Giant aneurysm of the left main coronary artery in Takayasu aortitis

Takayasu aortitis is a chronic inflammatory vasculitis characterised by stenosis or obliteration of large and medium sized arteries. Although coronary arteries are affected in approximately 10% of cases, most of the lesions are luminal narrowing, and coronary aneurysm formation is extremely rare. A case is described of giant aneurysm of the left main coronary artery complicated with Takayasu aortitis in a 46 year old Japanese woman who was followed until her death at age 71. Pronounced intimal proliferation and adventitial fibrous thickening of the involved arterial wall usually induce constriction or occlusion at the orifice of the main branch of the aorta in Takayasu aortitis. However, systemic hypertension, which resulted from renovascular stenoses in this case, is likely to have enlarged the vessel lumen before replacement of medial and adventitial fibrosis after extensive destruction of medial elastic fibres in the left main coronary artery. Moreover, associations such as autoimmune hepatitis, chronic thyroiditis, and Sjögren syndrome strongly suggests that Takayasu aortitis may be an autoimmune disease.

Keywords: giant coronary aneurysm; Takayasu aortitis; renovascular hypertension; autoimmune disorders     

Comparative coronary anatomy in six twin pairs with coronary artery disease

OBJECTIVE—To compare the coronary anatomy and the location of coronary lesions in monozygotic and dizygotic twin pairs affected with coronary artery disease.
DESIGN—Coronary angiographic findings were compared with respect to the distribution of coronary blood supply and the location of coronary lesions.
MAIN OUTCOME MEASURES—Distribution of coronary blood supply, diameters and length of proximal coronary arteries.
RESULTS—The lumen diameters of the left main coronary artery, the left anterior descending coronary artery, the circumflex artery, and the right coronary artery, as well as the lengths of the left main coronary artery, showed similar variability within monozygotic and dizygotic twin pairs. With respect to the dominance pattern of coronary blood supply, two of three monozygotic twin pairs differed, while all dizygotic twin pairs were concordant. Concordant and discordant locations of stenoses were found with similar frequency in monozygotic and dizygotic twin pairs.
CONCLUSIONS—The dominance pattern of coronary blood supply and the location of coronary lesions are not strictly hereditary. The high concordance of premature coronary artery disease found in monozygotic twin pairs may largely be related to factors that are independent of the macroanatomic distribution of the coronary blood supply.


Keywords: twin studies; coronary anatomy; coronary lesions     

A young woman with chest pain

A case of a previously fit young woman admitted with chest pain, who was found at coronary angiography to have dissection of the left main stem which extended to the left anterior descending and circumflex coronary arteries, is presented. Emergency coronary artery bypass grafting was performed (vein grafts to the left anterior descending, the diagonal, and circumflex arteries). The patient made an uneventful recovery, and three years after initial presentation she remains free of cardiac symptoms.


Keywords: spontaneous coronary artery dissection     

Transthoracic ultrasonic visualisation of coronary aneurysm, stenosis, and occlusion in Kawasaki disease

OBJECTIVE—To determine the sensitivity and specificity of our transthoracic echocardiographic technique using high frequency (7.5 MHz) transducers for identification of the presence and type of coronary artery disease in patients with Kawasaki disease.
DESIGN—The results of the prospective echocardiographic study in each of seven segments of the four major coronary arteries were compared with the selective coronary angiograms.
SETTING—Kitasato University Hospital.
SUBJECTS—60 patients with Kawasaki disease, ranging in age from 8.0 months to 22 years (median, 6.0 years).
RESULTS—Adequate echocardiographic images were obtained in 397 (95%) of 420 coronary segments. Coronary angiography showed the presence of coronary aneurysms in 87 segments and stenosis or occlusion in 28. The overall sensitivity and specificity of cross sectional echocardiography for correctly identifying coronary aneurysms were 95% and 99%, respectively; for correctly identifying coronary stenosis or occlusion the values were 85% and 98% for the right coronary artery, and 80% and 97% for the left anterior descending coronary artery. Agreement on the presence or absence of coronary aneurysms and obstructive lesions on echocardiograms between the two observers was 1.0 and 0.98, respectively.
CONCLUSIONS—Echocardiography may provide a non-invasive means of identifying the presence and type of coronary artery disease in patients with Kawasaki disease.


