冠状动脉左主干病变的治疗研究

冠状动脉左主干病变（LMCA）因其高危险、高死亡率,一直受到心脏科医师的高度重视,且在不断的努力探索LMCA的有效治疗策略。单纯药物治疗预后差,冠状动脉旁路移植术（CABG）一直以来是LMCA的首选治疗策略,但随着经皮冠状动脉介入治疗（PCI）相关技术的发展,新一代药物涂层支架的问世,使LMCA患者的PCI治疗预后显著改善。本文总结了近年来CABG和PCI治疗LMCA的相关研究,以探讨LMCA的最佳治疗策略。     

右冠状动脉起源于左冠状窦的血流动力学分析

目的通过计算流体动力学(computational fluid dynamics,CFD)分析右冠状动脉起源于左冠状窦(anomalous origin of the right coronary artery from the left coronary artery sinus,AORL)的血流动力学参数,从而有效评估疾病。方法选取正常右冠状动脉(right coronary artery,RCA)和AORL两例个体病例,在Mimics软件中重建两个病例的血管模型,并将模型导入ANSYS CFX软件中进行血流动力学模拟计算,比较正常和AORL两种模型的血流动力学情况。结果 AORL模型右冠状动脉入口截面具有较小的血流量(9. 35 cm~3/s),有可能会导致右冠状动脉下游供血不足; AORL模型右冠状动脉急性拐角处的压力(13. 78 kPa)相比于正常模型右冠状动脉(14. 9 kPa)较低; AORL模型壁面剪切力(12. 83 Pa)大于正常模型(9. 74 Pa); AORL模型血管壁变形量较大。结论 AORL入口流速及拐角处压力均比正常RCA小,从而可能导致缺血症状发生。研究结果对临床上有效评估缺血等疾病具有理论指导意义。     

左主干狭窄的冠状动脉旁路移植术的麻醉处理

目的观察左主干狭窄冠心病人行冠状动脉旁路移植术的麻醉。方法回顾25例冠状动脉左主干狭窄的患者在全麻下实施了冠状动脉旁路移植术（CABG）的麻醉,对血流动力学、正性肌力药物及围麻醉期心血管事件进行分析。结果本组25例病人均完成CABG术,18例为非体外循环下完成,7例在体外循环下完成。血管活性药物使用率100%,15例有心律失常,8例有明显的ST段改变,1例体外下行CABG者术后24h死于左心衰,余安全出院。结论左主干狭窄病人行CABG术麻醉要求高,正确的围麻醉期处理可减少心血管事件的发生。     

右冠状动脉左房后支变异一例

在解剖一成年男尸心脏时，发现其右冠状动脉的左房后支变异，现报告如下：右冠状动脉起于主动脉右窦中部，始处直径4．32mm，沿冠状沟内走行至房室交点处分为左室后支和后室间支。左室后支起始处直径为2．20mm，起始后在冠状沟内发出四支至左心室膈面，另有一支发出后分为两支，分别布于左心     

先天性左冠状动脉主干闭锁3例超声心动图特征及文献复习

目的 通过研究先天性左冠状动脉主干闭锁（LMCAA）的超声心动图表现,提高对LMCAA诊断的准确性.方法 回顾性分析经冠状动脉造影证实的3例LMCAA患儿的超声心动图检查结果,并复习相关文献,总结LMCAA超声心动图特征.结果 LMCAA特异性超声心动图特征：①主动脉左冠状动脉窦内无左冠状动脉主干开口,左冠状动脉主干近心端闭锁呈盲端,远心端内径细窄,发育不良;②右冠状动脉内径增宽;③多切面未显示左冠状动脉与肺动脉确切连接的证据.LMCAA非特异性超声心动图特征：①左心室明显扩大,左室收缩功能可正常或减低;②二尖瓣腱索、乳头肌回声显著增强,可伴有二尖瓣脱垂.彩色多普勒超声特征：①收缩期二尖瓣口可见中至大量反流信号;②左、右冠状动脉之间形成细小侧支循环; ③左冠状动脉前降支和回旋支血流为逆向灌注（向心性）;④发育不良的左冠状动脉虽然在肺动脉周围分布,但彩色多普勒超声不能显示其与肺动脉连接的确切逆灌血流信号.结论 LMCAA有特异性的超声心动图特征,提高对LMCAA的全面认识是诊断本病的关键.     

