Coronary ostial stenosis: surgical considerations

To investigate the clinical significance of coronary ostial stenosis, we reviewed eight patients with such lesions, including three with isolated stenosis at the orifice of the coronary artery. There were five male and three female patients, with an average age of 46.25 years (range 32–69 years). Their symptoms consisted mainly of angina (6 patients), with dyspnoea and palpitation being the presenting features in the remaining two patients. All patients underwent preoperative coronary angiography which confirmed stenosis at the level of the orifice with absence of reflux of contrast medium into the sinus of Valsalva as the main features. Delay in the appreciation of stenosis of the orifice of the right coronary artery resulted in the death of two patients, whose diagnosis was confirmed at post mortem examinations. Stenosis of the orifice of the right coronary artery was present in seven patients, with two patients also having stenosis of the orifice of the left coronary artery. The remaining patient had isolated stenosis of the left coronary arterial orifice. Coronary artery bypass grafting was performed in five patients, including two who had patch angioplasty to the right coronary artery. The patient with isolated stenosis of the orifice of the left coronary artery had patch angioplasty only. Follow-up of up to three years in the surviving patients showed good functional results. The ease with which it is possible to miss right coronary ostial stenosis is emphasized and angiographic features are reviewed.     

Variant angina pectoris: a clinical and coronary arteriographic spectrum

The clinical course and coronary arteriographic findings in eight patients with Prinzmetal's variant angina pectoris are reviewed and contrasted to previously reported cases. In six patients with S-T-elevation inferiorly, three had normal coronary arteriograms, one had complete right coronary artery occlusion, one had diffuse triple-vessel disease, and one did not undergo coronary arteriography. In two patients with S-T-elevation anteriorly, severe stenosis of the anterior descending coronary artery was present. Medical treatment in four patients and surgical revascularization of the anterior descending coronary artery in two patients were both accompanied by marked symptomatic improvement. Spontaneous loss of angina occurred in two patients. During 17 months' mean follow-up, seven patients have remained free of angina and one died suddenly. Variant angina pectoris may be accompanied by a variety of coronary arteriographic findings and the prognosis appears more favorable than previously reported.     

Noninvasive visualization of coronary arterial aneurysm in infants and young children with mucocutaneous lymph node syndrome with two dimensional echocardiography

Real time two dimensional echocardiographic studies of the main coronary arteries were performed in 30 normal subjects and 58 patients with the mucocutaneous lymph node syndrome. Four echocardiographic coronary arterial patterns were observed: linear, dilated, fusiform or spherical. In normal subjects the left main coronary artery generally had a linear pattern but had a dilated pattern in two patients. The right coronary artery could not be visualized clearly. In 7 of the 58 patients with the mucocutaneous lymph node syndrome, a portion of the left main coronary artery had a fusiform or spherical pattern, or both, and the stem of the right coronary artery also had a spherical pattern in 2 patients. In all five patients who had coronary angiography, the procedure confirmed an aneurysm in the left main coronary artery or its branching point and the stem of the left anterior descending coronary artery or the stem of the right coronary artery, or both. In three of the five patients, coronary arterial aneurysms were predicted before coronary angiography was performed. Thus, two dimensional echocardiography is a reliable noninvasive method for evaluating coronary arterial aneurysms in infants and young children.     

Clinical course of patients with coronary ectasia.

OBJECTIVE: To compare the clinical prognosis between patients with diffuse coronary ectasia and those with localized coronary ectasia. DESIGN: Patients with coronary ectasia were divided into two groups based on the Markis classification (group D: types I-III and group L: type IV), and the clinical manifestations and prognosis were compared between the two groups. RESULTS: Group D patients (52.1 +/- 4 years) were significantly younger than group L patients (62.5 +/- 7 years). During the study, 4 patients in group D died suddenly. Three of the patients had type I coronary ectasia, and 1 had left main coronary ectasia. CONCLUSION: The results of the present study indicate that patients with diffuse coronary ectasia and left main coronary ectasia should be followed carefully.     