Keywords: Kawasaki disease; coronary artery aneurysm; coronary artery stenosis; echocardiography     

Coexistence of giant aneurysm of sinus of Valsalva and coronary artery aneurysm associated with idiopathic hypereosinophilic syndrome

Aneurysms of the coronary sinuses of Valsalva and coronary artery aneurysms are uncommon cardiac anomalies, and cases in which these two uncommon lesions occur at the same time are extremely rare. A case of a woman with unstable angina who had a giant aneurysm of the left coronary sinus and multiple coronary artery aneurysms associated with an idiopathic hypereosinophilic syndrome is presented. Her sustained eosinophilia, elevated eosinophilic cationic protein concentration, and pathological findings of eosinophil infiltration of the aortic wall suggested the association of eosinophilia induced vascular injury as the cause of these aneurysms. This is the first such case to survive following surgical treatment.


Keywords: aneurysm; arteritis; coronary sinus; eosinophilia     

The power of collateral circulation: a case of asymptomatic chronic total occlusion of the left main coronary artery

Total occlusion of the left main coronary artery predominantly presents with recurrent angina or myocardial infarction. Long-term survival and myocardial function depends on the well-developed right to left collaterals. We report a case of a 46-year-old man who was referred because of incidental finding of low ejection fraction during work-up for syncope 5 months prior. The patient denied any recurrence or any other symptom after that episode and claimed an unchanged exercise capacity. He had hypertension, hyperlipidemia, and history of 15-pack/year smoking. Except for class II morbid obesity, he had completely normal vital signs, physical examination, and lab tests on admission. The echocardiogram was suggestive of previous anterior wall myocardial infarction and demonstrated a low left ventricle ejection fraction with diffuse hypokinesis of the left ventricle. The patient underwent cardiac catheterization, which revealed total occlusion of the left main coronary artery, dominant right coronary artery with a 95% stenosis in the proximal segment, and collaterals from the right to the left coronary arteries. The patient was immediately referred for coronary artery bypass surgery. This case demonstrates the power of collateral circulation in protecting the patient from symptoms and death despite total occlusion of the left main coronary artery and severe stenosis of the proximal right coronary artery.     

Randomised trial of elective stenting after successful percutaneous transluminal coronary angioplasty of occluded coronary arteries

Background—The value of angioplasty in occluded coronary arteries is limited by a restenosis/reocclusion rate of 50-70%. In patients with subtotal occlusion, stent implantation has been shown to reduce clinical and angiographic restenosis. Retrospective observational studies have suggested that stenting could reduce restenosis in total occlusions. The value of sustained coronary patency on global and regional left ventricular function in this clinical setting has not been defined clearly.
Objectives—To assess the medium term effect of elective intracoronary stent deployment after successful percutaneous transluminal coronary angioplasty (PTCA) of an occluded coronary artery.
Methods—Sixty patients with a total coronary occlusion successfully treated by PTCA were randomised to receive an intracoronary stent or no stent. Patients underwent clinical and angiographic follow up at six months.
Results—Thirty patients received a stent (group A) and 30 were treated by angioplasty alone (group B), all with initial success. One patient in group B required repeat angioplasty with stenting at 24 hours and one patient died after 10 days. Angiographic follow up was available for 57 patients. This showed a significantly reduced reocclusion rate in group A compared with group B (7% v 29%, p < 0.01) and a tendency to a reduced restenosis rate (22% v 40%, p = 0.105) in patients with no reocclusion. Left ventricular function, both global and regional, improved in group A. Only the regional left ventricular function in the area supplied by the target coronary artery improved in group B. Recurrence of symptoms and clinical events such as repeat angioplasty, coronary artery bypass grafting, death or myocardial infarction tended to be reduced in group A (4 (13%) v 9 (30%)).
Conclusions—Intracoronary stent insertion is effective in reducing the rate of reocclusion and shows a trend towards reduced restenosis after opening of a total coronary occlusion by balloon angioplasty. Sustained patency of the target coronary artery is associated with improvement in global and regional left ventricular function.

Keywords: intracoronary stenting;  total coronary occlusion;  left ventricular function     

Endogenous endothelin maintains coronary artery tone by endothelin type A receptor stimulation in patients undergoing coronary arteriography

