14例急性ST段抬高心肌梗死急诊PCI的近期疗效观察

目的观察心肌梗死急诊经皮冠状动脉介入(PCI)治疗的疗效及安全性。方法对14例急性ST段抬高心肌梗死(STEMI)患者在发病12h内行急诊PCI.其中急性前壁、急性前间壁心梗10例,急性下壁心梗4例。结果14例患者中,冠脉造影显示梗死相关动脉(IRA)为前降支8例,回旋支3例,右冠脉4例,13例患者(92.9%)介入治疗获得成功,置入支架15枚,全部获得TIMI血流3级。1例因术中发生室颤,经除颤转为窦性心律后家属放弃手术未能成功。结论对急性STEMI患者行急诊PCI治疗是积极有效的,安全性高,能明显提高患者生活质量,降低住院死亡率。     

Myocardial infarction in the distribution of a patent anomalous left circumflex coronary artery

Anomalous origin of the left circumflex coronary artery is the most common congenital coronary artery anomaly. Myocardial infarction has been seen in the distribution of this anomalous vessel. This has been noted most typically when the vessel is atherosclerotic. Sudden death and myocardial infarction, however, also have been seen in a case without atherosclerotic involvement. This is a case report of a 45-year-old man who suffered a myocardial infarction after strenuous and sustained physical effort and who was found to have nonatherosclerotic coronary arteries with an anomalous left circumflex coronary artery arising from the right sinus of Valsalva.     

Survival with total occlusion of the left main coronary artery. Significance of the collateral circulation

Four patients with total occlusion of the left main coronary artery are described. Angina pectoris was severe (NYHA class 3-4) and had lasted 20 months to seven years. Three patients had experienced a myocardial infarction. All displayed large collaterals arising from a nearly normal right coronary artery and feeding both the left anterior descending and the left circumflex arteries. The left ventricular ejection fractions ranged from 20% to 65%, and all patients had varying degrees of left ventricular asynergy. Coronary artery bypass surgery resulted in a marked improvement in three patients; one patient who underwent an aneurysmectomy died two months after the operation. The data show that total occlusion of the left main coronary artery is compatible with survival if adequate collateral supply develops from the right coronary artery. In this rare angiographic subset collateral circulation is clearly functionally significant.     

Multiple coronary artery fistulae treated with a single Amplatzer vascular plug: Check the back door when the front is locked

Congenital coronary artery fistulae are rare anomalies, which can result in myocardial ischemia or infarction, congestive heart failure, fistula rupture, or death. In this report, the authors describe a 56‐year‐old woman with new onset chest pain and palpitations. Exercise myocardial perfusion imaging was significant for a reversible perfusion defect in the anterior left ventricular wall. Left and right heart catheterization demonstrated multiple fistulous communications between the right coronary and left anterior descending coronary arteries with the pulmonary artery. All fistulae drained into the pulmonary artery by a common ampulla. Closure was achieved via a percutaneous approach using a single Amplatzer vascular plug. © 2009 Wiley‐Liss, Inc.     

Multiple coronary thrombosis in a patient with thrombocytosis

A 59-year-old woman was admitted with acute inferior myocardial infarction. Cardiac catheterization revealed total occlusion in the right coronary artery and thrombus-like filling defect in the left anterior descending coronary artery. With simultaneous intracoronary urokinase infusion to the right and left coronary arteries, the right coronary artery became patent and the thrombus in the left anterior descending coronary artery was released to the distal coronary artery. Thrombocytosis was disclosed by laboratory examination. The relationship between myocardial infarction and thrombocytosis is discussed.     

Primary percutaneous coronary intervention of an anomalous right coronary artery arising from the left coronary cusp using an undersized Judkins catheter: A case report

Occlusion of an anomalous right coronary artery arising from the left coronary cusp is a rare cause of acute inferior wall myocardial infarction. The case of a 66-year-old man who presented with an acute inferior wall myocardial infarction from occlusion of an anomalous right coronary artery arising from the left coronary cusp is described. An undersized Judkins left guide catheter was successfully used to perform primary percutaneous coronary intervention for this anomaly. Computed tomographic angiography was subsequently used to characterize the origin and anatomical course of the anomalous right coronary artery and assess coronary stent patency.     

Coronary collateral circulation

The occurrence and influence of coronary collateral circulation and obstruction of the supplying coronary arteries on left ventricular contractility, prevalence of myocardial infarction, and bicycle exercise ergometer test were studied in a random sample of 286 patients with angiographically documented coronary artery disease. Collaterals appeared increasingly in all three main coronary arteries with grade of obstruction. The highest prevalence of collaterals occurred in stenosis of the right coronary artery (60%), followed by the left descending artery (45%); they occurred least in the left circumflex artery (21%) (p less than 0.001). The frequency of intra-arterial collateral circulation was 42%, 11%, and 12%, respectively (p less than 0.001). With total occlusion of the left anterior descending coronary artery, 22% of the patients had normokinetic anterior and apical left ventricular wall when collaterals were present. More often, the inferior wall showed normal contraction with total occlusion of the right coronary artery and collaterals [52%, p less than 0.001 compared with left anterior descending artery (LAD)]. The prevalence of inferior myocardial infarction was 39%, with collateral circulation to the totally occluded right coronary artery. The respective prevalence of anterior infarction and total occlusion in the left coronary artery was 58% (p less than 0.02). The presence or absence of collaterals had no obvious influence on ST-segment response during bicycle ergometer test. In triple-vessel disease, peak work capacity was better when collaterals to LAD were not jeopardized (427 kpm) than when jeopardized (321 kpm) (p less than 0.02).     