Morphology of ambulatory ST segment changes in patients with varying severity of coronary artery disease. Investigation of the frequency of nocturnal ischaemia and coronary spasm

The frequency and magnitude of objectively determined myocardial ischaemia during normal daily activities of patients with varying severity of coronary artery disease are unknown. Furthermore, the incidence of nocturnal resting myocardial ischaemia and frequency of coronary spasm in patients with normal coronary arteries and chest pain are also not known. One hundred consecutive patients with chest pain referred for coronary angiography were therefore investigated with exercise testing and ambulatory ST segment monitoring. Fifty two of 74 patients with significant coronary artery disease and six of 26 with no significant coronary narrowing had episodes of ST segment change during 48 hours of ambulatory monitoring. Two patients, one with normal coronary arteries and localised spasm and one with three vessel disease, had episodes of ST segment elevation, whereas all other patients had episodes of ST segment depression. The frequency, duration, and magnitude of ST segment changes were greater in patients with more severe types of coronary artery disease. Thus more than six episodes of ST segment change per day occurred in patients with two or three vessel disease or left main stem stenosis and in the only patient with coronary spasm and normal coronary arteries. Nocturnal ischaemia occurred in 15% of patients with coronary artery disease and was almost an invariable indicator of two or three vessel coronary artery disease or left main stem stenosis. Episodes of ST segment change occurred most commonly during the morning hours and least commonly during the night, in parallel with changes in basal hourly heart rates. The heart rate at the onset of ST segment change tended to be lower in patients with coronary artery disease than in those with normal coronary arteries. The duration of exercise to ST segment depression tended to be shorter in patients with more severe disease, but it could not predict patients with nocturnal myocardial ischaemia, left main stem stenosis, or coronary spasm, whereas ambulatory ST segment monitoring was able to identify most of these patients.     

双支冠脉慢性闭塞病变介入治疗的效果

目的:观察和分析双支冠状动脉慢性闭塞病变患者的临床和病变特点及介入治疗的效果,提高危重冠心病患者的介入治疗成功率和生存率。方法: 选取2006年1月～2009年1月住院经冠脉造影检查证实两支冠脉慢性闭塞并行经皮冠脉介入治疗( PCI)的患者104例,分为3组,A组:右冠状动脉+左冠状动脉前降支闭塞,33例;B组:右冠状动脉+左冠状动脉回旋支闭塞,30例;C组:左冠状动脉前降支+回旋支闭塞,41例。对患者临床资料、PCI结果、并发症、心功能和随访期间主要心血管不良事件(major adverse coronary events,MACE)等进行回顾性分析。结果: 各组PCI再通率高（双支开通率占96%）,并发症少,术中无死亡病例,术后住院期间无MACE发生,无患者进行急诊冠状动脉旁路移植术(CABG)。术后各组心功能（左室射血分数）均较术前有显著的改善［A组:(36±8)% vs. (47±9)%,P<0.01;B组:(41±8)% vs. (51±8)%,P<0.01;C组:(36±7)% vs. (45±8)%,P<0.01］。术后MACE发生率1年随访结果显示:C组MACE发生率高于A组或B组(P<0.05),而A组和B组间无统计学差异。结论: PCI治疗双支冠脉慢性闭塞病变并发症少,双支同时开通成功率高,左前降支和左旋支闭塞介入治疗MACE较其它组高,但PCI治疗可显著提高重症冠状动脉闭塞患者的心功能,改善长期临床预后。     

选择性冠脉造影术并发心室颤动的原因及预防对策

目的：分析选择性冠状动脉造影（SCA）术中发生心室颤动（VF）的原因及其预防措施。方法：回顾性分析5050例SCA术中发生VF病例的资料。结果：SCA术中,7例发生VF（均为右冠造影时）,其中桡动脉造影5例;用5F Terumo TIG造影导管4例;三支冠脉病变2例、双支冠脉病变1例;右冠脉发育细小3例、导管进入窦房结动脉1例、导管插入过深2例;5例患者存在不同程度造影剂滞留现象;5例患者发生VF前首先表现为冠脉内压力下降,2例无冠脉内压力下降。所有患者均1次电复律成功。结论：右冠细小、造影剂滞留、器材选择及操作不当是冠脉造影发生室颤的主要原因,充分认识并避免之可防止VF发生。     

无预扩张直接冠状动脉内支架置入术20例临床观察

目的：探讨无预扩张直接冠状动脉内支架置入术的可行性、临床效果及其优越性。方法：将46例冠心病病人随机分为无预扩张直接冠状动脉内支架置入术组(观察组)20例，与传统的经球囊预扩张后冠状动脉内支架置入术组(对照组)26例进行对比分析。结果：两组病人手术操作成功率相似，均能获得满意的支架置入后冠状动脉造影结果；缓解心绞痛的效果两组无差异：随访期间两组均未发生死亡、急性心肌梗死等心脏急性事件；但观察组可缩短手术时间34．87％，减少X线曝光时间26．76％，减少造影剂用量35．80％，降低治疗费用27．62％。结论：无预扩张直接冠状动脉内支架置入术是一种安全有效的治疗方法，在某些方面优于传统的经球囊预扩张后冠状动脉内支架置入术。     

Coronary artery to pulmonary artery fistulas.

