冠状动脉夹层的造影诊断与内支架治疗

目的　评价冠状动脉造影 (CAG)和内支架置入 (CASI)治疗对冠状动脉夹层的诊断及治疗价值。方法　10 82例冠状动脉造影及 434例冠状动脉成形术 (PTCA)检出 12例冠状动脉夹层患者 ,均行内支架置入治疗。结果　 12例冠状动脉夹层患者全部成功置入内支架 ,夹层闭合 ,患者症状缓解。结论　冠脉造影是诊断冠状动脉夹层的最佳方法 ,而内支架置入对治疗冠脉夹层安全有效     

Myocardial infarction and pregnancy: a case report

Coronary artery dissection is a rare, sometimes fatal traumatic condition, with 80% of cases affecting women. The coronary artery develops a tear, causing blood to flow between the layers, which force them apart. We describe the case of a 35-year-old multiparous woman with acute myocardial infarction secondary to right coronary artery dissection at 32 weeks' gestation. The patient underwent successful primary percutaneous coronary intervention with the placement of 4 coronary stents. She subsequently experienced preterm labor and preeclampsia 11 days following the procedure. Elective cesarean delivery under general anesthesia was performed uneventfully at 35 weeks' gestation.     

经胸超声心动图诊断冠状动脉起源异常的临床价值

目的探讨经胸超声心动图(TTE)诊断冠状动脉起源异常(CAOA)的临床应用价值.方法应用TTE对11例CAOA患者进行检查,显示冠状动脉的起源、走行、血流方向、性质、时相和速度,观察有无合并其他心血管畸形,并与冠状动脉造影和手术结果比较.结果左冠状动脉起源于肺动脉5例、起源于右冠状动脉1例,左前降支起源于右冠状动脉1例,疑诊左前降支或左回旋支起源于右冠状动脉窦1例,左前降支和左回旋支单独起源于左冠状动脉窦2例,右冠状动脉高位发出1例.其中合并右冠状动脉-右室瘘1例,卵圆孔未闭1例,二尖瓣前叶夹层动脉瘤形成伴破裂1例,继发性心内膜弹力纤维增生症3例.超声结果与冠状动脉造影和手术结果符合.结论经胸超声心动图能准确提供冠状动脉的起源、走行、血流状态等信息,具有重要的临床应用价值.     

Case of the month: Right coronary artery dissection following sports-related blunt trauma

Coronary artery dissection is a rare life-threatening complication resulting from blunt traumatic injury. Most cases of coronary artery injury, including dissection, involve the left anterior descending artery given its anatomical location relative to the impact. Right coronary artery (RCA) dissection secondary to blunt trauma is a particularly unusual occurrence, and has not previously been reported in the emergency medicine literature. We present a case of RCA dissection following low impact sport-related blunt chest trauma and discuss the pathophysiology, risk factors, diagnosis and current treatment options.     

Spontaneous Coronary Artery Dissection: A Comprehensive Overview

Spontaneous coronary artery dissection is an underdiagnosed cause of acute coronary syndrome that primarily impacts young women. Spontaneous coronary artery dissection as a cause of acute coronary syndrome is not rare and should not be overlooked. Spontaneous coronary artery dissection should be considered on the list of differential diagnosis of any chest pain occurring in young women with few typical risk factors. The purposes of this article are to broaden the understanding and increase awareness of spontaneous coronary artery dissection, specifically its diagnosis and clinical outcomes.     

Case of the month: Right coronary artery dissection following sports‐related blunt trauma

Coronary artery dissection is a rare life‐threatening complication resulting from blunt traumatic injury. Most cases of coronary artery injury, including dissection, involve the left anterior descending artery given its anatomical location relative to the impact. Right coronary artery (RCA) dissection secondary to blunt trauma is a particularly unusual occurrence, and has not previously been reported in the emergency medicine literature. We present a case of RCA dissection following low impact sport‐related blunt chest trauma and discuss the pathophysiology, risk factors, diagnosis and current treatment options.     

