Right coronary artery cirsoid with fistulous connection to the coronary sinus

A 61-yr-old woman was referred to our hospital for evaluation of a suspected right atrial myxoma. The transesophageal echocardiogram suggested the presence of an anomalous right coronary artery with fistulous connection to the coronary sinus. At cardiac catheterization, an oxygen stepup in the right atrium indicated a 1.3:1.0 left-to-right shunt. Aortic root angiography showed a large and calcified right coronary artery cirsoid draining to the coronary sinus, which appeared remarkably dilated. In this rare anomaly, cardiac catheterization is necessary, not only to quantify the magnitude of the left-to-right shunt, which is an important requirement for the indication to surgical treatment, but also to confirm the echocardiographic diagnosis.© 1993 Wlley-Liss, Inc     

食道心房超速负荷试验中QT间期离散度诊断冠心病的价值

目的 :评价食道心房超速负荷试验的 QT间期离散度 （QTd）诊断冠心病的价值。方法 :对 32例冠心病患者 （冠心病组 ）及 34例正常者 （对照组 ）进行食道心房超速负荷试验 ,记录试验前后 12导联同步心电图 ,测量其 ST段、校正 QT间期 （QTc）及 QTd。根据 ROC曲线求出 QTc及 QTd的截断点 ,以冠脉造影为诊断冠心病的标准诊断方法 ,利用四格表法 ,分别计算各观测指标的特异度及敏感度。并与“并联试验”相互比较。结果 :ST段下移、QTc,QTd诊断冠心病的特异度分别为 10 0 % ,6 8% ,94% ;敏感度分别为 5 3% ,78%和 84%。 ST段下移和 QTd并联试验时敏感度可达 94%。结论 :食道心房超速负荷试验时 ,如以传统的诊断指标 ST段下移 ,结合 QTd,可明显提高其诊断的敏感度 ,可作一项重要参考指标     

冠状动脉疾病评分系统研究进展

冠状动脉病变的严重程度和冠心病患者预后密切相关,也是制定冠心病患者临床治疗策略的重要影响因素。目前不同的研究已经开发出了一系列的冠状动脉评分系统,主要基于冠状动脉造影、冠状动脉CT血管造影的影像结果来量化评估冠状动脉粥样硬化病变程度,用以更好地评估患者预后,并指导临床治疗。不同评分系统各有其优劣及适用范围。本文就目前常用的评分系统进行综述,希望能有助于了解各种冠状动脉评分系统的特点和应用范围,以便更好地评估患者预后,并制定出更有益于改善患者预后的治疗策略。     

Coronary angiography in cardiac myxomas: Findings in 19 consecutive cases and review of the literature

We reviewed the coronary angiographic findings of 19 patients with a cardiac myxoma, who underwent cardiac catheterization before surgery. Seventeen myxomas were localized in the left atrium and seven had angiographically visible tumor vascularity emerging from atrial branches of the right coronary artery in four patients and the circumflex coronary artery in three. In one patient, we found significant coronary artery disease of the circumflex coronary artery and in another we saw a thrombus-like lesion in the proximal third of the left anterior descending coronary artery. Our results are compared with the findings in two smaller groups of patients with cardiac myxoma who underwent coronary angiography preoperatively. We conclude that the major importance of coronary angiography in patients with cardiac myxomas is to exclude concomitant coronary artery disease before surgery. In a very small minority of patients, a selective coronary angiography is the clue to the diagnosis of cardiac myxoma. © 1993 Wiley-Liss, Inc.     

Utility and Challenges of an Early Invasive Strategy in Patients Resuscitated From Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest (OHCA) is frequently triggered by acute myocardial ischemia. Coronary angiography is an important component of post-resuscitation care for patients with OHCA without an evident noncardiac cause, to identify underlying coronary artery disease and allow revascularization. Most patients undergoing coronary angiography after OHCA have obstructive coronary artery disease, and nearly one-half of patients have acute coronary occlusion. Early coronary angiography and percutaneous coronary intervention after OHCA have been associated with improved survival in observational studies, but these studies demonstrate selection bias, and randomized trials are lacking. Selection of patients for coronary angiography after OHCA can be challenging, particularly in comatose patients whose outcomes are driven primarily by anoxic brain injury. As for other patients with acute coronary syndromes, patients with ST-segment elevation after OHCA have a high probability of acute coronary occlusion warranting emergent coronary angiography. Patients with cardiogenic shock after OHCA are a high-risk population also requiring emergent coronary angiography. Among patients in stable condition after OHCA without ST-segment elevation, other clinical predictors can be used to identify those needing early coronary angiography to identify obstructive coronary artery disease. Despite the challenges with early neurological prognostication in comatose patients with OHCA, those with multiple objective markers of poor prognosis appear less likely to benefit from revascularization, and early coronary angiography may be reasonably deferred in appropriately selected patients meeting these criteria. The authors propose an algorithm to guide patient selection for coronary angiography after OHCA that combines clinical predictors of acute coronary occlusion and early clinical predictors of severe brain injury.     