OBJECTIVE—To examine the contribution of endothelin type A (ET_A) receptor stimulation by endogenously generated endothelin-1 (ET-1) to the maintenance of coronary vascular tone in humans.
DESIGN—Controlled clinical study.
SETTING—Tertiary cardiovascular referral centre.
PATIENTS—14 subjects were studied, seven with normal coronary arteries and seven with coronary artery disease, mean (SEM) age, 53 (2) years.
INTERVENTIONS—After diagnostic coronary arteriography, BQ-123 (a selective ET_A receptor antagonist; 100 nmol/min) in 0.9% saline, was infused into the left coronary artery at a rate of 1 ml/min for 60 minutes. Eight control subjects received saline alone.
MAIN OUTCOME MEASURES—Blood flow velocity in the left anterior descending coronary artery, measured using a Doppler flow guidewire; coronary arteriography performed at baseline and immediately at the end of the BQ-123 or saline infusion to measure the diameter of proximal and distal left anterior descending coronary artery segments.
RESULTS—The diameter of the proximal segment increased by 6 (2)%, while that of the distal segment increased by 12 (3)% after BQ-123 (both p < 0.05 v baseline). Coronary blood flow increased from 75 (10) to 92 (10) ml/min and coronary vascular resistance decreased from 1.99 (0.36) to 1.44 (0.22) mm Hg/ml/min after BQ-123 (both p < 0.05 v baseline). The response to BQ-123 of patients with and without coronary artery disease was similar. There was no effect of saline in the controls.
CONCLUSIONS—Endogenously produced ET-1 contributes to the maintenance of basal coronary artery tone in humans by ET_A receptor stimulation. The role of ET_B receptors remains to be defined.


Keywords: endothelins; arteries; blood flow; coronary circulation; angiography     

Diffuse nonatherosclerotic coronary aneurysms: an unusual cause of sudden death in a young male and a literature review

Coronary artery aneurysms are uncommon, usually associated with atherosclerosis and rarely involve all 3 main coronary arteries. Sudden death from documented thrombosis within large coronary aneurysms has been rarely reported. The authors report a case of a previously healthy 36-year-old male who presented with myocardial infarction complicated by sudden cardiac death. The patient was successfully resuscitated, and coronary angiography revealed diffuse, severe aneurysmal disease without evidence of atherosclerosis. A thrombus was visualized in a large aneurysm of the proximal left anterior descending artery, and there was total occlusion of a second diagonal branch, presumably due to thrombus embolization. The patient had no history of Kawasaki disease, and evaluation revealed no inflammatory or autoimmune condition. Optimal treatment and prognosis for patients with nonatherosclerotic coronary aneurysms remains unclear. Our patient was treated medically with chronic warfarin and low-dose aspirin therapy and recovered without complication.     

Contrast enhanced electron beam computed tomography to analyse the coronary arteries in patients after acute myocardial infarction

OBJECTIVE—To evaluate the accuracy of contrast enhanced electron beam computed tomography (EBCT) after acute myocardial infarction in determining patency of the infarct related artery and detecting high grade stenoses and occlusions in the coronary vessels.
DESIGN—Case study using blinded comparison with invasive coronary angiography.
PATIENTS—36 patients (mean age 53 years) 4-70 days after acute myocardial infarction.
INTERVENTIONS—The patients were studied by EBCT and invasive coronary angiography. For EBCT, 50 axial images of the heart (3 mm slice thickness) were acquired. They were triggered by the ECG during breath holding, after intravenous injection of contrast agent. The original images, surface reconstructions, and maximum intensity projections were evaluated for the presence of high grade stenoses and occlusions of the coronary arteries.
MAIN OUTCOME MEASURES—EBCT results were compared with invasive coronary angiography.
RESULTS—Of a total of 144 coronary arteries (left main, left anterior descending, left circumflex, and right coronary artery in 36 patients), 29 (20%) were unevaluable by EBCT. In the remaining arteries, 33 of 36 high grade lesions were correctly detected (92% sensitivity). Specificity was also 92% (73/79). Patency of the infarct related artery was correctly detected in 15 of 16 cases (94%). Five of the 14 occluded infarct related arteries (35%) were mistaken as stenotic but patent, and six could not be assessed.
CONCLUSIONS—EBCT is very accurate in detecting significant coronary artery lesions in patients after acute myocardial infarction, but differentiation between occluded and patent infarct related arteries is currently unreliable.


Keywords: electron beam CT; coronary angiography; myocardial infarction; computed tomography     