Large atherosclerotic plaque related severe right coronary artery dissection during coronary angiography

Catheter-induced coronary artery dissection and occlusion is a rare but serious complication of diagnostic cardiac angiography. A 50 year-old man presented with unstable angina. ECG, exceptional of bradycardia, was normal (57 beat/min). Selective coronary angiography demonstrated 98% narrowing in the mid-portion of the left anterior descending coronary artery (LAD). During the right coronary angiography, following catheter manipulation in the vicinity of the aortic valve, the patient complained of severe chest discomfort, and he had electrocardiographic evidence of acute inferior wall myocardial infarction. Right coronary artery (RCA) was free of the significant obstruction, and it was observed to be having a dominant artery with a spiral dissection (NHLBI Grade IV) located between ostium and the proximal portion of the posterior descending and posterolateral artery bifurcation. The patient was immediately operated with off-pump coronary artery bypass surgery. Consequently, iatrogenic right coronary dissection that is a very rare condition as a cause of myocardial infarction, is discussed in this case report.     

青年女性自发冠状动脉夹层导致急性心肌梗死1例并文献复习

目的 探讨自发性冠状动脉夹层的临床特点,以期提高对该病的诊治与认识。方法 回顾性分析1例青年女性自发性冠状动脉夹层导致急性心肌梗死患者的临床资料,并以“自发性冠状动脉夹层”、“急性心肌梗死”以及“青年女性”等关键词,通过检索中国知网、PubMed及万方数据库,筛选公开发表的相关中英文文献,以分析自发性冠状动脉夹层的临床特点。结果 本例为青年女性,35岁,因间断胸痛就诊,心电图检查提示I、aVL及V2-V5导联ST段抬高,肌钙蛋白T升高(>2 000 ng/L),冠状动脉造影结果示左主干(LM)自开口可见夹层,延伸至左前降支(LAD)远段及回旋支(LCX)中段,管腔全程受压,近段血管部分不能显影,经血管内超声(intravenous ultrasound, IVUS)指导下行经皮冠状动脉介入(percutaneous coronary intervention, PCI)治疗,随访1个月并复查冠状动脉造影(coronary angiography, CAG)患者治疗效果良好。结论 自发性冠状动脉夹层是导致急性冠脉综合征的罕见病因,其疾病特点及治疗方法与冠状动脉粥样硬化不同,诊断具有...     

Acute aortic dissection mimicking an acute coronary syndrome through occlusion of the right coronary artery

Occlusion of the right coronary artery (RCA) is an uncommon complication of type A aortic dissection. Aortic dissection and acute coronary syndrome (ACS) share a similar pathogenesis in atherosclerosis and hypertension. Consequently a patient with ischaemic risk factors presenting with chest pain and dynamic ECG change may well be incorrectly treated for ACS if careful attention is not paid to the presenting symptoms and signs. This case report describes a 59-year-old man who presented with chest pain, confusion and an ischaemic ECG and was initially treated for ACS. He subsequently deteriorated clinically and imaging confirmed type A aortic dissection complicated by RCA occlusion. Following emergent surgery with aortic root replacement and coronary artery bypass grafting he later made a good recovery.     

Anomalous coronary artery, aortic dissection, and acute myocardial infarction.

The combination of acute coronary occlusion and aortic dissection because of involvement of one or other coronary vessels in the dissection flap is uncommon. Furthermore, the occurrence of an anomalous coronary artery and its involvement in acute myocardial infarction is even more uncommon. We describe a patient with acute myocardial infarction in whom an acute aortic dissection involved the ostium of an anomalous circumflex artery.     

Spontaneous retrograde dissection of ascending aorta from descending thoracic aorta--a case review

