Reversible occlusion of a side branch and the left anterior descending coronary artery following angioplasty

A 61-year-old man with unstable angina underwent emergency angioplasty of a proximal left anterior descending coronary stenosis. This was successful but a major first septal branch involved in the stenosis was occluded following the procedure. Recovery was uncomplicated, however, without chest pain or other evidence of myocardial infarction. Predischarge treadmill stress testing was negative for ischaemia but two hours afterwards abrupt coronary occlusion required a second emergency angioplasty procedure. Recanalization of the left anterior descending artery was achieved and the first septal branch was shown to be fully patent. Spasm probably accounted for the side branch occlusion which complicated the first procedure but the mechanism of the abrupt coronary occlusion following stress-testing is unclear.     

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.     

Intracoronary adenosine causes angina pectoris like pain--an inquiry into the nature of visceral pain

STUDY OBJECTIVE--The aim was to study the tentative role of adenosine as a messenger between myocardial ischaemia and angina pectoris. DESIGN--Adenosine was administered in serial doses of 0.1-20 mg either as an intravenous bolus, or intra-arterially over 10 s into the left coronary artery, the aorta and the iliac artery. Coronary sinus flow was determined by thermodilution. ECG was monitored continuously. The patient was not aware of which site or dose was used. After each injection, the start of, maximum, end, magnitude, and location of pain were noted. PATIENTS--Six patients with angina pectoris referred for coronary angiography entered the study. MEASUREMENTS AND RESULTS--After intracoronary adenosine injection in the absence of ischaemic ECG changes, a dose dependent degree of chest pain was experienced not different in quality or location from the patients' habitual angina pectoris. Adenosine into the aorta provoked pain in lower chest and upper abdomen, whereas injection into the iliac artery provoked pain in the ipsilateral leg. On intravenous injection equipotent doses of adenosine caused chest pain of the same degree and quality as after intracoronary injection. Immediately after intracoronary injection the coronary sinus blood flow started to increase, but the onset of chest pain was delayed. Onset of pain was earlier the higher the dose, the maximum dose resulting in onset after 18(SEM 2) s. Coronary sinus blood flow increased dose dependently after left coronary artery injection but following intravenous injection no further increase was seen beyond that induced by the lowest dose. CONCLUSIONS--We suggest that adenosine is an important messenger for the sensation of angina pectoris and the effect is not due to coronary steal leading to myocardial ischaemia.     

Retroaortic course of the anomalous left main coronary artery: is it a benign anomaly? A case report and review of literature

BACKGROUND: Left coronary artery sharing a common origin with the right coronary artery and taking a retroaortic course is a rare coronary anomaly. It has been considered a benign entity. CASE REPORT: We report a 19-year-old man who presented with chest pain. Cardiac enzymes were elevated suggesting myocardial ischaemia. Coronary angiography revealed single origin of the coronary artery in the right coronary sinus. The left main coronary artery followed a retroaortic course before bifurcating. The anomalous left coronary artery was dissected and reimplanted in the left coronary sinus. The patient made an uneventful recovery. One year later, he is well with no recurrence of symptoms. CONCLUSIONS: Surgery to restore the normal anatomic position of the left coronary ostium is advisable whenever this anomaly is discovered.     

Coronary sinus potassium concentration recorded during coronary angioplasty.

Coronary sinus potassium concentration was measured continuously in two patients undergoing angioplasty of a significant stenosis of the left anterior descending coronary artery. After each coronary occlusion there was a transient rise in coronary sinus plasma potassium concentration caused by washout of potassium which had accumulated in the extracellular fluid during the short period of ischaemia. There were no significant changes in the surface electrocardiogram and the patients experienced no chest pain. Changes in coronary sinus potassium concentration provide a sensitive and early indication of myocardial ischaemia in man.     

Atresia of the right atrial orifice of the coronary sinus with persistent left superior vena cava: a case report

A 39-year-old woman presented with atresia of the right atrial orifice of the coronary sinus with a persistent left superior vena cava detected at cardiac catheterization. She was admitted with frequent episodes of angina at rest and on exertion. Coronary angiography, including spasm provocation test, yielded normal results. However, left coronary arteriography demonstrated a dilated coronary sinus and a persistent left superior vena cava draining into the innominate vein. The contrast medium leaked slightly into the right atrial cavity through the obstructed orifice of the coronary sinus. Atresia of the coronary sinus orifice is a rare malformation usually found at autopsy. Only 3 cases have been reported in Japan. This is the first adult Japanese case detected when the patient was still alive.     