右冠状动脉开口于左前降支1例报道

左、右冠状动脉分别起自左、右主动脉窦内。以主动脉瓣附着缘连线为界,可将主动脉分分为窦内和窦外,开口的绝大多数（80％～91％）处于窦内,少数开口在窦外或窦线上。右冠状动脉起自右主动脉窦。     

左冠状动脉旋支异位开口于右冠状动脉窦1例

成年男性 ,心脏正常。右冠状动脉发自右冠状动脉窦中 1/3,开口处内径 5ｍｍ ,经右冠状沟分布于右心。左冠状动脉旋支直接开口于右冠状动脉窦 ,紧接右冠状动脉口的后方。此口略呈园形 ,内径 3ｍｍ(附图 )。此支发出后 ,贴绕主动脉起始部急转变向后方行走 ,管腔呈裂隙样 ,平对右主动脉窦上界行向左 ,发窦房结动脉 (外径 1ｍｍ ) ,此动脉穿房间肌束上行 ,以逆时针方向绕上腔静脉口达结区。旋支主干沿主动脉壁向左前达左冠状沟 ,分支分布于左心。左冠状动脉前室间支直接开口于左冠状动脉窦 ,开口处内径 4ｍｍ。前室间支起始段与旋支未段平行 ,两…     

新疆汉族、维吾尔族左冠状动脉分叉夹角及左主干长度与夹角区动脉粥样硬化的MSCT相关性研究

目的　利用MSCT分析维吾尔族与汉族左冠状动脉分叉夹角（LAD-LCX）及左主干长度（LM）与冠状动脉夹角区动脉粥样硬化的关系。 方法　回顾性分析本地区6所医院行冠状动脉CTA检查患者资料,将左冠状动脉主干分叉区按管腔狭窄受累情况分为Ⅰ~Ⅳ级,分析比较维吾尔族及汉族不同分级之间的左冠状动脉分叉夹角及左主干长度差异;分析左冠状动脉分叉夹角与左主干长度的相关性。 结果　纳入研究1276例,汉族916例,维吾尔族360例。汉族左冠状动脉夹角均值为(84±38.8)º(29º~158º), 左冠状动脉主干长度均值为(9.2±5.3)mm(1.6~28.6 mm);维吾尔族左冠状动脉夹角均值为(85±34)º(24º~155º),LM长度均值为(9.6±6.6)mm(2.4~18.3mm)。维吾尔族与汉族的左冠状动脉夹角在Ⅰ级与Ⅱ、Ⅲ、Ⅳ级之间差异有统计学意义,而Ⅱ、Ⅲ、Ⅳ级之间的左冠状动脉夹角差异无统计学意义。两民族左冠状动脉分叉夹角与左冠状动脉主干长度均呈中度相关(汉族R=0.307;维吾尔族R=0.421)。 结论　大的冠状动脉夹角及更长的左主干长度更容易引起夹角区冠状动脉硬化,但与夹角区管腔受累程度没有明显相关性;左冠状动脉分叉夹角与左冠状动脉主干长度呈中度相关,维吾尔族略高于汉族。     

左冠脉主干和三大主粥样硬化与心机梗塞的对比调查（附128例尸检分析）

对128例心肌梗塞尸检进行了分析，其中60岁以上92例（71．9％）、59岁以下36例（28．1％），左冠脉主干动脉粥样硬化（As）Ⅳ级共21例（16．4％），年龄在60岁以上仅有15例（11．7％），59岁以下6例94．7％）。但在前降支AsⅣ级有106例（82．8％），左旋支71例（55．5％），右冠脉主干88例（68．7％），说明左主干AsⅣ级狭窄明显轻于三大主支。左主干AsⅣ级狭窄的出现也较三大主支为晚。左主干AsⅣ级狭窄发生陈旧性透壁心肌梗塞多于急性透壁性心肌梗塞，其心肌梗塞范围也较广泛。左主干As狭窄程度与心肌梗塞并发症的产生虽无直接相关，但有加重作用。左主干无1例在As基础上并发新鲜血栓，而三大主支并发血栓有66例（51．6％）。     

Main trunk of the left coronary artery: anatomic study of the parameters of clinical interest