Post myocardial infarction ventricular septal rupture in a patient with single coronary artery

A 52-year-old male developed ventricular septal rupture on the third day after acute anterior wall myocardial infarction. Coronary angiogram showed a single coronary artery (right coronary from left main stem) with significant lesions in left anterior descending and in left circumflex coronary arteries. This association has not been reported so far.     

Surgical Management of Acute Myocardial Infarction Caused by Intramural Anomalous Left Coronary Artery in a Young Female Athlete

In the complex spectrum of coronary anomalies, the origin of the left coronary artery from the right sinus of Valsalva with intramural course could represent a catastrophic life-threatening condition leading to extensive myocardial infarction and sudden cardiac death, especially in young athletes. We report the case of a young female athlete with anomalous left coronary artery from the opposite sinus who survived a major non–ST-elevation myocardial infarction during the eighth kilometer of a running race. It was successfully treated by creating a neo-ostium of the left coronary artery in the left sinus at the point at which the artery left the aortic wall.     

Coronary vasospasm as a potential cause of myocardial infarction and paroxysmal atrial fibrillation in a relatively young woman

Vasospasm-related myocardial infarction in young women with normal coronary arteries has infrequently been reported and vasospasm-related paroxysmal atrial fibrillation (PAF) has rarely been described. We present a 33-year-old woman with old inferior myocardial infarction and postinfarction angina at rest; the angina was accompanied by PAF and electrocardiographic ST-segment elevation in the inferior leads. Coronary angiography revealed normal coronary arteries and intracoronary acetylcholine provoked an intense and diffuse spasm of the right and left coronary artery. The spasm of the right coronary artery was associated with PAF and ST-segment elevation in the inferior leads. Frequently documented PAF, accompanied by chest discomfort and ST-segment elevation in the inferior leads, was more effectively removed with isosorbide dinitrate than with disopyramide. These data suggest that coronary vasospasm is a likely cause of myocardial infarction and even PAF, although the precise mechanism leading to PAF remains unknown.     

Positron emission tomography with oxygen-15 of stunned myocardium caused by coronary artery vasospasm after recovery.

Stunned myocardium is often observed after unstable angina, myocardial infarction, thrombolysis, angioplasty, and bypass surgery but rarely after coronary vasospasm. A case of stunned myocardium caused by diffuse coronary artery vasospasm and mimicking myocardial infarction is reported. The patient had an emergency coronary angiography, which showed no pathological coronary disease, but the left ventricular ejection fraction showed severe left ventricular dysfunction. Repeat coronary angiography 24 days later after medical treatment (diltiazem and nitrates) showed complete recovery of wall function, and a diffuse vasospasm was induced in both coronary arteries (left anterior and right coronary arteries). Two days later the patient underwent a positron emission tomography study with water labelled with oxygen-15 to evaluate the viable myocardium and oxygen-15 to evaluate oxidative metabolism. The results showed normal myocardial blood flow and perfusable tissue density, confirming that the myocardium was viable, and normal myocardial oxidative metabolism, reflecting the recovery of the left ventricular function.     

Unruptured left ventricular pseudoaneurysm following myocardial infarction

A 73 year old man developed a left ventricular pseudoaneurysm following acute myocardial infarction. Coronary angiography showed triple vessel disease with total occlusion of the right coronary artery. On left ventriculography, a serpentine-like pseudoaneurysm was demonstrated that originated from the posterobasal wall of the left ventricle and extended to the right ventricular free wall. He underwent coronary artery bypass surgery with no plication of the pseudoaneurysm. An organised thrombus was also found within the cavity of the pseudoaneurysm. He was doing well approximately eight months after the operation. The prognosis might be determined by the organised thrombus, the serpentine-like structure of pseudoaneurysm, the coronary revascularisation, and the vigorous medical management.

Keywords: acute myocardial infarction;  pseudoaneurysm;  coronary artery bypass surgery     

Acute myocardial infarction after simultaneous thrombosis in normal right and left coronary arteries

A 32-year-old male patient with clinical and electrocardiographic evidence of acute myocardial infarction underwent coronary angiographic study. We observed nonocclusive thrombosis simultaneously in right and left anterior descending coronary arteries, without confirmation of spasm or obstructive artery disease in other coronary branches. Documentation of coronary thrombosis in more than one artery is rare, and its pathophysiology is still unknown. With the advent of thrombolytic therapy and immediate coronary angiographic studies in patients with evolving myocardial infarction, it has been possible to confirm the presence of thrombus and the type of coronary disease. In this case, we observed total lysis of both thrombi and the final aspect of "normal" angiographically reperfused coronary arteries.     

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.     

