Proximal RCA occlusion producing anterior ST segment elevation,Q waves,and T wave inversion

An ST segment elevation myocardial infarction (STEMI) that produces anterior ST segment elevation (STE) is typically caused by acute occlusion of the left anterior descending (LAD) artery. Anterior STE, however, may also be caused by acute occlusion of either the proximal right coronary artery (RCA) or the right ventricular marginal branch (RVB). It has been thought that, in contrast to occlusions of the LAD, proximal RCA/RVB occlusion rarely causes Q waves in the right precordial leads. We present a case where a proximal RCA occlusion produced not only anterior STE, but also anterior T wave inversions and anterior Q waves.     

Coronary to pulmonary artery fistulas: an incidental finding with challenging therapeutic options

We report the incidental finding of 2 coronary to pulmonary artery fistulas observed at coronary angiography performed in a 48-year-old man presenting with acute inferior ST-elevation myocardial infarction (STEMI). Coronary angiography revealed an acute thrombotic occlusion of the mid segment of the right coronary artery (RCA), which was treated with thromboaspiration and bare-metal stenting. Significant stenoses of the left anterior descending (LAD) and left circumflex (LCX) arteries were also observed during angiography, as well as the presence of 2 large coronary to pulmonary artery fistulas, one originating from the proximal LAD and the other from the ostial RCA. The clinical evolution was uneventful and the patient underwent successful coronary bypass grafting of the LAD and LCX lesions associated with ligation of the coronary artery fistulas 6 weeks later. The fact that 2 large coronary to pulmonary artery fistulas were observed during an acute coronary syndrome in a previously asymptomatic patient with extensive coronary artery disease is of particular interest, because it allowed early surgical correction of this rare inborn coronary anomaly before the development of late and irreversible left ventricular dysfunction.     

Computerized classification of proximal occlusion in the left anterior descending coronary artery

Proximal occlusion within the left anterior descending (LAD) coronary artery in patients with acute myocardial infarction leads to higher mortality than does nonproximal occlusion. We evaluated an automated program to detect proximal LAD occlusion.All patients with suspected acute coronary syndrome (n = 7,710) presenting consecutively to the emergency department of a local hospital with a coronary angiogram-confirmed flow-limiting lesion and notation of occlusion site were included in the study (n = 711). Electrocardiograms (ECGs) that met ST-segment elevation myocardial infarction (STEMI) criteria were included in the training set (n = 183). Paired angiographic location of proximal LAD and ECGs with ST elevation in the anterolateral region were used for the computer program development (n = 36). The test set was based on ECG criteria for anterolateral STEMI only without angiographic reports (n = 162). Tested against 2 expert cardiologists' agreed reading of proximal LAD occlusion, the algorithm has a sensitivity of 95% and a specificity of 82%.The algorithm is designed to have high sensitivity rather than high specificity for the purpose of not missing any proximal LAD in the STEMI population. Our preliminary evaluation suggests that the algorithm can detect proximal LAD occlusion as an additional interpretation to STEMI detection with similar accuracy as cardiologist readers.     

体表心电图预测梗死相关动脉及部位的敏感性和特异性

目的总结体表心电图（ECG）判断ST段抬高心肌梗死（STEMI）患者的梗死相关动脉（IRA）的流程,确定其敏感性、特异性和准确性。方法入选896例STEMI患者。根据公认的ECG判断标准,制订相应流程,判断IRA及其具体部位,并与即刻冠状动脉造影对比,确定流程的敏感性、特异性和准确性。结果判断左主干病变的敏感性为100%、特异性99%和准确性99%;判断前降支病变的敏感性、特异性和准确性分别为99%、99%和99%,其中近段为84%、90%和88%,中远段为57%、94%和88%;判断回旋支病变的敏感性、特异性和准确性分别为64%、95%和91%;判断右冠状动脉病变的敏感性、特异性和准确性为89%、92%和91%,其中近段为51%、96%和88%,中远段为68%、92%和85%。结论本研究的流程可以准确判断左主干、前降支和右冠状动脉近段病变,但区分回旋支和右冠状动脉中远段病变时有一定限度。     