The objective of this study was to analyze in one single series all the characteristics of the main trunk of the left coronary artery (MT) that may be of use in the diagnosis and treatment of its pathologies. One-hundred human hearts from autopsies were used. The average age of the sample studied was 63.15 years +/- 18.76 (range = 17-94 years). The heart was removed after resection of the costosternum and placed in 10% formaldehyde. With gradual separation and retraction of the myocardial fasciculi the MT was exposed. The length of the MT, the luminal diameter of the MT at its midpoint, and the luminal diameter of the left coronary orifice were measured with a caliper. The angle of division between the anterior interventricular and circumflex branches was also measured, and the number of terminal branches originating from the MT was recorded. In four cases, there was no MT and the anterior interventricular and circumflex branches originated directly from the left aortic sinus. The average length of the MT was 10.8 +/- 5.52 mm (range = 2-23 mm); the average diameter at its midpoint was 4.86 +/- 0.80 mm; and there was no significant difference noted between the midpoint diameter of the MT and the diameter of the left coronary orifice. The most frequent type of division of the MT was bifurcation (62%); in 38% of cases the MT divided into three or more branches. An average value of 86.7 +/- 28.8 degrees was obtained for the angle of division of the terminal branches of the MT (range = 40-165 degrees ). There was a positive correlation between the length of the MT and the angle of division of its terminal branches, with the longest MTs having the largest angle of division.     

Variant of the left coronary artery with an unusual origin and course: Anatomic and postmortem angiographic findings

This study demonstrates anatomic and postmortem angiographic findings characterizing the origin of the left coronary (LC) artery arising in common trunk with the right coronary (RC) artery from the right aortic sinus and its course via the ventricular septum (VS) to the left heart. This anomaly was a single finding observed among 388 angiographies and 60 corrosion castings. The course of the LC was divided in four segments. The first three form a curve that is upward concave. Large branches to the septomarginal trabecula (ST), VS, diagonals (DS), and the small anterior interventricular (anterior descending) artery originated from the outer part of this curve. In the anteroposterior x-ray, the above curve resembles a deep-bottom pot with a handle corresponding to the fourth segment. In the right anterior oblique, the first and second segments form a large erect angle. The third segment occupies the lower part of the absent proximal anterior interventricular artery, and the fourth crosses the outflow tract and the first segment in the middle. The course of these four segments of LC resembles the shape of the number 6. These findings are important for interpreting coronary angiographies in patients with this anomaly. Clin. Anat. 11:367–371, 1998. © 1998 Wiley-Liss, Inc.     

Superdominant right coronary artery with absent left circumflex artery

Noninvasive imaging of coronary artery disease is rapidly replacing angiography as the first line of investigation. Multislice CT is the non-invasive modality of choice for imaging coronary artery disease and provides high speed with good spatial resolution. CT coronary angiography in addition to detecting and characterising atherosclerotic coronary artery disease is also a good imaging tool for evaluating anomalies of coronary arteries. Superdominant right coronary artery with absent left circumflex artery is one such rare coronary artery anomaly which is well evaluated with multislice CT angiography. The authors report one such case of superdominant right coronary artery with absent left circumflex artery imaged with 64-slice MDCT.     

The relationship of myocardial bridges to coronary artery dominance in the adult human heart

Myocardial bridging is recognized as an anatomical variation of the human coronary circulation in which an epicardial artery lies in the myocardium for part of its course. Thus, the vessel is 'bridged' by myocardium. The anterior interventricular branch of the left coronary artery has been reported as the most common site of myocardial bridges but other locations have been reported. The purpose of this study was to provide more definitive information on the vessels with myocardial bridges, the length and depth of the bridged segment, and the relationship between the presence of bridges and coronary dominance. Two hundred formalin-fixed human hearts were examined. Myocardial bridges were found in 69 (34.5%) of the hearts with a total of 81 bridges. One bridge was found in 59 of these hearts and multiple bridges were observed in ten (eight with double bridges and two with triple bridges). Bridges were most often found over the anterior interventricular artery (35 hearts). Bridges were also found over the diagonal branch of the left coronary artery (14), over the left marginal branch (five) and over the inferior interventricular branch of the left coronary artery (six). Bridges were also found over the right coronary artery (15 hearts), over the right marginal branch (four) and over the inferior interventricular branch of the right coronary artery (two). The presence of bridges appeared to be related to coronary dominance, especially in the left coronary circulation. Forty-six (66.6%) of the hearts with bridges were left dominant. Forty-two of these had bridges over the left coronary circulation and four over the right coronary circulation. Seventeen hearts (24.6%) were right dominant. Eleven of these had bridges over the right coronary circulation and six over the left coronary circulation. The remaining six hearts were co-dominant with four having bridges over the left coronary circulation and two over the right coronary circulation. The mean length of the bridges was 31 mm and the mean depth was 12 mm. The possible clinical implications of myocardial bridging may vary from protection against atherosclerosis to systolic vessel compression and resultant myocardial ischaemia.     