Twelve patients with a total of 14 coronary artery to pulmonary artery fistulas were discovered at the time of diagnostic coronary angiography. Six patients had severe coronary artery disease, five patients had normal coronary arteriography, one patient had insignificant coronary artery disease, and one patient had rheumatic heart disease. Only two patients had characteristic continuous murmurs; one patient had a normal coronary angiogram, and the second patient had severe coronary artery disease. Ten fistulas originated from the left anterior descending artery, three from the right coronary artery, and one from the left circumflex artery. The fistulas were either composed of one large (five fistulas) or one or more small channels (seven fistulas) or poorly defined plexiform channels (two fistulas). Hydrogen studies performed in two patients were negative and dye dilution curves performed in all patients were normal. In only four out of the six patients with severe coronary artery disease, the fistulas originated from a diseased vessel and in each case the origin was proximal to the narrowing. The pathogenesis and functional role of these fistulas is largely unknown.     

Spontaneous and catheter-induced secondary coronary artery dissection: a single-centre experience

6497 consecutive patients who underwent coronary angiography in our institution in a three-year period were analysed. Spontaneous coronary artery dissection was noted in five, and unexpected dissection secondary to coronary arteriography in three patients. All patients with spontaneous dissection presented clinically as myocardial infarction. Three patients (two of them with spontaneous dissection) underwent urgent coronary artery bypass grafting. Percutaneous coronary intervention was successful in two patients with spontaneous and in one with unexpected secondary dissection. One patient with spontaneous and one with secondary dissection were treated medically after failed intervention. In conclusion, spontaneous coronary artery dissection is rare, but not exceptional. Its true incidence might have been underestimated before the advent of coronary interventions in acute myocardial infarction. Survival of all our patients, in contrast to earlier reports on mortality rates up to 50%, may be attributed to the benefits of modern surgery and interventional cardiology.     

Morphology of ambulatory ST segment changes in patients with varying severity of coronary artery disease. Investigation of the frequency of nocturnal ischaemia and coronary spasm.

The frequency and magnitude of objectively determined myocardial ischaemia during normal daily activities of patients with varying severity of coronary artery disease are unknown. Furthermore, the incidence of nocturnal resting myocardial ischaemia and frequency of coronary spasm in patients with normal coronary arteries and chest pain are also not known. One hundred consecutive patients with chest pain referred for coronary angiography were therefore investigated with exercise testing and ambulatory ST segment monitoring. Fifty two of 74 patients with significant coronary artery disease and six of 26 with no significant coronary narrowing had episodes of ST segment change during 48 hours of ambulatory monitoring. Two patients, one with normal coronary arteries and localised spasm and one with three vessel disease, had episodes of ST segment elevation, whereas all other patients had episodes of ST segment depression. The frequency, duration, and magnitude of ST segment changes were greater in patients with more severe types of coronary artery disease. Thus more than six episodes of ST segment change per day occurred in patients with two or three vessel disease or left main stem stenosis and in the only patient with coronary spasm and normal coronary arteries. Nocturnal ischaemia occurred in 15% of patients with coronary artery disease and was almost an invariable indicator of two or three vessel coronary artery disease or left main stem stenosis. Episodes of ST segment change occurred most commonly during the morning hours and least commonly during the night, in parallel with changes in basal hourly heart rates. The heart rate at the onset of ST segment change tended to be lower in patients with coronary artery disease than in those with normal coronary arteries. The duration of exercise to ST segment depression tended to be shorter in patients with more severe disease, but it could not predict patients with nocturnal myocardial ischaemia, left main stem stenosis, or coronary spasm, whereas ambulatory ST segment monitoring was able to identify most of these patients.     

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 Artery Complications after Right Ventricular Outflow Tract Reconstruction Surgery

Background: Mechanisms and clinical manifestations of coronary artery complications after right ventricular outflow tract reconstruction surgery are not well known. Methods: Patients who had coronary artery complications after pulmonary valve replacement or the Rastelli procedure at a single tertiary centre were retrospectively analysed. Results: Coronary artery complications were identified in 20 patients who underwent right ventricular outflow tract reconstruction surgery. The median age at diagnosis of coronary artery complication was 21 years (interquartile range: 13–25 years). Mechanisms of coronary artery complications were compression by adjacent materials in 12 patients, dynamic compression of intramural course of coronary artery in two patients, and intraoperative injury in six patients. Congenital coronary artery anomalies were identified in 50% (10/20) of patients. Four patients presented with early postoperative haemodynamic instability. Fourteen patients showed late onset symptoms or signs of coronary insufficiency, including chest pain, ventricular dysfunction, or ventricular arrhythmias. Coronary artery stenosis was incidentally found on cardiac computed tomography angiography in two asymptomatic patients. Four patients underwent surgical interventions, and one patient underwent percutaneous coronary intervention for coronary stenosis. One patient with recurrent ventricular tachycardia required an implantable cardioverter-defibrillator. There were two deaths in patients with intraoperative coronary injury. Conclusion: Preoperative coronary evaluation and long-term follow-up for the development of coronary artery complications are required in patients undergoing right ventricular outflow tract reconstruction surgery to prevent ventricular dysfunction, arrhythmias, and death, especially among those with congenital coronary anomalies.     