Creation of a coronary sinus to atrial communication in coronary sinus ostial atresia improves cardiac function after Fontan.

Coronary sinus ostial atresia is a rare anatomic condition which is occasionally associated with drainage of coronary veins via a persistent left-sided superior vena cava. This anatomic condition is normally clinically insignificant. However, when the systemic venous pressure is higher than that of the atrium, cardiac function can be impaired. We report our experience with a young adult who underwent a Fontan due to tricuspid atresia. The patient presented to our institution with poor systolic and diastolic ventricular function. A catheterization revealed an atretic coronary sinus ostium, and the coronary veins drained via a persistent left-sided superior vena cava. Creation of a communication from coronary sinus to the common atrium resulted in a significant decrease in coronary venous pressures. The patient has experienced improvement following the interventiona catheterization.     

Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression

A 69-year-old woman presented with chest pain and electrocardiographic evidence ofsubacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a post-traumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.     

Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression: An Echocardiographic Case Report

A 69-year-old woman presented with chest pain and electrocardiographic evidence of subacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a posttraumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.     

Clinical features and surgical outcome in 25 patients with fenestrations of the coronary sinus

OBJECTIVE: To analyze symptoms, associated anomalies, diagnostic approach, and surgical procedures in patients with partial fenestrations of the coronary sinus, a rare congenital disorder. BACKGROUND: Partial fenestrations of the walls that usually separate the coronary sinus from the left atrium, also known as partial unroofing of the coronary sinus, may result in increased flow of blood to the lungs, cyanosis, or bidirectional shunting. The diagnosis is important, but difficult to confirm. METHODS: We reviewed retrospectively the clinical, echocardiographic, operative, and follow-up data on 25 patients with partial fenestration of the coronary sinus. The patients had a median age of 8 years, and underwent cardiovascular surgery at Mayo Clinic between 1958 and 2003. RESULTS: The initial diagnosis of a fenestration of the coronary sinus was made by the surgeon at repair of other congenital cardiac anomalies, by cardiac catheterization, or by echocardiography. In 14 patients, fenestration was missed during previous cardiovascular surgery. The most common associated cardiac lesions were atrial septal defects within the oval fossa, persistent left or right superior caval veins, and pulmonary or tricuspid atresia. In 7 patients, the symptoms were at least partially attributable to the fenestration, and included dyspnea, cerebral abscess, transient ischaemic attacks, and cyanosis. The fenestration was addressed surgically in 23 patients, and consisted of closure of the mouth of the coronary sinus, creation of an intra-atrial baffle, or direct repair of the fenestration. Death occurred in 1 patient due to complications unrelated to the repair. In the 24 early survivors, who have been followed up for a median of 85 months, 1 patient has died after a third reoperation for complex congenital cardiac disease. CONCLUSIONS: Fenestrations of the coronary sinus are often missed in the preoperative evaluation of congenitally malformed hearts. When associated with right heart hypoplasia, atrial septal defect, or persistent superior caval vein, fenestrations of the coronary sinus should be considered as a possible additional finding. Once the diagnosis has been made, repair is straightforward.     

Coronary Sinus Ostial Atresia and Persistent Left-Sided Superior Vena Cava: Clinical Significance and Strategies for Cardiac Resynchronization Therapy

A 48-year-old male patient underwent cardiac resynchronization therapy defibrillator implantation, and he was found to have atresia of the coronary sinus ostium with venous drainage occurring via a persistent left-sided superior vena cava, which was connected to the right-sided superior vena cava by the innominate vein. This is a rare benign cardiac anomaly that can pose problems when the coronary sinus needs to be cannulated. To identify the course of the coronary sinus, a coronary angiogram can be performed with attention directed to the venous phase of the angiogram. Although the technical difficulty of coronary sinus cannulation increases, various catheters, wires, and delivery systems can be utilized and this anomaly does not usually prevent successful left ventricular lead placement in cardiac resynchronization therapy via a left-sided superior vena cava approach. There however needs to be consideration regarding caliber of the left-sided superior vena cava being sufficiently large to avoid compromise of venous drainage after lead insertion.     

