Coronary-cameral fistula in association with intracardiac tumour and aortic stenosis in an adult

We present a patient with the unexpected association of left ventricular tumor, a fistula between the right coronary and the right atrium, and senile valvar aortic stenosis. He had anginal complaints. Doppler echocardiography revealed moderate aortic stenosis with mild aortic and moderate mitral regurgitation. A tumour was detected in the left ventricle. Selective coronary angiography disclosed normal anatomy with a fistula originating from the proximal right coronary artery and draining into the right atrium. He refused operative treatment and is still alive, 1 year after the diagnosis was made, without complications.     

Pre-infarction angina secondary to calcific aortic stenosis with Bernheim's effect.

Pre-infarction angina, in the absence of coronary artery disease, was found in a 62 year-old man with severe calcific aortic stenosis. After application of intraaortic balloon pump counter-pulsation, the condition was stabilized, and coronary arteriograms were safely carried out. Interestingly, an elevated right atrial and right ventricular end-diastolic pressure with an associated Bernheim's effect was demonstrated by cardiac catheterization. The hemodynamics of the right heart returned to normal after surgical correction of the aortic stenosis. The clinical indications for intra-aortic balloon pump counterpulsation in this setting are discussed.     

Incidence and concomitant factors of tricuspid valve insufficiency in patients with aortic and mitral valve diseases

Invasive data about the frequency and associated factors of tricuspid regurgitation in normals and in patients with aortic and mitral valve disease are still rare. Thus, right ventricular biplane angiograms (RAO/LAO projection), the mean pulmonary artery pressure and the presence of atrial fibrillation were analyzed with regard to tricuspid regurgitation in 30 normals and 165 patients with pure mitral regurgitation, mitral stenosis, aortic regurgitation, aortic stenosis, combined mitral valve disease or combined aortic valve disease. Patients with tricuspid stenosis or coronary artery disease were excluded. In 52 of the 195 patients tricuspid regurgitation was present. Tricuspid regurgitation occurred statistically more often in patients with mitral stenosis (33%), mitral regurgitation (48%) or combined mitral valve disease (68%) than in patients with aortic regurgitation (4%) or combined aortic valve disease (3%). In patients with aortic stenosis and in normals tricuspid regurgitation was not present. In patients with combined mitral valve disease, tricuspid regurgitation was more often present than in patients with pure mitral stenosis (p less than 0.002), despite comparable values of the mean pulmonary artery pressure, the right ventricular enddiastolic and endsystolic volume indexes, the right ventricular ejection fraction and the frequency of atrial fibrillation. Only in patients with pure mitral regurgitation tricuspid regurgitation was associated with an elevated mean pulmonary artery pressure (p less than 0.02). Differences in the right ventricular size and function did not occur between normals and patients with mitral or aortic valve disease. Therefore, the mean pulmonary artery pressure, atrial fibrillation and the size and function of the right ventricle are not major determinants for the occurrence of tricuspid regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral ostial coronary stenosis and rheumatic aortic valve stenosis

A 49-year-old patient presented with angina pectoris and clinical findings of aortic valve stenosis and regurgitation. Rheumatic aortic valve stenosis and regurgitation was diagnosed on echocardiography. Coronary angiography findings showed severe calcification in the aorta root with right coronary ostial occlusion, and were suggestive of left main ostial stenosis and proximal main stem stenosis, which was confirmed on CT angiography. Curvilinear calcification of the aorta was present on CT angiography. The findings suggested syphilitic aortitis. Syphilis serology was positive (RPR titre 1/16). The angina was caused by severe coronary ostial disease likely due to syphilitic aortitis and exacerbated by the rheumatic aortic valve stenosis and regurgitation.     

Angiographic demonstration of blood supply of right atrial myxoma.

A 53-year-old woman underwent cardiac catheterization for assessment of coronary arterial disease. An unexpected finding of a gradient between right atrium and right ventricle led to the discovery of an unsuspected right atrial myxoma. The diagnosis was established by the presence of a filling defect in the right atrial angiocardiogram and by the demonstration of "tumour vessels" by selective right coronary angiography. Selective coronary angiography can visualize the blood supply to an intracardiac tumour and thus confirm the diagnosis preoperatively.     