Detection of culprit coronary lesion location in pre-hospital 12-lead ECG

BackgroundPre-hospital 12-lead ECG interpretation is important because pre-hospital activation of the coronary catheterization laboratory reduces ST-segment elevation myocardial infarction (STEMI) discovery-to-treatment time. In addition, some ECG features indicate higher risk in STEMI such as proximal left anterior descending (LAD) culprit lesion location. The challenging nature of the pre-hospital environment can lead to noisier ECGs which make automated STEMI detection difficult. We describe an automated system to classify lesion location as proximal LAD, LAD, right coronary artery (RCA) and left circumflex (LCx) and test the performance on pre-hospital 12-lead ECG.MethodsThe overall classifier was designed from three linked classifiers to separate LAD from non-LAD (RCA or LCx) in the first step, RCA from LCx in a second classifier and proximal from non-proximal LAD in the third classifier. The proximal LAD classifier was designed for high specificity because the output may be used in the decision to modify treatment. The LCx classifier was designed for high specificity because RCA is dominant in most people. The system was trained on a set of emergency department ECGs (n = 181) and tested on a set of pre-hospital ECGs (n = 80). Both sets were based on a sequential sample starting with symptoms suggesting acute coronary syndromes. Culprit lesion location was determined from coronary catheterization laboratory reports. Inclusion criteria included STEMI interpretation by computer and culprit lesion with 70% or more narrowing. Algorithm accuracy was measured on the test set by sensitivity (SE), specificity (SP), and positive predictive value (PPV).ResultsSE, SP and PPV were 50, 100 and 100% respectively for proximal LAD lesion location; 90, 100 and 100% for all LAD; 98, 72 and 78% for RCA; and 50, 98 and 90% for LCx. Specificity and PPV were high for proximal LAD, LAD and LCx. Specificity and PPV are not as high for RCA by design since the RCA-LCx tradeoff favors high specificity in LCx.ConclusionAlthough our test database is not large, algorithm performance suggests culprit lesion location can be reliably determined from pre-hospital ECG. Further research is needed however to evaluate the impact of automated culprit lesion location on patient treatment and outcomes.     

Transthoracic echocardiography in the detection of chronic total coronary artery occlusion

Aims: The aim of our study was to detect chronic total occlusion ofthe left anterior descending coronary artery (LAD), circumflexcoronary artery (Cx), and right coronary artery (RCA) usingtransthoracic echocardiography (TTE) in 110 consecutive patientswho underwent coronary angiography for investigation of angina. Methods and results: Coronary blood flow direction was assessed in the epicardialcollaterals [distal LAD (dLAD), obtuse marginal branches andright posterior descending artery (PDA)] and intramyocardialcollaterals [LAD septal branch (SB LAD) and RCA septal branch(SB RCA)]. The sensitivity and specificity of retrograde flowfor identification of the occluded LAD by TTE in the dLAD onlywere 78 and 96%, respectively, and those in both dLAD and SBLAD were 89 and 96%, respectively. The retrograde SB LAD flowdetects proximal LAD occlusion with 88% sensitivity and 75%specificity. The sensitivity and specificity of retrograde flowfor identification of the occluded RCA by TTE in the PDA onlywere 79 and 97%, respectively, and those in both PDA and SBRCA were 89 and 97%, respectively. The retrograde SB RCA flowdoes not allow us to differentiate between proximal and non-proximalRCA occlusion. Transthoracic echocardiography is not a methodfor diagnosing Cx occlusions as the success in visualizing theCx epicardial collaterals was achieved in 31% of cases only. Conclusion: TTE is a sensitive and highly specific non-invasive method fordiagnosis of LAD and RCA occlusions, based on the detectionof the coronary blood flow direction in the epicardial and intramyocardialcollaterals.     

Acute myocardial infarction showing total occlusion of right coronary artery and thrombus formation of left anterior descending artery

A 33-year-old Japanese man had an attack of chest pain associated with ST-segment elevation in the inferolateral leads on his electrocardiogram. Emergency coronary angiography showed total obstruction in the mid right coronary artery (RCA) and a movable thrombus in the proximal left anterior descending artery (LAD). We performed emergency percutaneous transluminal coronary angioplasty (PTCA) for the RCA lesion. The operation was successful and we then conducted intracoronary thrombolysis (ICT) with tisokinase 6,400,000 IU for the LAD thrombus. Its size was reduced by ICT. He had an uneventful hospital course. After 1 month, repeat coronary angiography showed no significant stenosis in the RCA nor thrombus in the LAD. A coronary spasm provocation test was performed using acetylcholine. Coronary spasm in the LAD was induced by an intracoronary injection of 100 microg acetylcholine. In this case, we observed a unique condition suggesting simultaneous double coronary artery occlusion.     