Coronary subclavian steal syndrome after internal mammary artery bypass grafting. A cause of severe postoperative recurrent myocardial ischemia

A 65-year-old underwent a triple bypass: internal artery mammary-descending coronary artery, aorta diagonal-lateral coronary (sequential). Three weeks later he started to have severe angina pectoris with ST depression in anterior EKG leads. A left transradial coronary angiography was performed. The examination showed a total occlusion of the left subclavian artery 2 cm after the aortic arch and a retrograde flow in the internal mammary artery (IMA). Via transfemoral approach, angiography showed the patency of the aorto-veinous sequential graft and a retrograde flow through anastomosis in the left mammary artery. The patient underwent a reimplantation of the IMA on the brachiocephalic artery. One month later the patient is doing well without chest pain. A coronary subclavian steal syndrome should be suspected in case of recurrent ischaemia after IMA bypass, particularly if there is more than 20 mmHg systolic pressure differential between the arms. Left transradial approach achieved diagnostic in case of total left subclavian artery occlusion.     

Effect of percutaneous transluminal coronary angioplasty on arrhythmias complicating angina.

Four patients who had stenosis of a single major coronary artery which was treated by percutaneous transluminal coronary angioplasty are described. Three had exercise induced myocardial ischaemia complicated by ventricular tachycardia, fibrillation, and sinus bradycardia, respectively. Asystole developed in a fourth patient who had spontaneous chest pain. After successful percutaneous transluminal coronary angioplasty these arrhythmias did not recur spontaneously or on treadmill exercise testing. Percutaneous coronary angioplasty can be effective in preventing arrhythmias complicating acute myocardial ischaemia secondary to stenosis of a single major coronary artery.     

Angiographic identification of primary coronary anomalies causing impaired myocardial perfusion

The origin and early branching of the coronary arteries is fairly constant. Anomalous origin of the coronary arteries, which produced significant abnormalities of myocardial perfusion, were documented in 13 adult patients undergoing investigation because of chest pain. All underwent surgical treatment with relief of the presenting symptoms. They can be divided into four groups: (1) Origin of the left anterior descending branch of the left coronary artery (LCA) from the pulmonary artery (PA) (three cases); (2) origin of the LCA from the anterior sinus. Acute angulation of the ostium and compression of the intramural segment of this coronary produced severe myocardial ischaemia in three patients. (3) Origin of the LCA from the right coronary artery with its proximal segment closely related to the noncoronary sinus (one patient) in whom relief of symptoms was obtained by surgery. (4) Origin of the LCA from the PA with reversal of coronary flow and left to right shunting (six patients). It is concluded that anomalies of the origin of the coronary arteries are rare, but can produce specific clinicopathological entities that can be diagnosed with confidence and corrected surgically. Moreover, the study emphasises the need for angiographic awareness of these coronary anomalies, even in adult patients in whom atherosclerotic disease would be the most likely finding at cardiac catheterisation.     

Effect of percutaneous transluminal coronary angioplasty on arrhythmias complicating angina

Four patients who had stenosis of a single major coronary artery which was treated by percutaneous transluminal coronary angioplasty are described. Three had exercise induced myocardial ischaemia complicated by ventricular tachycardia, fibrillation, and sinus bradycardia, respectively. Asystole developed in a fourth patient who had spontaneous chest pain. After successful percutaneous transluminal coronary angioplasty these arrhythmias did not recur spontaneously or on treadmill exercise testing. Percutaneous coronary angioplasty can be effective in preventing arrhythmias complicating acute myocardial ischaemia secondary to stenosis of a single major coronary artery.     

Single coronary artery from the left sinus of Valsalva

A patient with chronic exertional angina and electrocardiographic signs of myocardial ischemia at exercise stress test had recent onset of rest chest pain and underwent coronary arteriography. Besides severe atherosclerotic coronary disease (which was probably responsible for clinical presentation), a single coronary artery arising from the left sinus of Valsalva was discovered. This is an exceptional finding, and its in-life diagnosis may be relevant for surgical treatment.     

The electrocardiogram as an adjunct in diagnosing congenital coronary arterial anomalies

Congenital coronary arterial abnormalities as isolated lesions are exceedingly rare. The electrocardiogram, while a reasonable adjunct in the diagnosis of coronary arterial abnormalities, should not supplant a good history and physical examination. Careful attention must be devoted to any signs or symptoms of ischaemic pain in the chest or syncope, which must not be overlooked. Exertional pain in the chest and exertional syncope should prompt an extensive evaluation by both the echocardiographer and the electrophysiologist. Clearance for participation in sports should be curtailed until a complete evaluation has ruled out the presence of any of the following disorders: a channelopathic mutation, a cardiomyopathy, or a congenital coronary arterial anomaly. Major abnormalities in the coronary arteries may present in the first few months of life or remain dormant until the exertional demands of adolescence unmask symptoms of myocardial ischaemia. Congenital coronary arterial anomalies may be analysed in the following major diagnostic groups: anomalous origin of the left coronary artery from the pulmonary artery, anomalous aortic origin of a coronary artery from the wrong aortic sinus of Valsalva, atresia of the left main coronary artery, myocardial bridges, and coronary arterial fistulas. The advent of state-of-the-art modalities of imaging seems, at times, to have supplanted the electrocardiogram in making the diagnosis of potentially serious coronary artery abnormalities, especially in asymptomatic patients. However, as is also the case for a detailed history and physical examination, the electrocardiogram provides a potentially insightful look at the coronary arteries. Furthermore, the past decade has witnessed an increase in the use of the electrocardiogram as a screening tool in the assessment of the risk of sudden cardiac death in athletes in high school.     