Recurrence of myocardial infarction related to different vessels in a patient with diffuse coronary artery spasm without underlying severe organic stenosis

A 59-year-old man had a first myocardial infarction in the right coronary artery, followed by an another infarction in the left anterior descending coronary artery. Coronary thrombolysis for both occasions of acute myocardial infarction was successfully performed without severe residual stenosis. In the chronic phase after the second myocardial infarction, ergonovine test showed diffuse coronary artery spasm. The etiology of myocardial infarction is briefly discussed.     

26例急性心肌梗死患者急诊介入治疗的疗效

目的：观察急性心肌梗死介入治疗的临床效果。方法：对12h内发病的26例急性心肌梗死患者行急诊经皮冠脉介入术(PCI)。结果：26例中梗死相关血管28支．其中前降支12支(42．86％)．回旋支6支(21．43％)．右冠状动脉6支(21．43％)．第一对角支2支(7．1％)．第二对角支!支(7．1％)。其植入支架32枚．23例成功(88．46％)。住院期间并发心源性休克5例．其中1例死亡。结论：急性心肌梗死时行急诊PCI成功率高．并发症少。     

Resolution of an intra-coronary filling defect in the proximal left anterior descending coronary artery demonstrated by 64-slice multi-detector computed tomography.

The evolution of acute coronary syndromes (ACS) is not always clearly understood, and our understanding has been limited by the absence of serial information regarding the coronary vasculature in these patients. We describe a young patient with an acute inferior wall myocardial infarction in whom repeat multi-detector computed tomographic scanning (MDCT), supported by invasive studies, revealed a transient filling defect in the proximal left anterior descending coronary artery and nonobstructed circumflex and right coronary arteries. New generation 64-slice MDCT scanning provides a new method for visualizing both the coronary lumen and coronary plaque, and may prove to be a useful tool in improving our understanding of the dynamics of ACS.     

Quantitative comparison of extent of coronary narrowing and size of healed myocardial infarct in 33 necropsy patients with clinically recognized and in 28 with clinically unrecognized (“silent”) previous acute myocardial infarction

Clinical and necropsy observations are described in 61 patients with a healed transmural myocardial infarction, 33 with and 28 without a clinical history of acute myocardial infarction. There were no significant differences between the 2 groups of patients in mean age, sex, or frequency of angina pectoris, chronic congestive heart failure, systemic hypertension, sudden coronary death, or fatal acute myocardial infarction. Compared with the patients with clinically recognized acute myocardial infarction, the patients with clinically unrecognized (silent) infarction had a significantly (p < 0.05) higher incidence of diabetes mellitus (43 versus 15%), death from noncardiac causes (39 versus 9%), posterior (inferior) wall infarcts (82 versus 55%), and smaller infarcts (mean size 7 versus 17% of left ventricular wall). The patients with and without clinically recognized infarction had similar numbers of the 4 major coronary arteries severely (76 to 100% in cross-sectional area) narrowed (mean 2.8 versus $\text{2.9}\text{4.0}$ per patient), insignificant differences in incidence of severe narrowing of the left main coronary artery (18 versus 29%), similar overall percents of 5 mm segments of the 4 major coronary arteries severely narrowed (43 versus 42%), and similar percents of severely narrowed 5 mm segments of the right (46 versus 55%), left anterior descending (39 versus 33%), and left circumflex (41 versus 41%) coronary arteries.     

Origin of the right from the left main coronary artery (single coronary ostium in aorta)

Origin of both the right and left main (LM) coronary arteries from the aortic wall of the right sinus of Valsalva frequently is a lethal anomaly.¹ Origin of both the right and LM coronary arteries from the aortic wall of the left sinus of Valsalva, in contrast, usually is a benign anomaly.² Although many studies have described origin of both LM and right coronary arteries from the aortic wall of the same sinus of Valsalva, few^1,2 have described origin of the right coronary artery from the LM. Husaini et al³ described angiographic features of this anomaly in a 52-year-old man who underwent selective coronary angiography after probable acute myocardial infarction. Muus and McManus⁴ described this anomaly in a fullterm stillborn infant who also had a bicuspid aortic valve. Whether the coronary anomaly played a role in the stillbirth is uncertain. In both of these previously described patients, the anomalously arising right coronary artery coursed between aorta posteriorly and the pulmonary trunk anteriorly.     

Incomplete myocardial rupture after coronary embolism of an isolated single coronary artery.

An 82-year-old female was admitted to the coronary care unit with an anterior wall myocardial infarction and cardiogenic shock. She was in chronic atrial fibrillation without oral anticoagulation. Coronary angiography showed occlusion of the left main coronary artery which originated together with a normal right coronary artery from the right sinus of Valsalva. The advanced age, the presence of chronic atrial fibrillation not anticoagulated and the normal appearance of the remaining coronary arteries suggested a thromboembolic origin. Transthoracic echocardiography showed an abrupt interruption of the myocardial wall, in the apical portion of the interventricular septum, not communicating with the pericardial sac or right ventricular cavity suggesting the presence of an incomplete contained rupture of the myocardial wall at this location. She died in cardiogenic shock due to the extensive left ventricular damage.