Coronary anatomy and left ventricular function in the first 12 hours of acute myocardial infarction: the Western Washington Randomized Intracoronary Streptokinase Trial

The relationships among clinical variables, coronary anatomy, and left ventricular function during the early hours of acute myocardial infarction (AMI) were evaluated from data acquired in the Western Washington Intracoronary Streptokinase Trial. All patients had symptoms and electrocardiographic changes typical of AMI. All data were obtained before treatment with streptokinase. Mean time to catheterization was 4.1 hr after onset of symptoms. Coronary angiograms (n = 245) were analyzed for location of infarct-related occlusion and collateral flow to the infarct bed. Left ventricular ejection fraction and regional left ventricular function were quantitated in 227. Sixty-two percent of occlusions were in the most proximal segment of the involved coronary artery. Collateral circulation was seen in 42% overall, in 31% with left anterior descending artery (LAD) occlusion, and in 52% with right coronary artery (RCA) occlusion (p less than .005). Left ventricular ejection fraction was lowest and regional function was most abnormal in the group with proximal LAD occlusion. Hyperkinesis was present in 32%; in those with hyperkinesis, hyperkinetic segment length was longest in those with RCA or circumflex occlusion. Multivariate analysis identified proximal LAD occlusion as the factor most closely associated with left ventricular ejection fraction and with measures of left ventricular regional hypofunction. We conclude that (1) AMI is usually caused by occlusion or subtotal occlusion in the most proximal portion of the involved coronary artery, (2) collateral circulation is more frequent with RCA than with LAD occlusion, and (3) location of the infarct-related occlusion is the most important determinant of global and regional left ventricular function in the early hours of AMI.     

Correlation of remote ST segment depression and coronary anatomy during acute coronary occlusion

BACKGROUND: The appearance of remote ST segment depression (RSTD) on an electrocardiogram (ECG) is associated with more extensive infarction and a worse clinical outcome than when RSTD is absent. OBJECTIVE: To determine whether RSTD predicts coronary anatomy during acute coronary occlusion. It was hypothesized that RSTD is associated with the occlusion of a proximal lesion, an extensive artery and an artery without distal collateralization. PATIENTS AND METHODS: In 113 consecutive patients with single vessel disease undergoing percutaneous transluminal coronary angioplasty (PTCA), 12-lead ECGs (recorded at baseline and during balloon inflation) and angiographical data were analyzed independently. Patients with ST segment elevation in the primary territory and RSTD (greater than 1 mm ST depression at 80 ms after the J point) (group A) were compared with patients without RSTD (group B). Proximal lesions were defined as lesions located in the segments proximal to the acute marginal branch, first diagonal artery or first obtuse marginal branch. An extensive right coronary artery (RCA) was one that supplied the posterolateral wall; an extensive left anterior descending (LAD) artery was one that supplied the inferoapical wall; and an extensive circumflex artery was one that supplied the posterior descending artery. RESULTS: Fifty-four patients (48%) had PTCA of the proximal vessels, 43 patients (38%) had extensive target vessels and 11 patients (9.7%) had collaterals. Target vessels included 33% in RCA, 44% in LAD artery and 23% in circumflex artery. Forty-five patients (40%) developed RSTD during balloon inflation (group A). Patients in group A were more likely to have extensive vessels on the angiogram than those in group B (group A 49%, group B 31%; P=0.05). None of the patients in group A had collaterals to the culprit artery, while 16% of patients in group B did (P=0.003). The two groups were not significantly different with respect to the number of proximal lesions (group A 58%, group B 42%; P=0.08). Analysis performed according to the target artery revealed that RSTD was associated with occlusion of an extensive RCA during RCA occlusion (extensive RCA in group A 100%, group B 57%; P=0.006). For the LAD artery, RSTD was associated with proximal lesions (group A 74%, group B 41%; P=0.02) and absence of collaterals (group A 100%, group B 74%; P=0.01). CONCLUSIONS: During acute coronary occlusion, the presence of RSTD on 12-lead ECG was specific for the absence of collaterals. The presence of RSTD during RCA occlusion was strongly associated with an extensive RCA, suggestive of posterolateral wall ischemia. During LAD artery occlusion, the presence of RSTD was associated with proximal occlusion, which resulted in ischemia of the LAD artery and the major diagonal artery territories.     

Correspondence between left ventricular 17 myocardial segments and coronary arteries.