New family of preformed left atrial-coronary catheters for retrograde left atrial catheterization and coronary and/or aortocoronary bypass angiography via brachial artery cutdown

A previously described preformed No. 7 Oucor catheter for retrograde left atrlal catheterizatlon was modified for coronary anglography and used In 358 consecutive patients, 22 of whom had 26 of 51 previous aortocoronary bypass grafts still patent in 42 patients these catheters were also employed for retrograde left atrial catheterlzation. Sixty percent of right coronary, 96% of left coronary, and 96% of aortocoronary bypass anglography attempts were successful. Complete left heart study and anglography were accomplished with one catheter in ten patients (2.8%), with two catheters in 200 patients (55.9%), with three catheters in 132 patients (36.9%), and with more than three catheters In 16 patients (4.5%). Except in 4 of 12 patients with aortic valve deformities, left atrial catheterlzation was achieved whenever attempted. The complication rate was within acceptable limits. Average left heart and angiography procedure and fluoros-copy times were respectively 29.4 and 6.5 minutes. In addition to reconfirming usefulness for retrograde left atrial catheterlzation, these data demonstrate this family of catheters is useful for coronary–particularly left–and aortocoronary bypass angiography.     

老年心房纤颤与冠心病

对 2 6例经过冠状动脉造影的老年心房纤颤患者做回顾性分析。将患者分为 2组 ,第 1组 17例 ,无心电图心肌缺血证据 ;第 2组 9例 ,有心电图心肌缺血证据。结果显示 ,第 1,2组分别有 2 （11.8% ）和 8（88.9% ）例患者存在 1支以上冠状动脉大于管腔直径 5 0 %的狭窄 ,被诊断为冠心病。2组之间差异显著 （P<0 .0 1）。结果提示 ,当无心电图心肌缺血依据时 ,老年房颤不一定由冠心病引起     

Atrial fibrillation in coronary artery disease

To answer whether atrial ischemia plays an important role in the genesis of atrial fibrillation in patients with coronary artery disease, we analyzed the electrocardiograms obtained at the time of coronary angiography and left ventriculography in 3220 consecutive patients. Atrial fibrillation was found in 74 (2.3%). Among those with significant coronary artery disease were 49 (66.2%) patients with atrial fibrillation and 88.5% with sinus rhythm (P<0.02). Angiograms of patients with atrial fibrillation and significant (>50%) coronary stenosis were re-evaluated and results compared to the control group which consisted of 108 consecutive patients who were in sinus rhythm at the time of coronary angiography. There were no differences between groups with respect to either frequency of injury to the right coronary artery and circumflex branch of left coronary artery or localization of the injury to this region (before or after atrial branch take-off). But patients with atrial fibrillation significantly more often had heart failure (55.1% versus 18.5%, P<0.001) and three vessel disease (30.5% versus 20.4%, P=0.05) as well as mitral valve insufficiency (20.4% versus 10.2%, P<0.05). In conclusion, in patients with coronary disease, systolic heart failure may be more important than atrial ischemia in causing atrial fibrillation.     

常规静息心电图慢性ST-T改变与冠状动脉病变的临床探讨

目的探讨心电图慢性ST-T改变与冠状动脉病变及超声心动图房室肥大、瓣膜钙化的关系。方法对178例接受冠状动脉造影的非心梗病人的心电图资料进行分析,与冠脉造影和超声心动图结果进行比较。结果常规静息心电图有慢性ST-T改变的81例患者中,56例(64%)冠脉造影未见病变;冠脉造影证实存在冠脉病变的122例病人中,91例(74.56%)常规静息心电图正常,其中超声心动图结果正常的76例患者中,75例(99%)常规静息心电图正常。结论常规静息心电图慢性ST-T改变不能做为冠心病的诊断依据。     