Magnesium causes nitric oxide independent coronary artery vasodilation in humans

OBJECTIVE—To determine how magnesium affects human coronary arteries and whether endothelium derived nitric oxide (EDNO) is involved in the coronary arterial response to magnesium.
DESIGN—Quantitative coronary angiography and Doppler flow velocity measurements were used to determine the effects of the nitric oxide synthase inhibitor N^G-monomethyl-L-arginine (L-NMMA) on magnesium induced dilation of the epicardial and resistance coronary arteries.
SETTING—Hiroshima University Hospital a tertiary cardiology centre.
PATIENTS—17 patients with angiographically normal coronary arteries.
INTERVENTIONS—Magnesium sulfate (MgSO₄) (0.02 mmol/min and 0.2 mmol/min) was infused for two minutes into the left coronary ostium before and after intracoronary infusion of L-NMMA.
MAIN OUTCOME MEASURES—Diameter of the proximal and distal segments of the epicardial coronary arteries and coronary blood flow.
RESULTS—At a dose of 0.02 mmol/min, MgSO₄ did not affect the coronary arteries. At a dose of 0.2 mmol/min, MgSO₄ caused coronary artery dilation (mean (SEM) proximal diameter 3.00 (0.09) to 3.11 (0.09) mm; distal 1.64 (0.06) to 1.77 (0.07) mm) and increased coronary blood flow (79.3 (7.5) to 101.4 (9.9) ml/min, p < 0.001 v baseline for all). MgSO₄ increased the changes in these parameters after the infusion of L-NMMA (p < 0.001 v baseline).
CONCLUSIONS—Magnesium dilates both the epicardial and resistance coronary arteries in humans. Furthermore, the coronary arterial response to magnesium is dose dependent and independent of EDNO.


Keywords: coronary artery; coronary blood flow; magnesium sulfate; nitric oxide     

Left internal mammary graft stenosis and restenosis following angioplasty and stenting

Coronary bypass grafts using the internal mammary artery usually have an excellent record of success and long term patency. We report a 42 year old man who initially presented with a history of atypical left sided chest pain, who had coronary artery bypass surgery for a severe stenosis in his proximal left anterior descending coronary artery (LAD) and moderate stenosis of his proximal circumflex artery, with his LIMA being grafted to his mid-LAD and a saphenous venous graft to the proximal LAD. He subsequently developed multiple stenoses in the LIMA graft which required coronary augioplasty and stenting, on more than one occasion, in view of very rapid restenosis within the LIMA graft.


Keywords: graft patency; left internal mammary artery grafts; restenosis; stenosis     

Bifurcating aneurysm of the left main coronary artery involving left anterior descending and left circumflex arteries--a case report.

Coronary artery aneurysm is a rare coronary abnormality, usually diagnosed incidentally by coronary angiography. Major causes of coronary aneurysms include coronary ectasia, Kawasaki disease, and atherosclerosis. Most of the discrete coronary aneurysms are of atherosclerotic origin. The incidence of atherosclerotic coronary aneurysms is about 0.2%, and the left main coronary artery is the least frequently involved artery. Only a few cases of left main coronary artery aneurysm have been reported in the literature, and a left main coronary artery aneurysm involving the proximal segments of the left anterior descending and the left circumflex arteries has not been reported previously. The authors describe this finding in a man who presented with worsening exertional angina pectoris. Coronary angiography demonstrated an aneurysm of the distal left main coronary artery extending into the proximal segments of the left anterior descending and the left circumflex arteries. In addition, a significant flow-limiting atherosclerotic lesion was present in the proximal portion of the left anterior descending artery distal to the aneurysm.     

Angiographic documented coronary arterial spasm in absence of critical coronary artery stenoses in a patient with variant angina episodes during exercise and dobutamine stress echocardiography

Dobutamine stress echocardiography is widely performed as a useful diagnostic tool in patients with known or suspected coronary artery disease. Dobutamine induced myocardial ischaemia is frequently associated with ST segment depression. ST segment elevation is uncommon and is almost always associated with prior myocardial infarction or transient total coronary occlusion. Dobutamine induced ST segment elevation in absence of significant coronary artery disease is a rare condition and is supposed to be a consequence of severe coronary artery spasm. The case of a 58 year old man with variant angina episodes at rest, during exercise test, and dobutamine stress echocardiography is reported, in whom coronary spasm without significant coronary artery stenoses was documented angiographically.


Keywords: coronary spasm; variant angina; Prinzmetal angina; dobutamine stress echocardiography; exercise test     

A 72 year old woman with ALCAPA

ALCAPA syndrome (anomalous origin of the left coronary artery from the pulmonary artery), which causes the left coronary artery to grow with an anomalous origin from the pulmonary artery, is a rare disease which may result in myocardial infarction, congestive heart failure, and sometimes death during the early infantile period. A 72 year old woman with ALCAPA syndrome is presented. The asymptomatic patient presented with a cardiac murmur which was discovered during a routine check up for a gynaecological intervention. Coronary cineangiography established the diagnosis. Although surgical correction is the usual treatment for such cases, medical treatment was preferred for this patient because she was asymptomatic without clinical signs of heart failure.