Bilateral ostial coronary stenosis and rheumatic aortic valve stenosis

A 49‐year‐old patient presented with angina pectoris and clinical findings of aortic valve stenosis and regurgitation. Rheumatic aortic valve stenosis and regurgitation was diagnosed on echocardiography. Coronary angiography findings showed severe calcification in the aorta root with right coronary ostial occlusion, and were suggestive of left main ostial stenosis and proximal main stem stenosis, which was confirmed on CT angiography. Curvilinear calcification of the aorta was present on CT angiography. The findings suggested syphilitic aortitis. Syphilis serology was positive (RPR titre 1/16). The angina was caused by severe coronary ostial disease likely due to syphilitic aortitis and exacerbated by the rheumatic aortic valve stenosis and regurgitation.     

Iatrogenic ostial stenosis of the left coronary artery. Report of a case with Starr-Edwards aortic prosthesis (author's transl)

A case of a 41 years-old-man, who had undergone surgical intervention ten years previously for aortic valve replacement in ECC with the coronary perfusion technique, is reported. This patient was studied because of the appearance of angina pectoris three months after the intervention and its progressive development. Selective left coronary angiography showed an ostial subocclusive stenosis; the run-off from the right coronary artery provided distal blood supply to the left coronary artery. A venous bypass was implanted between the aorta and the left anterior descending branch; the prosthesis was substituted because it was altered and caused hemolysis' problems. In accordance with most Authors late ostial coronary stenosis is a complication of the coronary perfusion technique, which is adopted for myocardial protection during surgical interventions for aortic valve replacement.     

Krypton-81m in the physiologic assessment of coronary arterial stenosis in man.

Fifteen patients with frequent anginal chest pain underwent diagnostic cardiac catheterization. After coronary arteriography a specially designed cardiac catheter was seated in the aortic root, permitting the continuous infusion of krypton-81m into the right and left aortic sinuses. A gamma camera, areas of interest and a visual display unit were used to record images and the regional myocardial equilibrium of activity before, during and after a standarized atrial pacing test. The unique physical properties of krypton-81m allowed the continuous imaging and recording of moment to moment changes in regional myocardial perfusion. This investigation revealed that when the coronary arteriogram was normal or revealed lumonal stenosis of less than 50 percent, regional myocardial perfusion was uniform at rest and during stress. Two patients with a previous history of myocardial infarction had defects of regional perfusion at rest and during stress. Krypton scintigraphy demonstrated reversible regional defects in myocardial perfusion during stress in seven patients with greater than 70 percent stenosis of one or more coronary arteries. Alterations in regional myocardial perfusion occurred within 30 seconds of the start of atrial pacing in all the patients and preceded the onset of electrocardiographic signs of ischemia or chest pain.     

Effect of aortic valve replacement on coronary flow velocity during metabolic stress in a patient with aortic stenosis

The effect of aortic valve replacement on coronary flow velocity during atrial pacing and papaverine-induced-resistance vessel dilatation was tested in a patient with aortic stenosis. Although systolic flow reversal disappeared early after the valve replacement, rapid atrial pacing caused myocardial ischemia with lactate production. The coronary flow reserve also remained depressed. These results suggest that the alteration in the coronary flow profile early after the aortic valve replacement does not reflect an improvement in the flow increase during metabolic stress in a patient with aortic stenosis. Cathet. Cardiovasc. Diagn. 40:287–290, 1997. © 1997 Wiley-Liss, Inc.     

Intracoronary adenosine triphosphate for refractory coronary artery spasm

A 62-year-old woman underwent aortic valve replacement for aortic stenosis. Her hemodynamics deteriorated with ST-T depression 6 hours postoperatively. Emergency coronary catheterization showed diffuse right coronary artery spasm. The spasm persisted despite intracoronary infusion of nitrates and calcium antagonists. Intracoronary adenosine triphosphate infusion finally resolved the spasm and stabilized the cardiac function.     