急性冠脉综合征患者D-二聚体水平与支架置入治疗的关系研究

目的观察急性冠脉综合征患者D-二聚体水平与支架置入治疗之间的关系。方法对36例急性冠脉综合征患者和32例稳定型心绞痛患者进行经皮冠状动脉介入治疗(PCI),并对其PCI术前与术后1周、6个月D-二聚体水平进行比较。冠脉造影确定两组患者是否需要进行支架置入。结果两组患者D-二聚体水平在PCI术前、术后1周、术后6个月比较,差异均有统计学意义(P<0.05)。且急性冠脉综合征组患者行冠脉造影均提示冠脉病变需支架置入,对照组患者冠脉造影均提示斑块稳定,无需支架置入。结论 D-二聚体水平的高低可作为冠状动脉病变不稳定的一个重要监测指标来指导临床早期诊断和预后的判断,亦可作为预测冠脉造影是否需要支架置入的辅助指标。     

Coronary Embolus: An Underappreciated Cause of Acute Coronary Syndromes

Coronary embolism is the underlying cause of 3% of acute coronary syndromes but is often not considered in the differential of acute coronary syndromes. It should be suspected in the case of high thrombus burden despite a relatively normal underlying vessel or recurrent coronary thrombus. Coronary embolism may be direct (from the aortic valve or left atrial appendage), paroxysmal (from the venous circulation through a patent foramen ovale), or iatrogenic (following cardiac intervention). Investigations include transesophageal echocardiography to assess the left atrial appendage and atrial septum and continuous electrocardiographic monitoring to assess for paroxysmal atrial fibrillation. The authors review the historic and contemporary published data about this important cause of acute coronary syndromes. The authors propose an investigation and management strategy for work-up and anticoagulation strategy for patients with suspected coronary embolism.     

Coronary artery dissection following radiofrequency ablation for atrial fibrillation: Case report and review of the literature

Coronary artery injury following catheter ablation for cardiac arrhythmias is very rare. We present a case of left circumflex (LCx) coronary artery dissection causing inferoposterior ST-elevation myocardial infarction following radiofrequency (RF) ablation for atrial fibrillation (AF) in a 39-year-old male with no cardiovascular risk factors. This was confirmed on coronary angiography and intracoronary vascular ultrasound (IVUS). The likely etiology is thermal injury during RF ablation for AF, due to the close proximity of the left atrial appendage and left pulmonary veins to the LCx. He was successfully treated with primary percutaneous coronary intervention with good outcome. This is, to our knowledge, the first reported case of proven acute coronary dissection secondary to RF ablation for AF reported in the literature, and highlights the importance of considering this as a mechanism for coronary occlusion in these patients.     

Intravenous verapamil therapy in imminent myocardial infarction

We studied 16 patients with small myocardial infarction who had further episodes of chest pain with ST-segment elevation, a sign of transmural myocardial ischemia and imminent infarction extension. Coronary angiography in 14 showed a critical lesion in 13. Intravenous verapamil abolished chest pain and ST-segment elevation. It caused a fall in right atrial and left ventricular end-diastolic pressures (LVEDP) and cardiac output, reflex systemic vasoconstriction, and a rise in systemic vascular resistance. There was no reflex tachycardia. Volume expansion raised LVEDP and restored a normal cardiac output. Accelerated junctional rhythm with isorhythmic A-V dissociation occurred in 5 patients. Two patients sustained a transmural infarction, 10 underwent coronary artery bypass grafting, and 4 are symptom-free with oral treatment. Intravenous treatment was an effective method of treating acute episodes of transmural myocardial ischemia and preventing their recurrence in patients with critical coronary artery narrowing. Continuous verapamil infusion stabilized the patients' condition and enabled smooth coronary angiography and induction of anesthesia for surgery.     

阵发性室上性心动过速合并肌钙蛋白升高患者临床分析

目的：探讨阵发性室上性心动过速(paroxysmal supraventricular tachycardia, PSVT)发作时合并肌钙蛋白升高对冠心病的诊断意义。方法：对以突发心悸作为首发症状并通过体表心电图、食道调搏或心内电生理检查诊断为PSVT的患者,在起病24小时内进行血清肌钙蛋白的检测,并在住院期间进行冠脉造影检查,对这些患者的肌钙蛋白水平、冠脉造影结果进行分析。共入选21例PVST患者,其中肌钙蛋白正常组5例（血清肌钙蛋白水平< 0.0262 ng/ml）,肌钙蛋白显著升高组（血清肌钙蛋白水平 > 0.3 ng/ml）5例,肌钙蛋白临界组（0.0262 ng/ml ＜血清肌钙蛋白水平＜0.3 ng/ml）组11例。结果：冠脉造影结果提示冠心病例数：肌钙蛋白正常及临界组0例,肌钙蛋白显著升高组中3例。肌钙蛋白正常组与临界组冠心病发生率相比无统计学意义,肌钙蛋白显著升高组较临界组有统计学意义,P<0.05。结论：PSVT患者发作时可导致肌钙蛋白水平升高,当肌钙蛋白显著升高时（> 0.3ng/ml）,需警惕合并冠心病可能。     