A 56-year-old man with sudden onset chest pain, absent right lower limb pulses and ECG changes suggestive of inferior ST elevation MI underwent coronary angiogram through the right radial artery with a view to primary percutaneous coronary intervention (PCI). The left coronary angiogram demonstrated severe proximal stenotic disease in the left anterior descending and circumflex coronary arteries, but the right coronary artery could not be selectively cannulated. An ascending aortogram to visualise the right coronary artery not only failed to demonstrate it, but revealed, instead, a dissection flap in the ascending aorta, arch and descending thoracic aorta, with moderately severe aortic regurgitation. At operation, the patient was found to have an acute dissection of the ascending aorta, arch and descending aorta with an entry tear in the descending aorta below the left subclavian artery origin. Triple coronary artery bypass grafting with re-suspension of the aortic valve, supracoronary replacement of the ascending aorta and hemiarch and transaortic repair of the descending aortic tear was performed. The patient made an uncomplicated recovery, with the re-appearance of right limb pulses. A postoperative magnetic resonance (MR) scan revealed complete thrombosis of the false channel in the residual arch and a considerably shrunken false channel in the descending aorta and no aortic regurgitation. Retrograde dissection of the ascending aorta from the descending aorta has been reported infrequently in the past. We believe the scale of the problem has been underestimated because of the failure to adopt open distal anastomosis routinely in the past and, hence, failure to inspect the arch and the descending aorta routinely, particularly when the intimal tear was not identified in the ascending aorta. Retrograde dissection of the ascending aorta from an intimal tear in the descending aorta, when identified as such, has been managed, either on the principle of exclusion of the tear in the descending aorta by various elephant trunk procedures and their variants or, alternatively, on the principle of excision of the tear by extended one-stage aortic replacement, usually combined with an elephant trunk procedure. Neither of these procedures is widely adopted, owing to procedural, institutional and outcome considerations. We describe a transaortic repair of the intimal tear in the descending aorta with supracoronary interposition graft replacement of the ascending aorta and hemiarch with excellent clinical and radiological result. We also review the diagnostic and therapeutic approaches to this incompletely understood lethal disease.     

Spontaneous coronary artery dissection: a rare threat to young women

Spontaneous coronary artery dissection not associated with underlying coronary artery disease is rare. When the dissection does occur, it most often is manifested as an acute ST-elevation myocardial infarction in young women. Although the condition can occur in men, most often it involves women who are in their third trimester of pregnancy or the early postpartum period or are engaging in vigorous exercise. Because little is known about spontaneous coronary artery dissection in this population of women, recommendations for treatment are the same as for treatment of acute myocardial infarction associated with atherosclerotic coronary disease.     

Spontaneous Left Main Coronary Artery Dissection and the Role of Intravascular Ultrasonography

Objective. Spontaneous left main coronary artery (LMCA) dissection is a rare event with an unknown incidence and high risk of sudden cardiac death. The diagnosis of LMCA dissection is often challenging given the limitations of 2‐dimensional angiography. The 3‐dimensional perspective of intravascular ultrasonography (IVUS) is often indispensable in confirming or excluding the diagnosis of spontaneous LMCA dissection. We report 2 cases of spontaneous LMCA dissection with unique angiographic presentations wherein IVUS was essential in defining the extent of LMCA involvement and facilitated the subsequent referral for emergent coronary artery bypass grafting. Methods. Two patients presented to our facility with acute coronary syndrome prompting coronary angiography, which was notable for an unusual angiographic appearance of the LMCA. Intravascular ultrasonography was performed in each case, revealing spontaneous LMCA dissection. Results. Intravascular ultrasonography permitted the prompt diagnosis and aided in definitive surgical intervention in our 2 cases of spontaneous LMCA dissection. Conclusions. Intravascular ultrasonography is a useful adjunctive imaging modality in the diagnosis and management of spontaneous LMCA dissection.     

Spontaneous coronary artery dissection causing acute coronary syndrome: an early diagnosis implies a good prognosis