Acute coronary syndrome of very unusual etiology

Aortitis is one of many possible manifestations of tertiary syphilis. Aortic disease is the most common of all cardiovascular syphilitic lesions. Aortic diseases caused by tertiary syphilis include aortitis, aortic root dilation, aneurysm formation, aortic regurgitation and coronary ostial stenosis. A less common manifestation of syphilitic aortitis is coronary artery ostial narrowing related to aortic wall thickening. We report a case of a 40‐year‐old male patient admitted with a clinical picture of acute coronary syndrome (unstable angina). He had no risk factors for coronary artery disease. The physical examination revealed nothing remarkable. The admission electrocardiogram (ECG) showed ST segment depression in the anterolateral and inferior leads (Figure 1). The coronary angiogram showed critical ostial stenosis of the right (RCA) and left main coronary artery (Figure 2a, b). Cardiac‐computed tomography showed aortic wall thickening with involvement of bilateral coronary ostia (Figure 2b, c). The patient was referred for coronary bypass surgery after treatment with two doses of penicillin G. The laboratory test was strongly positive for syphilitic infection. Postoperative treatment with benzathine penicillin, in doses recommended for tertiary syphilis, was implemented.     

Angina pectoris in a case of Takayasu's disease: revascularization by coronary ostioplasty and bypass grafting

A young man with Takayasu's disease had severe right and leftcoronary ostial stenoses. Severe angina was relieved by operationat which the right coronary ostium was enlarged by a pericardialpatch extending across the stenosis from aorta to coronary artery;the aortic end of a vein graft to the left coronary artery wasattached to this patch. This technique may reduce the risk ofrecurrence of ostial stenosis or of stenosis at graft origins.     

Angina pectoris in a case of Takayasu's disease: revascularization by coronary ostioplasty and bypass grafting

A young man with Takayasu's disease had severe right and leftcoronary ostial stenoses. Severe angina was relieved by operationat which the right coronary ostium was enlarged by a pericardialpatch extending across the stenosis from aorta to coronary artery;the aortic end of a vein graft to the left coronary artery wasattached to this patch. This technique may reduce the risk ofrecurrence of ostial stenosis or of stenosis at graft origins.     

Sténose aortique et lésions coronaires : la fractional flow reserve (FFR) est-elle valide ?

A 54-year-old woman was hospitalized for an acute pulmonary oedema revealing a severe aortic stenosis (AS) associated with an aortic aneurysm and a left ventricular hypertrophy (LVH). The coronary angiography found an equivocal left main lesion. Fractional flow reserve (FFR) showed hemodynamic significance (FFR = 0.78) and optical coherence tomography confirmed this result with a minimal lumen area of 4.9 mm². FFR-guided percutaneous intervention is reported to improve outcome in patients with stable coronary disease. However, only few data are available in cases of AS. In this condition, secondary LVH is associated with microcirculatory dysfunction, which interferes with optimal hyperemia. An elevated right atrial pressure could also modify FFR measurement. This risk of underestimation of a coronary lesion in patients with severe AS has to be taken into consideration in clinical practice.     

Detection of valvar obstruction by intracardiac masses using Doppler echocardiography

The purpose of this paper was to examine valvar involvement in patients with intracardiac masses. Seven patients with intracardiac masses were studied by cross-sectional and Doppler echocardiography. In one, a candida vegetation on a mitral Starr-Edwards prosthesis obstructed the aortic valve with a peak transvalvar velocity of 2 m/sec and aortic regurgitation. Another patient with endocarditis demonstrated mitral stenosis as did two patients with left atrial myxomata. Tricuspid stenosis was demonstrated in three patients with right ventricular intracardiac masses (primary and secondary tumour and thrombus). By Doppler, the mitral and tricuspid stenosis was similar to from that seen in rheumatic heart disease with increased peak transvalvar velocity and prolonged pressure half-time. Because of the hazards associated with cardiac catheterisation in intracardiac masses, we conclude that Doppler ultrasound allows for the adequate assessment of the haemodynamic alterations so as to complement the images obtained by cross-sectional echocardiography.     

