Systolic total narrowing of left anterior descending coronary artery and flow interruption secondary to myocardial bridge: a rare case report and review of literature

A 33-y-old man was admitted to the emergency department with sudden onset of severe substernal chest pain radiating to the left arm and neck. No pathological signs were recorded upon physical examination. The admission electrocardiogram (ECG) recorded during chest pain showed a large anterior wall myocardial infarction. Intravenous (IV) infusion of 1.5 million units of streptokinase over 1 h was initiated. Coronary angiography revealed total narrowing and flow interruption in the midsegment of the left anterior descending (LAD) coronary artery secondary to a myocardial bridge during systole and disappearance with diastole. He was discharged on aspirin (300 mg/d), metoprolol (100 mg/d), enalapril (10 mg twice daily), and atorvastatin (40 mg/d) treatment at the follow-up period.     

Dual left anterior descending coronary artery (dual lad)

Presence, extent, and evolution of atherosclerotic coronary narrowings, as well as the anatomic possibilities for revascularization, can be reliably defined at (and only at) selective coronary angiography. The latter remains, therefore, the pivotal diagnostic tool for patients with suspected coronary artery disease. However, in spite of the increasing availability of on-line quantitative coronary angiography, it still holds that the functional (physiologic) consequences of an epicardial coronary narrowing cannot be completely derived from geometric (anatomic) information. Clinical decision making can be particularly difficult in lesions of intermediate severity (40–70% diameter reduction), in postinterventional segments, and in some particular anatomic settings, namely, ostial stenoses, bifurcation lesions, and diffuse atherosclerotic disease. This has led to an explosive growth of new methods for assessing the physiological significance of coronary narrowings documented at angiography. Among them, Doppler blood flow velocitometry and transstenotic pressure gradient measurements have emerged as the only techniques easily applicable in most catheterization laboratories. Here, we briefly review the clinical interest of measuring transstenotic pressure gradients. © Wiley-Liss, Inc.     

Simultaneous transesophageal Doppler assessment of coronary flow reserve in the left anterior descending artery and coronary sinus allows differentiation between proximal and non-proximal left anterior descending artery stenoses.

AIM AND METHODS: The role of simultaneous transesophageal Doppler assessment of coronary flow reserve (CFR) in the left anterior descending artery (LAD) and coronary sinus (CS) in the diagnostics of hemodynamically significant LAD stenoses of various localization was studied in 16 CAD patients with angiographically proven >50% stenotic atherosclerosis of the LAD (nine--in the proximal third, seven--in the mid and/or distal third) and 23 healthy volunteers (all men). Dipyridamole was used as a stress agent. The diastolic phase of coronary flow in the LAD and the antegrade phase of coronary flow in the CS were analyzed. CFR in the LAD and CS was calculated in two ways: one--as ratio of peak hyperemic flow velocity to the peak baseline blood flow velocity (CFR by Vp); two--as ratio of volume hyperemic blood flow velocity to the volume baseline blood flow velocity (CFR by VBF). The level of the CFR <2 in both ways of calculation was diagnosed as reduced. RESULTS: It was found that in CAD patients with LAD proximal stenosis the values of CFR in the LAD were significantly lower than those in healthy individuals by both Vp (1.87 +/- 0.43 and 3.54 +/- 0.82; P<0.001) and VBF (1.79 +/- 0.77 and 3.85 +/- 1.25; P<0.01). In proximal stenosis CFR in the LAD by Vp was significantly lower than that in non-proximal stenosis (1.87 +/- 0.43 and 3.31 +/- 1.44; P<0.05). Sensitivity and specificity of CFR <2 in the LAD by Vp in the diagnostics of LAD proximal stenosis were 56% and 97%, respectively; and CFR <2 in the LAD by VBF--89% and 93%, respectively. In CAD patients with both proximal and non-proximal LAD stenoses CFR in the CS by Vp was significantly lower than that in healthy volunteers and was 1.74 +/- 0.53, 1.63 +/- 0.30 and 2.56 +/- 0.87; P<0.05, respectively. Sensitivity and specificity of CFR <2 in the CS by Vp in the diagnostics of hemodynamically significant LAD stenoses were 75% and 70%, respectively. The values of CFR in the CS by VBF in CAD patients and healthy volunteers did not differ significantly. CONCLUSIONS: Thus, simultaneous evaluation of CFR in the LAD and CS makes it possible to diagnose hemodynamically significant LAD stenoses and to differentiate between proximal and non-proximal impairments.     