Spontaneous coronary artery dissection is an unusual cause of acute coronary syndrome. We describe a series of cases that with an early diagnosis and aggressive treatment, which includes percutaneous angioplasty with stent implantation and cardiac surgery, had a good outcome. The objective was to study the demographic characteristics, clinical settings, treatments, and inhospital course of patients with spontaneous coronary artery dissection. We studied a retrospective case series in 3 coronary care units in third-level university hospitals. The spontaneous coronary artery dissection diagnosis was made by coronary angiography. Seven cases of spontaneous coronary artery dissections were recorded. They were 5 women and 2 men. The age range was 28 to 64 years. Two of them took oral contraceptives and one case occurred in the postpartum period. An acute anterior wall myocardial infarction was the most frequent clinical presentation, occurring in 4 of the 7 cases. In fact, the left anterior descending artery was involved in 6 cases. An urgent coronary angiogram was performed in all cases. Definitive treatment included percutaneous angioplasty and stent implantation in 3 cases, coronary artery bypass surgery in 2 case, and cardiac transplantation in another case. One patient was treated medically. None of the patients died in the hospital. Spontaneous coronary artery dissection remains an unusual cause of acute coronary syndrome. It should be included in the differential diagnosis of acute myocardial infarction, especially when it affects young, healthy females. An early clinical suspicion and diagnosis with urgent coronary angiography and aggressive treatment that includes percutaneous angioplasty with stent implantation and cardiac surgery could improve the prognosis of these patients.     

Acute myocardial infarction in twin pregnancy after assisted reproduction: A case report

BACKGROUNDAcute myocardial infarction (AMI) during pregnancy is rare, especially in twin pregnancy, and it can endanger the lives of the mother and children. Except for conventional cardiovascular risk factors, pregnancy and assisted reproduction can increase the risk of AMI during pregnancy. AMI develops secondary to different etiologies, such as coronary spasm and spontaneous coronary artery dissection.CASE SUMMARYA 33-year-old woman, with twin pregnancy in the 31^st week of gestation, presented to the hospital with intermittent chest tightness for 12 wk, aggravation for 1 wk, and chest pain for 4 h. Combined with the electrocardiogram and hypersensitive troponin results, she was diagnosed with acute ST-elevation myocardial infarction. Although the patient had no related medical history, she presented several risk factors, such as age greater than 30 years, assisted reproduction, and hyperlipidemia. After diagnosis, the patient received antiplatelet and anticoagulant treatment. Cesarean section and coronary angiography performed 7 d later showed stenosis and thrombus shadow of the right coronary artery. After receiving medication, the patient was in good condition.CONCLUSIONThis case suggests that, with the widespread use of assisted reproductive technology, more attention should be paid to perinatal healthcare, especially when chest pain occurs, to facilitate early diagnosis and intervention of AMI, and the etiology of AMI in pregnancy needs to be differentiated, especially between coronary spasm and spontaneous coronary artery dissection.     

Pregnancy-associated coronary artery dissection: a case report

We describe the case of a 38-year-old woman who presented with a chief complaint of chest heaviness approximately 2 weeks postpartum. She was otherwise healthy with no cardiac risk factors. Coronary angiography revealed a spiral dissection of the left main coronary artery that extended to the left anterior descending coronary artery. Pregnancy-associated coronary artery dissection is a disease that has in the past carried a high mortality rate. Even today many women die before reaching medical help. Early diagnosis and intervention are crucial. Percutaneous transluminal coronary angioplasty for single vessel disease and coronary artery bypass grafting for multi-vessel disease are becoming the treatments of choice.     

Acute coronary artery stent thrombosis caused by a spasm: A case report

BACKGROUNDAcute stent thrombosis (AST) is a serious complication of percutaneous coronary intervention (PCI). The causes of AST include the use of stents of inappropriate diameters, multiple overlapping stents, or excessively long stents; incomplete stent expansion; poor stent adhesion; incomplete coverage of dissection; formation of thrombosis or intramural hematomas; vascular injury secondary to intraoperative mechanical manipulation; insufficient dose administration of postoperative antiplatelet medications; and resistance to antiplatelet drugs. Cases of AST secondary to coronary artery spasms are rare, with only a few reports in the literature.CASE SUMMARYA 55-year-old man was admitted to the hospital with a chief complaint of back pain for 2 d. He was diagnosed with coronary heart disease and acute myocardial infarction (AMI) based on electrocardiography results and creatinine kinase myocardial band, troponin I, and troponin T levels. A 2.5 mm × 33.0 mm drug-eluting stent was inserted into the occluded portion of the right coronary artery. Aspirin, clopidogrel, and atorvastatin were started. Six days later, the patient developed AST after taking a bath in the morning. Repeat coronary angiography showed occlusion of the proximal stent, and intravascular ultrasound showed severe coronary artery spasms. The patient’s AST was thought to be caused by coronary artery spasms and treated with percutaneous transluminal coronary angioplasty. Postoperatively, he was administered diltiazem to inhibit coronary artery spasms and prevent future episodes of AST. He survived and reported no discomfort at the 2-mo follow-up after the operation and initiation of drug treatment. CONCLUSIONCoronary spasms can cause both AMI and AST. For patients who exhibit coronary spasms during PCI, diltiazem administration could reduce spasms and prevent future AST.     