Keywords: coronary vessel anomalies; ALCAPA syndrome     

In vivo assessment of three dimensional coronary anatomy using electron beam computed tomography after intravenous contrast administration

Intravenous coronary angiography with electron beam computed tomography (EBCT) allows for the non-invasive visualisation of coronary arteries. With dedicated computer hardware and software, three dimensional renderings of the coronary arteries can be constructed, starting from the individual transaxial tomograms. This article describes image acquisition, postprocessing techniques, and the results of clinical studies. EBCT coronary angiography is a promising coronary artery imaging technique. Currently it is a reasonably robust technique for the visualisation and assessment of the left main and left anterior descending coronary artery. The right and circumflex coronary arteries can be visualised less consistently. Improvements in image acquisition and postprocessing techniques are expected to improve visualisation and diagnostic accuracy of the technique.


Keywords: electron beam computed tomography; coronary angiography; coronary anatomy; volume rendering     

Antegrade transcatheter closure of coronary artery fistulae using vascular occlusion devices

Two children (a 9 year old boy and a 2.5 year old girl) with coronary artery fistulae communicating with the right ventricle underwent successful transcatheter occlusion using an antegrade technique. A Rashkind double umbrella device was used in one case and an Amplatzer duct occluder in the other.


Keywords: interventional cardiology; congenital heart defects; coronary artery fistula; paediatric cardiology     

Unusual congenital coronary anomaly and myocardial ischaemia

Angiography was used to diagnose a rare congenital coronary anomaly with myocardial ischaemia in a woman with typical angina. All three coronary arteries arose from a solitary coronary ostium in the right aortic sinus; the left anterior descending coronary artery followed a septal course, the circumflex coronary artery ran behind the ascending aorta, and the right coronary artery followed a normal course. No significant coronary lumen narrowing was found. Transoesophageal echocardiography confirmed the anomalous origin and course of the aberrant coronary arteries. An exercise test reproduced angina, and ECG changes and myocardial perfusion study showed an anterior reversible defect. In contrast to previous reports, myocardial ischaemia was associated with the septal (intramuscular) course of the left anterior descending coronary artery; there was no other significant coronary artery disease.


Keywords: congenital heart defects; myocardial ischaemia; angiography; echocardiography     

Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease

OBJECTIVE—To investigate the value of coronary pressure derived fractional flow reserve (FFR) measurements in supporting decisions about medical or surgical treatment in patients with angiographically equivocal left main coronary artery stenosis.
DESIGN—A two centre prospective single cohort follow up study.
INTERVENTIONS—FFR of the left main coronary artery was determined in 54 consecutive patients with angiographically equivocal left main coronary artery disease. If FFR was 0.75, medical treatment was chosen; if FFR was < 0.75, surgical treatment was chosen.
MAIN OUTCOME MEASURES—Freedom from death, myocardial infarction, or any coronary revascularisation procedure.
RESULTS—In 24 patients (44%), FFR was 0.75 and medical treatment was chosen (medical group). In the remaining 30 patients (56%), FFR was < 0.75 and bypass surgery was performed (surgical group). Mean (SD) follow up was 29 (15) months (range 12-65 months). Survival among patients at three years of follow up was 100% in the medical group and 97% in the surgical group. Event-free survival was 76% in the medical group and 83% in the surgical group.
CONCLUSIONS—FFR supports decision making in equivocal left main coronary artery disease. If FFR is below 0.75, the decision for bypass surgery is supported. If FFR is above 0.75, a conservative approach is justified.


Keywords: coronary artery disease; left main coronary artery; fractional flow reserve; coronary artery bypass     

Complete proximal occlusion of all three main coronary arteries complicated with a left main coronary aneurysm: a case report

A 68-year-old woman with recurrent chest pain was referred to our institution. Coronary angiography showed 100% obstruction of the left main trunk, the proximal right coronary artery with good collaterals to the left anterior descending artery and left circumflex artery along the conus artery. Emergency surgical revascularization was undertaken with two saphenous vein grafts. The saphenous vein grafts were placed in the left anterior descending artery, obtuse marginal branch and the posterolateral and posterior descending coronary arteries with excellent flow. The postoperative course was uneventful and follow-up angiography was obtained 20 days after the surgery. Coronary angiography demonstrated a saccular aneurysm (10 x 9 mm) originating at the distal segment of the left main coronary artery with 90% stenosis, and excellent patency of both saphenous vein grafts. Follow-up angiography was performed 1 and 3 years after the surgery. The size of the left main coronary aneurysm remained unchanged at both examinations. The patient did well with no further cardiac symptoms after 5 years.