A case of anomalous origin of the right coronary artery from the left sinus of Valsalva exhibiting the Wolff-Parkinson-White syndrome

A 56-year-old male with the Wolff-Parkinson-White syndrome wassuspected of having suffered a myocardial infarction followingattacks of chest pain. Serial measurements of serum creatinephosphokinase and the electrocardiographic findings after ajmalineloading virtually excluded the possibility of myocardial infarction.Paroxysmal tachycardia was not noted on 24 Holler electrocardiographicmonitoring. Both the left and right coronary arteries were foundby selective coronary angiography to originate from the leftsinus of Valsalva, but neither of the arteries showed organicstenoses. However, myocardial²⁰¹ Tl scintigraphy after exerciseindicated poor uptake in the high anterolateral wall, and atthe apex and septum near the anterior wall, which suggestedthe absence ofischaemia in the area supplied by the right coronaryartery. We speculate that a left coronary artery steal phenomenonwas the cause of the ischaemia after exercise in this patient.     

Coronary artery spasm as a cause of chest pain in a patient with anomalous origin of the right coronary artery from the left sinus of valsalva

The cause of chest pain in patients with anomalous origin of the right coronary artery from the left sinus of Valsalva has not yet been elucidated. In the following case, this anomaly was demonstrated, upon angiography, in a patient with recurrent chest pain and a negative stress test; in addition, spasm of the left anterior descending coronary artery was documented during ergonovine provocation. To our knowledge, this is the first time coronary artery spasm has been documented in a patient with this anomaly. On the basis of this case, we recommend ergonovine testing for all angina patients with aberrant coronary arteries in whom no other cause of chest pain is found at cardiac catheterization.     

Changes in coronary sinus pH during dipyridamole stress in patients with hypertrophic cardiomyopathy.

OBJECTIVES: The presence of angina pectoris and myocardial scarring in patients with hypertrophic cardiomyopathy (HCM) suggests that myocardial ischemia is a factor in the pathophysiology of the disease. The clinical evaluation of ischaemia is problematic in HCM as baseline electrocardiographic abnormalities are frequent and thallium-201 perfusion abnormalities correlate poorly with anginal symptoms. Coronary sinus pH measurement using a catheter mounted pH electrode is a validated sensitive technique for the detection of myocardial ischaemia. METHODS AND RESULTS: 11 patients with HCM and chest pain (eight men; mean (SD) (range) age 36 (11) (19-53) years) and six controls (two men; mean (SD) (range) age 49 (11) (31-62) years) with atypical pain and normal coronary angiograms were studied. Eight patients with HCM had baseline ST segment depression of > or = 1 mm and four had reversible perfusion defects during stress 201TI scintigraphy. A catheter mounted hydrogen ion sensitive electrode was introduced into the coronary sinus and pH monitored continuously during dipyridamole infusion (0.56 mg/kg over four min). The maximal change in coronary sinus pH during dipyridamole stress was greater in patients with HCM than in controls (0.082 (0.083) (0 to -0.275) v 0.005 (0.006) (0 to -0.012), P = 0.02). In six patients (four men; mean (SD) (range) age 29 (9) (19-40 years) the development of chest pain was associated with a gradual decline in coronary sinus pH (mean 0.123 (0.089)), peaking at 442 (106) s. There were no relations among left ventricular dimensions, maximal wall thickness, and maximum pH change. In patients with HCM there was a correlation between maximum pH change and maximum heart rate during dipyridamole infusion (r = 0.70, P = 0.02). CONCLUSION: This study provides further evidence that chest pain in patients with HCM is caused by myocardial ischaemia. The role of myocardial ischaemia in the pathophysiology of the disease remains to be determined but coronary sinus pH monitoring provides a method for quantifying and prospectively assessing its effects on clinical presentation and prognosis.