Successful bailout stenting strategy against rare spontaneous retrograde dissection of partially absorbed magnesium-based resorbable scaffold: A case report

BACKGROUNDIn the development of coronary stent technology, bioresorbable scaffolds are promising milestones in improving the clinical treatment of coronary artery disease. The “leave nothing behind” motto is the premise of the fourth revolution in percutaneous coronary intervention (PCI). Studies proving the safety and efficacy of the magnesium-based resorbable scaffolds (MgBRSs) include the BIOSOLVE-I and BIOSOLVE-II trials and the latest BIOSOLVE-IV registry. However, spontaneous retrograde dissection of a partially absorbed MgBRS may still occur, albeit rarely.CASE SUMMARYWe describe an unusual case of coronary artery disease in a patient who had undergone a successful PCI 8 mo earlier, where an MgBRS was implanted into the left anterior descending artery (LAD) and left circumflex artery with drug-coated balloons for a ramus intermedius branch stenosis to achieve the “leave nothing behind” therapeutic intention and was currently presenting with a gradual worsening of chest tightness. The distal edge vascular response, during subsequent attempts with balloon angioplasty was performed smoothly. However, spontaneous retrograde dissection of a partially absorbed MgBRS in the LAD ensued. Successful bailout stenting was performed with revascularization of the entry and exit sites created by spontaneous dissection and complete sealing of the intramural hematoma. The patient recovered well and was discharged after 2 d of intervention. When followed up in August 2020 (7 mo later), the patient showed uneventful recovery.CONCLUSIONSpontaneous retrograde dissection of a partially absorbed MgBRS was successfully treated using bailout sirolimus-eluting coronary stent strategy.     

Spontaneous rupture of a middle colic artery aneurysm arising from superior mesenteric artery dissection: Diagnosis by color Doppler ultrasonography and CT angiography

Both middle colic artery (MCA) aneurysm and spontaneous dissection of the superior mesenteric artery (SMA) are rare. We report the first case of concomitancy of both conditions, diagnosed by ultrasonography and CT angiography. A 56-year-old man with abrupt abdominal pain and hypovolemic shock was diagnosed initially with ruptured MCA aneurysm by color Doppler ultrasonography. Computed tomography and angiography confirmed MCA aneurysm and showed that it was arising from the false lumen of an SMA dissection and was probably associated with segmental arterial mediolysis. The MCA aneurysm was treated successfully by transcatheter coil embolization, and the SMA dissection was treated conservatively.     

老年冠心病患者肾功能减低与严重冠状动脉病变的关系

目的:探讨老年冠心病患者肾功能减低与冠状动脉病变严重程度的关系。方法:219例经冠状动脉造影确诊且未合并原发肾脏疾病的老年冠心病患者,以简化MDRD公式计算肾小球滤过率,依据冠状动脉造影结果判断冠状动脉病变严重程度。结果:104例(47.5%)患者肾功能减低,其中慢性肾脏疾病患者37例(16.9%);严重冠状动脉病变患者117例(53.4%)。严重冠状动脉病变患者肾小球滤过率明显减低(P<0.05)。肾小球滤过率<70mL/(min.1.73m2)为严重冠状动脉病变的最强预测因子(P<0.05)。既往高血压病史、合并糖尿病、低密度脂蛋白胆固醇>2.6mmol/L及低高密度脂蛋白胆固醇也是严重冠状动脉病变的独立预测因素。结论:合并肾功能下降是老年冠心病患者发生严重冠状动脉病变的独立危险因素,其预测价值超过传统冠心病危险因素。