Spontaneous coronary artery dissection and associated CT coronary angiographic findings: a case report and review

We report a case of an acute coronary syndrome in a 21-year-old male with invasive coronary angiography and computed tomography (CT) coronary angiography showing a spontaneous dissection of the left anterior descending artery. To our knowledge the CT coronary angiographic appearance of spontaneous coronary artery dissection has been reported only once before. We describe the role CT coronary angiography may have in the evaluation of coronary dissection as well as potential treatment options.     

Right atrial myxoma associated with vascular malformation and atypical chest pain

A 58-yr-old woman with a right atrial myxoma associated with a vascular malformation supplied by the right coronary artery is described. She presented with atypical chest pain that was reproduced during angiography of the malformation. Findings were confirmed during surgery. © 1992 Wiley-Liss, Inc.     

冠状动脉造影检查在冠心病诊断中作用的再探讨

目的探讨冠状动脉造影（CAG）检查在诊断冠心病中作用,就其对多年来被认为是金标准作用进行再探讨。方法对138例怀疑有冠心病的患者,均经普通ECG,动态ECG,活动平板和CAG。结果只有71例患者的冠状动脉造影检查符合目前冠心病标准,其余67例患者冠状动脉未达标（轻度-中度狭窄,或完全正常或仅见散在斑块形成）。结论冠心病的诊断是一个较为复杂的问题,CAG检查是诊断冠心病的一个重要依据,有相当比例的冠心病患者（CAG）无明显异常。     

充分挖掘冠状动脉计算机断层扫描的使用潜力

随着计算机断层扫描技术的飞速发展,冠状动脉计算机断层扫描作为一项无创性的检查手段,以其较高的准确度在冠心病的临床诊断中逐渐受到人们的接受与重视,相比与传统的冠状动脉造影,它具有无创、经济、可重复性强、提供信息更全面等特点。现主要结合冠状动脉计算机断层扫描自身特点,阐述这项诊断技术在指导危险分层,评估预后（如对主要心血管事件的预测价值）,辅助冠状动脉造影,评估支架再狭窄,优化病人管理等方面的应用,并讨论目前所存在的问题如辐射剂量,运动伪影等及最近的发展情况,旨在令更多的人了解到冠状动脉计算机断层扫描于临床的使用价值,我们应更充分更有效的利用这一临床资源,充分的发挥其使用潜力。更重要的是我们需要更多的临床试验来支持这项技术的每一步革新。     

Exercise testing? not at all

The traditional approach to the ambulatory patient with suspected or definite coronary disease is to evaluate the clinical features, to perform non-invasive tests for myocardial ischaemia, and to proceed, if necessary, to coronary angiography and coronary revascularisation. However, when the results of the exercise tests are discordant with the clinical classifications they are usually misleading as diagnostic tools. When the exercise lest is used to assist prognostication, the information provided overlaps with that available to the clinician and only the presence of ST segment depression is an independent prognosticator. The amount of ST segment shift has been found to be an inferior prognosticator to the severity of disease seen on a coronary angiogram and the latter allows for appropriate decisions to be made regarding coronary angioplasty or bypass surgery. A more appropriate use of exercise testing is as a gate for coronary angiography if there is real doubt or the nature of the chest pain or as an aid in therapeutic decisions if the coronary angiography interpretation is difficult.     

冠状动脉多层螺旋CT成像及冠脉造影对冠脉搭桥术后桥血管的评价

目的观察冠状动脉多层螺旋CT成像及冠脉造影对冠脉搭桥手术后桥血管的评价作用。方法33例冠脉搭桥手术患者,术前常规冠脉造影检查,手术行不停跳冠脉搭桥术,手术后1 a行冠状动脉多层螺旋CT成像,并于冠状动脉多层螺旋CT成像复查后1周内行冠脉造影检查。结果33例患者共行冠脉搭桥101支,冠状动脉多层螺旋CT成像能够成功显示99支,显示率为98.02%。冠状动脉多层螺旋CT成像与冠脉造影结果对比,其对冠脉搭桥手术后桥血管狭窄和阻塞评价敏感度达100%。结论应用冠状动脉多层螺旋CT成像对冠脉搭桥术后桥血管评价简便、无创,具有较好的可信性和可行性。