AIMS: The last guidelines recommend a standardized 17-segment model for tomographic imaging of the left ventricle. The aim of this study is to analyse the correspondence of the 17 left ventricular segments with each coronary artery by myocardial perfusion SPECT studies. METHODS AND RESULTS: Fifty patients selected for percutaneous revascularization of one coronary artery [24 left anterior descending (LAD), 15 right coronary artery (RCA), and 11 left circumflex (LCX)] were included. The (99m)Tc-labelled compound was injected immediately after the inflation of the balloon during percutaneous coronary angioplasty. At least 90 s of complete occlusion time was required. Maximal contour of regions of hypoperfusion corresponding to each coronary artery occlusion were delineated over the polar map of 17 segments. Nine segments corresponded to only one coronary artery: eight to LAD (basal anterior, basal anteroseptal, mid-anterior, mid-anteroseptal, apical anterior, apical septal, apical lateral, and apex) and one to LCX (basal anterolateral). Basal inferoseptal, mid-inferoseptal, and apical inferior segments could correspond to LAD or RCA. Basal inferior, basal inferolateral, mid-inferior, and mid-inferolateral segments could correspond to RCA or LCX, whereas the mid-anterolateral segment could correspond to LAD or LCX. CONCLUSION: The most specific segments (anterior, anteroseptal, and all apical segments except the infero-apical) correspond to LAD but no segment can be exclusively attributed to the RCA. Inferoseptal segments can be attributed to LAD or RCA, inferior and inferolateral segments to RCA or LCX, and mid-anterolateral segment to LAD or LCX.     

A pitfall of fractional flow reserve associated with the presence of collateral circulation

An 82-year-old man had a severe stenosis in the proximal left anterior descending artery (LAD) and an intermediate stenosis in the distal right coronary artery (RCA). The territory of mid to distal LAD was perfused via an angiographically well-developed collateral circulation from the distal RCA. Fractional flow reserve (FFR) in the distal RCA was 0.84. After successful coronary intervention for the proximal LAD, repeat FFR in the distal RCA was 0.96. In this case, the severity of the stenosis in the donor artery was overestimated by using FFR due to the presence of well-developed collateral circulation.     

Dissection coronaire spontanée dans le SCA ST+ chez un homme jeune : échec de fibrinolyse

Spontaneous coronary artery disease (SCAD) is a particular form of acute coronary syndrome affecting preferentially female patient with few or without traditional cardiovascular risk factors. Male patient is exceptionally concerned by SCAD. We report a case of a young male patient presenting with anterolateral STEMI in relation with SCAD of Left main and left anterior descending artery (LAD). He was initially managed by fibrinolysis, which is then complicated by cardiogenic choc. Coronary angiogram covered by intra-aortic balloon pump (IABP) showed an acute double occlusion of proximal LAD and the ostium of the left circumflex artery (LCX). After thrombus aspirations, the angiographic pattern recalled a SCAD, which is confirmed by OCT (Optical Coherence Tomography). The latter highlighted the intimal flap with true and false lumen involving both Left main and proximal LAD with huge thrombus burden. PCI was then performed successfully with implantation of 3 DES (Drug Eluting Stent). But given the cardiogenic shock persistence despite Dobutamin infusion and IABP, ECMO (Extracorporeal membrane oxygenation) was indicated. Unfortunately, the patient died of haemorrhage during ECMO implantation.     

Left main coronary artery arising from right sinus of Valsalva: a rare congenital anomaly associated with distal vasospasm

A 50 year-old female patient was admitted to our outpatient clinic with a two year history of chest pain and dyspnoea on exertion. Echocardiography revealed apical hypokinesia with an ejection fraction of 50% on the left ventricle. Coronary angiography revealed that the left main coronary artery was arising from the right sinus of Valsalva and than coursing posterior to the aorta. There were significant stenoses at the proximal right coronary artery (RCA) and the proximal left anterior descending coronary artery (LAD). The RCA lesion disappeared after intracoronary nitroglycerine administration, and the LAD lesion disappeared the next day when the patient was due to undergo percutaneous intervention. Stress myocardial perfusion scintigraphy revealed anteroseptal ischaemia consistent with reversible ischaemia.     

Electrocardiographic patterns of proximal left anterior descending artery occlusion in ST-elevation myocardial infarction may be modified by 3-vessel coronary artery disease

BackgroundThe electrocardiographic (ECG) pattern of ST-segment deviation in myocardial infarction is integral to the proper assessment of the location, extent, and functional significance of the infarct but may be modified by the underlying coronary artery anatomy.MethodsWe describe the ECG findings in 2 cases of proximal left anterior descending (LAD) artery occlusion in ST-elevation myocardial infarction (STEMI) associated with 3-vessel coronary artery disease.ResultsBoth patients had atypical ECG patterns of ST-segment elevation in leads V₂, I, and aVL and ST-segment depression with positive T waves suggestive of extensive subendocardial ischemia in leads II, III, aVF, and V₃ through V₆; acute proximal LAD occlusion and concomitant 3-vessel coronary artery disease were observed angiographically.ConclusionElectrocardiographic changes in proximal LAD STEMI may be modified by the presence of significant atherosclerotic disease elsewhere in the coronary vasculature. Recognition of this ECG pattern may aid the clinician in the rapid identification of high-risk STEMI.     