Hypertrophic obstructive cardiomyopathy and coronary artery spasm.

Three patients had hypertrophic obstructive cardiomyopathy and coronary artery spasm. The clinical diagnosis of hypertrophic obstructive cardiomyopathy, in all patients, was confirmed by echocardiography and angiography. Significant spasm of the right coronary artery was demonstrated in each patient by selective coronary arteriography. One patient had atherosclerotic obstructive three vessel disease, while the other two showed no evidence of any fixed organic narrowing of the coronary arteries. ST segment elevation in the inferior ECG leads was documented in two of the patients in association with coronary spasm.     

Induction of coronary artery spasm by intracoronary acetylcholine: comparison with intracoronary ergonovine.

To investigate the mechanism of coronary spasm, we compared the action of acetylcholine with that of ergonovine in 11 patients with vasospastic angina (group 1) and in 15 patients with chest pain (group 2). Coronary arteriography was performed immediately after the patients received intracoronary injections of titrated increments of each agent. In the patients in group 1 occlusive or near-occlusive (99% luminal narrowing) coronary spasm associated with angina and ischemic electrocardiographic ST changes was noted in nine of 11 patients receiving acetylcholine and in all 11 patients receiving ergonovine. The region and the degree of the most severe coronary spasm on coronary arteriograms evoked by the two agents were the same in nine of the 11 patients in group 1. In the other two patients in group 1, spontaneous focal coronary spastic stenosis in the baseline coronary arteriogram was relieved by the intracoronary injection of acetylcholine, and a focal coronary occlusive spasm in the same region was induced repeatedly by the subsequent intracoronary injection of ergonovine (paradoxic phenomenon). In contrast, occlusive or near-occlusive coronary spasm was not induced by either agent in any patient in group 2. These results suggest that the two provocative tests for coronary spasm that involve acetylcholine and ergonovine are clinically useful in the diagnosis of vasospastic angina, but testing with intracoronary ergonovine is needed when a spontaneous focal coronary spasm is relieved by the intracoronary injection of acetylcholine. The results also indicate that in many patients with vasospastic angina, nonspecific hypersensitivity to acetylcholine or ergonovine in a definite region of the coronary arteries generally plays an important role in the induction of coronary spasm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diabetes is a predictor of coronary artery stenosis in patients hospitalized with heart failure

In patients with heart failure, coronary artery disease is the most common underlying heart disease, and is associated with increased mortality. However, estimating the presence or absence of coronary artery disease in patients with heart failure is sometimes difficult without coronary imaging. We reviewed 155 consecutive patients hospitalized with heart failure who underwent coronary angiography. The patients were divided into two groups: patients with (N = 59) and without (N = 96) coronary artery stenosis. The clinical characteristics and blood sampling data were compared between the two groups. The patients with coronary artery stenosis were older than those without. The prevalence of diabetes mellitus (DM), dyslipidemia and a history of revascularization was higher in the patients with coronary artery stenosis. Patients with coronary artery stenosis tended to have wall motion asynergy more frequently than those without. On the other hand, the prevalence of atrial fibrillation (AF) was lower in patients with coronary artery stenosis. The serum hemoglobin level and estimated glomerular filtration rate were lower in patients with coronary artery stenosis than in those without. In the multivariate analysis, DM (odds ratio 3.517, 95 % CI 1.601–7.727) was found to be the only the predictor of the presence of coronary artery stenosis in patients with heart failure. In conclusion, coronary imaging is strongly recommended for heart failure patients with DM to confirm the presence of coronary artery stenosis.     