Aberrant penetrating posterior descending artery from proximal right coronary artery

We report a rare variant of the posterior descending artery (PDA) in a 51-year-old African-American male discovered in coronary CT angiography. Arising from the proximal right coronary artery near its ostium, the anomalous PDA penetrated posteriorly toward the atrioventricular junction septum, exited through the inferior pyramidal space into the posterior interventricular groove and continued in the groove as a short PDA. Along its course it gave rise to small branches to the medial wall of the right atrium, the atrioventricular node region, and the inferoseptal wall of the right ventricle.     

Concomitant multi-vessel disease is associated with a lower procedural death rate in patients treated with percutaneous coronary interventions within the left main coronary artery (from the ORPKI registry)

IntroductionIn this study, we aimed to distinguish differences in the procedural complication rate in a group of patients undergoing percutaneous coronary interventions (PCI) of the left main coronary artery (LMCA) between patients with isolated LMCA disease and multi-vessel disease (MVD) with LMCA involvement and to identify their predictors.Material and methodsWe assessed 221,187 patients from the Polish Cardiovascular Intervention Society national registry (ORPKI) regarding all PCI procedures performed in Poland in 2015 and 2016. We extracted data of 1,819 patients with isolated LMCA disease and 3,718 patients with MVD and LMCA involvement. We compared those two groups in terms of procedural complications and their predictors.ResultsThe overall rate of procedural complications was significantly higher in patients treated with LMCA PCI both in the group of patients with isolated LMCA (6.5%) and the group with MVD with LMCA involvement (7.3%) compared to the non-LMCA PCI group (1.9%, p = 0.002). Multivariate analysis confirmed that MVD with LMCA involvement is an independent predictor of decreased risk of procedural death in the overall group of patients undergoing PCI of the LMCA (odds ratio: 0.583; 95% confidence interval: 0.4–0.848; p = 0.005).ConclusionsThe MVD involvement in patients treated with PCI of the LMCA may play a protective role. Patients with isolated LMCA involvement undergoing PCI should be subjected to special care and protected by various methods, such as devices to support left ventricle function.     

Impact of diabetes on mortality and complications after coronary artery by-pass graft operation in patients with left main coronary artery disease

PurposeLeft main disease (LMD) is a severe form of coronary artery disease (CAD). Fifty percent of patients with LMD treated conservatively die within 3–5 years of diagnosis. The aim of the study was to assess the influence of type 2 diabetes on early and late (2-year) prognosis and the risk of complications after coronary artery by-pass graft (CABG) surgery in patients with LMD.Material/methodsWe enrolled 257 patients diagnosed with LMD. 169 (67%) underwent CABG, 19 (8%) percutaneous coronary intervention (PCI) without left main stem protection. 30 (12%) patients had CABG previously. Patients treated with CABG were divided into two groups – with and without diabetes. There were 43 (25.4%) patients with diabetes and 126 (74.6%) without diabetes.ResultsWe observed more complications with wound healing (40.5% vs. 12.8%, p < 0.001) and sternal dehiscence (23.8% vs. 4.0%, p < 0.001) after CABG in patients with diabetes. There were no differences in 7-day, 30-day, 3-month and 1-year mortality. 2-Year mortality was also similar in both groups (11.6% vs. 11.1%, p = 0.928). Patients with diabetes were more frequently hospitalized due to other reasons than angina (39.5% vs. 20.6%, p = 0.014).ConclusionsPatients with diabetes and LMD had more often complications with wound healing and sternal dehiscence after CABG than patients without diabetes. Type 2 diabetes did not influence early and late mortality in patients with LMD treated with cardiac surgery, but the presence of diabetes was associated with more frequent hospitalizations.     

Extremely high origin of the right coronary artery from the ascending aorta.

Coronary artery anomalies, especially variations in the level of origin, are frequent. In most cases, the origin lies just a few millimeters superior to the supravalvular ridge; ectopic origins of more than one centimeter above this border are rare. We report a case in which the right coronary artery arises from the ascending aorta 38 mm above the supravalvular ridge.