Anomalous right coronary artery originating from the left anterior descending artery

An anomalous right coronary artery (RCA) arising from the left anterior descending artery (LAD) is very rare, and has previously been considered a variant of single coronary artery. This is the first report of an anomalous RCA arising from the LAD with a coexisting proximal RCA. The anomaly was discovered incidentally during cardiac catheterization for severe mitral regurgitation. The incidence, anatomy and clinical associations of anomalous coronary arteries are reviewed here.     

Fractional flow reserve for the assessment of complex multivessel disease in a patient after hybrid coronary revascularization

We present a case of a 43‐year‐old woman with history of hybrid coronary revascularization [endoscopic atraumatic coronary artery bypass (ACAB)] of left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and stent implantation in right coronary artery (RCA), who presented 6 years later with recurrent atypical angina. Coronary angiography revealed patent LIMA to LAD and RCA stent, with a new lesion in an obtuse marginal artery and significant progression of disease in the proximal/mid LAD proximal to LIMA touchdown. To further evaluate the hemodynamic significance of these new disease segments, the patient underwent fractional flow reserve (FFR) assessment of the left coronary system with subsequent stent implantation in the proximal/mid LAD. This case illustrates (1) the critical value of FFR assessment in determining the ischemia provoking lesions in this post ACAB patient with complex multivessel coronary artery disease; and (2) the accelerated progression of atherosclerosis in bypassed segments as compared to segments proximal to stents. © 2012 Wiley Periodicals, Inc.     

Comparison of angiographic findings in patients with acute anteroseptal versus anterior wall ST-elevation myocardial infarction

Anteroseptal ST elevation myocardial infarction (AS-STEMI), in which ST elevation is limited to leads V(1) to V(3), is considered confined to the basal and mid anterior and septal segments, sparing the apex. In contrast, extensive anterior STEMI (EA-STEMI), in which ST elevation extends to leads V(4) to V(6), is considered to involve more apical segments. However, it has been reported that AS-STEMI affects mainly the apex. Others have suggested that AS-STEMI may occur in patients with extensive anterior involvement if proximal occlusion of a wrapping left anterior descending coronary artery (LAD) results in cancelation of the basal-anterior and apical injury vectors. Therefore, the aim of this study was to identify, in 97 consecutive patients with STEMI, distinct coronary angiographic characteristics that could differentiate between cases of AS-STEMI (n = 39) and EA-STEMI (n = 58). Angiography was used to determine the length of the LAD, its site of occlusion, and whether there was an alternative blood supply to the apex. Patients with AS-STEMI were more likely than those with EA-STEMI to have ≥1 branches that reached the apex (p = 0.0015) and to have proximal LAD occlusion combined with either a short LAD or >1 large side branch (35.9% vs 12.1%, p = 0.011). However, patients with AS-STEMI were also more likely to have proximal occlusion before the first septal branch of a long LAD (35.9% vs 10.3%, p = 0.005). In conclusion, AS-STEMI can occur when only the basal and mid portions of the anterior wall are infarcted, but it can also arise when the infarction extensively involves the basal anterior and the distal inferior and apical segments.     

Anomalous origin of the right coronary artery from the left anterior descending coronary artery

This is the first presentation of anomalous origin of right coronary artery (RCA) from mid-left anterior descending (LAD) coronary artery. A 77-year-old male was catheterized because of recent onset of fatigue during exertion. The LAD demonstrated 50–60% narrowing just proximal to the anomalous origin of the RCA. The patient was maintained on oral medication. Cathet. Cardiovasc. Diagn. 44:328–329, 1998. © 1998 Wiley-Liss, Inc.     

Combination therapy for adult coronary artery aneurysm with off-pump coronary artery bypass grafting and vein graft-coated stent

We report on a 51-year-old Japanese female with bilateral coronary artery aneurysms. Severe calcified aneurysms were detected in the proximal right coronary artery (RCA) and left anterior descending branch (LAD). The RCA was totally occluded and supplied by the blood flow via septal branches of the LAD. A two-stage management plan, including an off-pump coronary artery bypass grafting for the RCA with a right gastroepiploic artery and catheter angioplasty with an autologous vein graft-coated stent for the LAD, was successfully completed. Prophylactic treatments for coronary artery aneurysm are still controversial, therefore, minimal invasive procedures should be favored to prevent acute cardiac shock or sudden death related to aneurysmal obstruction.