Detection of coronary artery disease by two-dimensional echocardiography and transesophageal atrial pacing

Two-dimensional echocardiography was performed at rest and during rapid transesophageal atrial pacing in 85 patients undergoing coronary arteriography for evaluation of chest pain. Transesophageal atrial pacing was performed with 10 ms pulses of 6 to 27 mA intensity; the rate was progressively increased up to 150 beats/min. Four patients were excluded: two because atrial capture was not achieved and two because of chest discomfort induced during transesophageal atrial pacing. Of the remaining 81 patients, 56 had significant coronary artery disease (greater than or equal to 75% stenosis of at least one major coronary vessel) and 25 had no significant coronary artery disease; 25 of the 56 patients with coronary artery disease had no wall motion abnormalities at rest. The test was considered positive if wall motion abnormalities were detected during pacing. Wall motion abnormalities occurred in 3 of 25 patients without coronary artery disease (specificity 88%) and in 51 of 56 patients with coronary artery disease (sensitivity 91%). Wall motion abnormalities developed in 20 of the 25 patients with coronary artery disease and normal regional wall motion at rest (sensitivity 80%); sensitivity for one, two and three vessel disease was 85% (17 of 20 patients), 94% (15 of 16 patients) and 95% (19 of 20 patients), respectively. In patients without coronary artery disease, wall motion score was 18 at rest and 17.7 +/- 0.9 during pacing (p = NS). In patients with coronary artery disease, wall motion score decreased from 15.2 +/- 3.6 at rest to 11.6 +/- 4.1 during pacing (p less than 0.001). In patients with coronary artery disease and normal regional wall motion at rest, wall motion score decreased from 18 at rest to 14.4 +/- 3.1 during pacing (p less than 0.001). Thus, two-dimensional echocardiography during transesophageal atrial pacing appears both sensitive and specific in detecting patients with coronary artery disease. This new procedure is a feasible and reliable alternative to exercise two-dimensional echocardiography.     

冠状动脉二支主干堵塞行介入治疗完全血运重建

目的：本研究探讨对16例冠状动脉二支主干堵塞者采用分步和分次冠状动脉介入治疗术（PCI）完全血运重建的有效性和安全性。方法：（1）对5例急性心肌梗死（AMI）,采取一次性分步直接PCI术完成血运重建;（2）对11例不稳定型心绞痛（UAP）,采取多次性分步PCI术达到完全血运重建,首先解除本次发病罪犯血管的堵塞;（3）恰当使用XB导引导管、Crossit硬导丝和Maverick球囊以及主动脉内球囊反搏（IABP）支持。结果：（1）5例AMI二支堵塞冠状动脉均成功植入支架,并首先使左前降支（LAD）再通。（2）11例UAP中21／22支冠状动脉二支主干堵塞处经球囊预扩张后,均成功植入支架,所有堵塞冠脉均获得TIMI-Ⅲ级血流。（3）16例患者术后心电图显示心肌缺血明显改善,心脏超声显示左室射血分数较术前明显改善,由（42±34）％升至（51±44）％。经过平均18个月随访,患者生活质量明显提高,未发生严重心血管事件。结论：冠状动脉二支主干堵塞者行PCI术完全血运重建安全可行;对AMI者优先开通LAD的一次性PCI术安全高效;对慢性堵塞UAP者,优先开通近期罪犯病变的多次性PCI术既可达到完全血运重建,又符合临床实际。     

Unstable angina with coronary to pulmonary artery fistulae

Three patients presenting with chest pain were found at cardiac catheterization to have fistulae between the left anterior descending coronary and the main pulmonary artery. Two patients presented with unstable angina, the third with atypical chest pain. Of the two patients presenting with unstable angina both had concomitant coronary artery disease. One was successfully treated with percutaneous transluminal coronary angioplasty. The other underwent successful double aorto-coronary bypass grafting and fistulae ligation. The remaining patient's symptoms resolved after informing him that he did not have atheromatous coronary artery disease. In no patient was the presence of the fistula felt to be related to the patients presenting complaint. In the two patients with unstable angina, a coronary steal phenomenon was postulated as a possible contributing factor.     

老年和中青年急性冠脉综合征血高敏C反应蛋白浓度的变化

目的：比较炎症标志物血高敏C反应蛋白（hs—CRP）浓度在老年和中青年急性冠脉综合征（ACS）患者中的变化。方法：对124例经冠状动脉造影明确冠心病的患者测定hs—CRP,并对其在老年和中青年ACS中的变化进行比较。结果：（1）老年和中青年ACS患者的hs—CRP浓度高于非ACS患者（P〈0．05）;（2）在老年组,hs—CRP水平在冠脉1、2、3支病变组的差异不显著;但在中青年组．冠脉2、3支病变组的hs-CRP水平显著高于单支病变组（P〈0．05）;（3）年龄与hs—CRP水平不相关（r=0．02,P〉0．05）。结论：急性冠脉综合征hs—CRP水平显著升高。中青年急性冠脉综合征患者的hs—CRP水平与冠脉病变支数有关。