Combined percutaneous aortic valvuloplasty and transluminal coronary angioplasty in adult patients with calcific aortic stenosis and coronary artery disease

Of 120 consecutive balloon aortic valvuloplasty procedures for critical aortic stenosis, valvuloplasty was performed in combination with coronary angioplasty in nine patients (average age 76 years). All nine patients were symptomatic with angina and congestive heart failure before combined procedures. Aortic valvuloplasty was performed with 20 to 23 mm balloon catheter advanced retrogradely from the femoral artery and resulted in an improvement in peak aortic valve gradient (60 +/- 19 to 33 +/- 13 mm Hg; p less than or equal to .01) and calculated aortic valve area (0.7 +/- 0.1 to 1.1 +/- 0.3 cm2; p less than or equal to .01). Single-vessel coronary angioplasty was performed via the femoral approach, with 2.0 to 3.5 mm balloon catheters, and resulted in a mean reduction of a critical coronary stenosis in each patient from 91 +/- 4% to 29 +/- 8%. The site of coronary angioplasty was the left anterior descending artery in three patients, the circumflex artery in three patients, the right coronary artery in two patients, and a bypass graft to the right coronary artery in one patient. Combined procedures were performed with a mean arterial time of 108 min. Complications included groin hematomas (n = 2), transient left bundle branch block (n = 1), and transient atrial fibrillation (n = 1). No patient experienced prolonged chest pain, myocardial infarction, major increase in aortic insufficiency, or embolic phenomena. Eight of the nine patients treated with combined procedures noted significant improvement in symptoms of angina and congestive heart failure and were discharged.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute coronary occlusion during radiofrequency catheter ablation of typical atrial flutter

We report the first case of acute right coronary artery occlusion in an adult patient during radiofrequency catheter ablation of typical atrial flutter. ST segment elevation rapidly resolved with antithrombotic therapy. This complication was thought to be due to the short distance between the endocardium and the right coronary artery at the ablation site, the high-wattage output from the radiofrequency generator, and the lack of sufficient cooling effect related to a severe upstream coronary stenosis. In patients with known right coronary artery stenosis who are suffering from typical atrial flutter, evaluation of the significance of the stenosis would be reasonable.     

Right coronary artery stenosis: An independent predictor of atrial fibrillation after coronary artery bypass surgery

Objectives. This study attempted to determine the importance of severe proximal right coronary artery disease as a predictor of atrial fibrillation in patients after coronary artery bypass surgery.Background. Studies in patients undergoing noncardiac surgery have suggested that ischemia in the right coronary artery distribution is associated with a high incidence of atrial fibrillation. However, the importance of right coronary artery disease as a predictor of atrial fibrillation after bypass surgery is unknown.Methods. The occurrence of sustained postoperative atrial fibrillation was studied prospectively in 168 consecutive patients undergoing coronary artery bypass grafting. Patients were followed up postoperatively until discharge. Severe right coronary artery stenosis was defined as ≥70% lumen narrowing.Results. Of 104 patients with proximal or mid right coronary artery stenosis, 45 (43%) had atrial fibrillation postoperatively compared with 12 (19%) of the 64 patients without significant right coronary disease (p = 0.001). Univariate predictors of atrial fibrillation included right coronary artery stenosis (p = 0.001), advancing age (p = 0.0001) and lack of beta-adrenergic blocking agent therapy after bypass surgery (p = 0.0004). Multivariate adjusted risk of developing atrial fibrillation after bypass surgery increased with the presence of severe right coronary artery disease (odds ratio 3.69, 95% confidence interval [CI] 1.61 to 8.48), advancing age (odds ratio 2.24/10 years, CI 1.48 to 3.41) and male gender (odds ratio 2.36, CI 1.01 to 5.49). The use of beta-blockers postoperatively was associated with a protective effect (odds ratio 0.4, CI 0.17 to 0.80).Conclusions. The presence of severe right coronary artery stenosis is an independent and powerful predictor of atrial fibrillation after coronary artery bypass surgery. In association with age, gender and postoperative beta-blocker therapy, these variables can be used to identify patients at increased risk for developing this arrhythmia.     

Combined percutaneous balloon dilatation of the aortic valve and coronary angioplasty

A 75 year old man with severe angina caused by aortic stenosis and coronary artery disease was considered to be unsuitable for cardiac surgery after the recent removal of a bronchial carcinoma. Combined percutaneous balloon dilatation of the aortic valve and right coronary angioplasty considerably ameliorated the patient's angina.     

Combined percutaneous balloon dilatation of the aortic valve and coronary angioplasty.

A 75 year old man with severe angina caused by aortic stenosis and coronary artery disease was considered to be unsuitable for cardiac surgery after the recent removal of a bronchial carcinoma. Combined percutaneous balloon dilatation of the aortic valve and right coronary angioplasty considerably ameliorated the patient's angina.