coronary artery anomaly: anomalous right coronary artery arising from the left anterior descending artery

Anomalous right coronary artery is a rare entity with an incidence of 0.26%. The anomalous origin usually arises from the left sinus valsalva. An anomalous right coronary artery arising from the left anterior descending artery is rare. It is usually known as a benign entity but may have clinical importance due to its course between the aorta and pulmonary artery which may cause myocardial ischemia or sudden cardiac death. Here we present an anomalous coronary artery arising from the left anterior descending artery detected by coronary artery angiogram and confirmed by multislice computed tomography thereafter. 40% retrospective electrocardiographic gating is performed and volume-rendered 3 D and axial MIP (maximum intensity projection) images were reconstructed on a Vitrea post- processing Workstation. The images demonstrated the anomalous origin of the right coronary artery arising from the proximal portion of left anterior descending artery after the first septal perforator and coursing.     

Left main coronary artery compression by dilated main pulmonary artery in endocardial cushion defect

A 56-year-old man was evaluated for exertional dyspnoea. Chest X-ray showed mild cardiomegaly and a dilated main pulmonary artery. On echocardiogram he was found to have ostium primum atrial septal defect with moderate tricuspid insufficiency. Cardiac catheterization revealed an oximetry step-up of 14% at low right atrium with angiogram demonstrating a cleft in the mitral valve, an elongated left ventricular outflow tract and ventricular septal defect closed by a septal aneurysm. Coronary angiogram revealed ostial compression of the left main coronary artery with the rest of the coronary artery anatomy being normal.     

Primary stenting of an anomalous left main trunk originating from the right coronary artery during acute myocardial infarction

In 1.5 to 2.0% of patients with AMI referred for primary percutaneous coronary intervention, the left main trunk is identified as the culprit vessel. Among the congenital coronary anomalies, an anomalous origin of the left main trunk from the right sinus of Valsalva is very rare. A 73-year-old patient with lateral acute myocardial infarction was referred to primary angioplasty. The initial angiogram showed an anomalous origin of the left main from the right coronary artery, apparently with a septal course, with an angiographic image of intraluminal thrombus; in addition, a severe lesion was present at the distal right coronary artery. The left main and right coronary arteries were successfully treated with direct stenting. The subsequent clinical course during hospitalization was uneventful, and the patient was discharged alive.     

Percutaneous occlusion by a detachable balloon of a fistula between the left coronary and the pulmonary artery

A large fistula between the left circumflex coronary artery and the distal branches of the right pulmonary artery resulting in myocardial ischemia in a 52 year old woman with no angiographic atheromatous coronary lesions, was occluded by a detachable balloon introduced percutaneously and positioned at the origin of the fistula. A control angiogram performed one month later showed the balloon in position and the disappearance of the fistula. The Thallium myocardial scintigraphic abnormalities regressed after occlusion of the fistula. This is the second case (the first one in France) of radical non-surgical treatment of a congenital coronary fistula.