Feasibility of measuring coronary flow velocity and reserve in the left anterior descending coronary artery by transthoracic Doppler echocardiography in a relatively obese American population

BACKGROUND: Transthoracic Doppler echocardiography (TTDE) assessment of coronary flow velocity reserve (CFVR) has been validated in Asian and European centers. This methodology has not gained acceptability in the United States due to the bias that coronary flow velocity (CFV) by TTDE might be difficult in an obese population with relatively poor acoustic windows. METHODS: Baseline CFV in the left anterior descending coronary artery (LAD) by TTDE was obtained in 67 nonselected American patients. A subset of 38/67 received adenosine infusion for measuring CFVR of the LAD. PURPOSE: The aim of this study was twofold: (1) to determine the feasibility of measuring CFV and CFVR in the LAD by TTDE in a relatively obese American population, and (2) to compare CFV and CFVR values in this population with those previously obtained in a group of Japanese patients. RESULTS: The mean body mass index (BMI) of the American population (28 +/- 6 kg/m2, range: 18-46 kg/m2) was significantly higher than that of the Japanese group (23 +/- 4 kg/m2, range: 15-37 kg/m2). Twenty-five American patients were classified as obese (BMI >30 kg/m2). Baseline CFV was obtained in 60/67 patients (feasibility: 90%) with a 10% need for intravenous contrast agent to enhance the delineation of the CFV envelope. The success rate in recording CFVR in American patients (92%) was nearly identical to that of a Japanese group (99%). The time-averaged peak diastolic coronary flow velocity increased from 15.6 +/- 5.5 cm/sec at baseline to 47.1 +/- 17.9 cm/sec during adenosine infusion, and CFVR was calculated to be 3.22 +/- 1.15 (range: 0.94-5.69). Intraobserver and interobserver variability for the CFV recording was 4.7 and 6.2%, respectively. CONCLUSIONS: These results suggest that the noninvasive measurement of CFV and CFVR of the LAD is feasible even in a relatively obese American population. Furthermore, the success rates for recording CFV and CFVR are similar to those measured in a Japanese population. This methodology has the potential to provide useful physiological information on the coronary circulation in American patients.     

经胸多普勒超声冠状动脉血流储备检查诊断左前降支显著狭窄

目的比较经胸多普勒超声冠状动脉血流储备（CFR）指标诊断左前降支（LAD）显著狭窄的临床价值。方法连续120例怀疑冠心病的患者于冠状动脉造影（CAG）前一天进行双嘧达莫（0．56mg／kg）负荷试验，测定LAD的CFR指标，包括收缩期最大冠状动脉血流储备（SCFRpeak）、收缩期平均冠状动脉血流储备（SCF Rmean）、收缩期流速时间积分储备（SCFRVTI）、舒张期最大冠状动脉血流储备（DCFRpeak）、舒张期平均冠状动脉血流储备（DCFRmean）和舒张期流速时间积分储备（DCFRVTI）。结果82例获得LAD血流频谱，按照CAG结果分为LAD显著狭窄组（A组，≥70％狭窄，n=16）和LAD非显著狭窄组（B组，〈70％狭窄，n=66）。A组患者各项CFR指标均显著低于B组。ROC曲线法分析显示，DCFRmean〈1．825诊断LAD显著狭窄的敏感性和特异性相对较高。结论经胸多普勒超声评价CFR有助于检出LAD显著狭窄，DCFRmean〈1．825是较好的判别指标。     

Comparison of transesophageal coronary sinus and left anterior descending coronary artery doppler measurements for the assessment of coronary row reserve

Background: Currently used methods for assessment of coronary flow reserve are invasive and require extensive laboratory equipment. Recently, noninvasive assessment of coronary flow reserve by transesophageal Doppler evaluation of coronary sinus (CS) or left anterior descending coronary artery (LAD) flow has been proposed. Direct comparison between these two techniques is lacking. Methods: Doppler recordings of CS and LAD flow velocity were obtained before and after 0.6 mg/kg/5 min dipyridamole in 16 patients with significant stenosis of the LAD (Group A) and in 14 control patients (Group B). Flow recordings and all measurements were performed in a blinded manner. For assessment of coronary flow reserve, Doppler measurements after dipyridamole were divided by the respective baseline values. Results: Doppler studies of the CS and LAD were feasible in 30 of 30 (100%) and 23 of 30 (71%) patients, respectively. Analyzing the maximum flow velocities, coronary flow reserve in Groups A and B was 1.18 ± 0.28 and 1.68 ± 0.53 with CS recordings and 1.78 ± 0.83 and 2.51 ± 0.76 with LAD recordings, respectively. Analyzing the velocity time integrals, coronary flow reserve in Groups A and B was 1.53 ± 0.68 and 2.59 ± 0.74 with CS recordings and 1.77 ± 0.38 and 2.68 ± 0.93 with LAD recordings, respectively. Correlation between LAD and CS recordings was 0.69 (p<0.001), when coronary flow reserve was calculated from the velocity time integral and 0.68 (p<0.001) when the maximum flow velocities were used. Conclusion: Both transesophageal Doppler techniques might be useful for noninvasive assessment of coronary flow reserve.     

Anomalous origin of the right coronary artery from the left anterior descending coronary artery: a case report.

We report on a 59-year-old man with effort angina of recent onset and a very uncommon right coronary artery originating from the middle portion of the left anterior descending; a tight stenosis of the left anterior descending coronary artery was also detected which involved the origin of the aberrant vessel.     

Iatrogenic fistula between the left anterior descending coronary artery and anterior interventricular vein following stenting

We describe the case of a 61-year-old male who had a critical stenosis of the left anterior descending artery (LAD). Intravascular ultrasound demonstrated that the LAD was attached to a large anterior interventricular vein (AIV). After stenting, a fistula was noted between the LAD and AIV, which was successfully sealed by deploying a covered stent. To our knowledge, this is the first case of iatrogenic arteriovenous fistula between the LAD and AIV that occurred following stenting of the LAD.     

经胸彩色多普勒检测冠心病患者冠状动脉左前降支和右冠状动脉远端血流储备

目的评价经胸彩色多普勒超声心动图(TTDE)检测冠状动脉前降支(LAD)和右冠状动脉后降支(PDA)血流储备和开放程度的可行性。方法65例(男48例,女17例)连续临床诊断或疑似冠心病患者,平均年龄(58±14)岁,左室射血分数(49±8)%,用TTDE冠状动脉显像方式于心尖两腔切面显示LAD和PDA远端的血流,在基础状态和持续静脉注射腺苷(140μg·kg-1·min-1)情况下分别测定其冠状动脉血流储备(CFR),结果与冠状动脉造影对比。结果所有患者基础和充血状态LAD血流均得到显示(其中4例应用造影剂),55例患者PDA得到显示(5例应用造影剂),有2例患者PDA闭塞,因此LAD的检测成功率为100%(65/65),PDA的CFR检测成功率为87%(55/63),所有患者腺苷静脉注射时间均少于4min,CFR检测平均时间为(7.3±1.6)min。以CFR≤2.0和CFR≤1.8分别作为判断冠状动脉狭窄(≥50%)和显著狭窄(≥70%)的标准,准确性相近,诊断LAD和RCA狭窄的灵敏度、特异度和ROC曲线下面积分别为89%/93%,86%/84%,0.89/0.92,诊断显著狭窄的灵敏度、特异度和ROC曲线下面积分别为88%/89%,90%/83%,0.94/0.95。结论经胸多普勒超声心动图检测LAD和PDA成功率和诊断冠状动脉狭窄的准确性均较高,有重要临床价值。     

Absence of left anterior descending coronary artery associated with anomalous origin of left circumflex coronary artery from the right coronary artery: a case report and review

In this report we present a case of a 30-year-old female patient with a single coronary artery, which consisted of a right coronary artery from which there was an anomalous origin of the left circumflex coronary artery. There was no left anterior descending coronary artery. The clinical and other noninvasive diagnostic features of this rare angiographic variant are described and compared to other known varieties of coronary anomalies. The absence of objective evidence of ischemia or left ventricular functional impairment and analysis of the angiographic data suggest that this is another benign variant of coronary anatomy.     

Giant left main pseudoaneurysm obstructing the left anterior descending coronary artery demonstrated by transesophageal echocardiography and coronary angiography

Left main pseudoaneurysm is a rare angiographic finding in young adults. We describe a 23-year-old male who presented with an acute anterior wall myocardial infarction. Coronary angiography and transesophageal echocardiography reveal a huge aneurysm of the distal left main obstructing the left anterior descending artery (LAD), which was defined by history as a pseudoaneurysm. The pseudoaneurysm was successfully resected and mammary artery was used to repair the distal left main and to bypass the LAD. © 1993 Wiiey-Liss, Inc.     

Anomalous origin of the right coronary artery from the left anterior descending artery in a patient with single left coronary artery: a rare coronary artery anomaly and review of the literature

A 44-year-old woman with hypertension was admitted because of recent onset chest pain. Coronary angiography revealed an anomalous right coronary artery originating as a separate branch from the left anterior descending artery. Associated with the present case all published case reports were thoroughly investigated and presented as a review of the literature.     

Distortion of the left anterior descending coronary artery after pulmonary valve replacement

Injury of the left main coronary artery may sometimes complicate a pulmonary valve replacement (PVR). We present the case of a 39‐year‐old man, with post‐operative distortion of the left anterior descending coronary artery, which caused onset of ventricular arrhythmia associated with electrocardiographic signs of myocardial ischemia. A coronary angiogram revealed the cause of the lesion. Stenting the coronary artery restored normal coronary blood flow and improved the patient's condition. Through this case, we describe a new life‐threatening complication after PVR. © 2015 Wiley Periodicals, Inc.