Two cases of coronary artery-left ventricular fistula associated with left ventricular hypertrophy]

Two cases of coronary artery-left ventricular fistula (AVF) associated with left ventricular hypertrophy were reported. The first patient was a 53-year-old man with chest pain. Selective coronary angiography (CAG) revealed bilateral coronary arteries draining into the left ventricle (LV). The second patient was a 46-year old man with electrocardiographic (ECG) abnormalities. CAG showed bilateral coronary artery which communicated via a maze of fine vessels into LV. In both cases, ECG showed ST depression and inverted T wave, and two-dimensional echocardiography revealed hypertrophic cardiomyopathy (HCM). Coexistence of coronary artery-left ventricular fistula and HCM seems to be a casual association.     

Severe infundibular pulmonary stenosis and coronary artery stenosis with ventricular tachycardia 24 years after mediastinal irradiation

A 28-year-old man developed severe infundibular pulmonary stenosis (PS), coronary artery stenosis with sustained ventricular tachycardia (VT) 24 years after mediastinal irradiation (total amount of 40 Gray) for non-Hodgkin's lymphoma. Repair of right ventricular outflow tract and coronary artery bypass graft procedure were performed. Infundibular PS was successfully relieved after operation and VT was also controlled by medication. Mediastinal irradiation often causes various cardiac complications after a latent period. Therefore, continuous careful observation is mandatory in patients with the history of mediastinal irradiation.     

Intercoronary connection and apical left ventricular hypertrophy: case report and review of the literature.

Cardiac catheterization in a 55-year-old man, presenting with chronic chest pain and new T wave inversion, showed apical left ventricular (LV) hypertrophy and a large intercoronary connection between the posterior descending artery (PDA) and left anterior descending (LAD). Although the LAD was normal, selective angiography of the right coronary artery (RCA) filled the LAD retrogradely. Possible mechanisms and the literature are reviewed.     

单纯右冠状动脉狭窄对左心室功能的影响

目的:探讨单纯右冠状动脉（RCA）狭窄不同狭窄程度和狭窄节段对左心室功能的影响。方法:将冠状动脉造影证实为单纯RCA狭窄的患者99例,按不同狭窄程度、不同狭窄节段和不同冠脉优势型进行分组,并与494例无冠状动脉狭窄的对照组比较,经左心室造影测定的左室射血分数（LVEF）和左室舒张末压（LVEDP）。结果:与对照组患者相比,轻度、中度和重度单纯右RCA狭窄患者的LVEF变化不显著,完全闭塞患者的LVEF显著下降（P<0.05）;右冠中段、右冠远段、后降支和侧后支病变患者的LVEF均无有意义变化,右冠近段病变患者LVEF下降有统计学意义（P<0.05）。单纯RCA狭窄患者中,右冠优势组LVEF略低于均衡优势组和左冠优势组,但差异未达显著水平。单纯RCA狭窄对LVEDP的影响并不明显。结论:单纯RCA主干近段狭窄和单纯RCA完全闭塞对左室收缩功能可产生一定程度的损害。     

Intercoronary connection and apical left ventricular hypertrophy: Case report and review of the literature

Cardiac Catheterization in a 55-year-old man, presenting with chronic chest pain and new T wave Inversion, showed apical left ventricular (LV) hypertrophy and a large intercoronary connection between the posterior descending artery (PDA) and left anterior descending (LAD). Although the LAD was normal, selective angiography of the right coronary artery (RCA) filled the LAD retrogradely. Possible mechanisms and the literature are reviewed.     

Rare presentation of intralobar pulmonary sequestration associated with repeated episodes of ventricular tachycardia

Arterial supply of an intralobar pulmonary sequestration (IPS) from the coronary circulation is extremely rare. A significant coronary steal does not occur because of dual or triple sources of blood supply to sequestrated lung tissue. We present a 60-year-old woman who presented to us with repeated episodes of monomorphic ventricular tachycardia (VT) in last 3 mo. Radio frequency ablation was ineffective. On evaluation, she had right lower lobe IPS with dual arterial blood supply, i.e., right pulmonary artery and the systemic arterial supply from the right coronary artery (RCA). Stress myocardial perfusion scan revealed significant inducible ischemia in the RCA territory. Coronary angiogram revealed critical stenosis of proximal RCA just after the origin of the systemic artery supplying IPS. The critical stenosis in the RCA was stented. At 12 mo follow-up, she had no further episodes of VT or angina.     

Vasospastic total occlusion at the left main tract in a single coronary artery.

A 64-year-old man was admitted to hospital under the suspicion of unstable angina pectoris. Coronary angiography showed that he has a single coronary artery originating from the right coronary artery (RCA) without significant fixed stenosis. Acetylcholine was superselectively infused into the left main coronary artery (LMCA), and confirmed the coronary vasospastic occlusion associated with chest pain and elevation of the ST-segment in the precordial leads. This is the first report of the induction of a totally occlusive spasm of the LMCA of a patient with a RCA type single coronary artery, and this case suggests that spasm of the aberrant coronary artery is a potential mechanism for sudden death in patients with a single coronary artery.     

右冠状动脉狭窄程度对左冠状动脉狭窄患者左室射血分数的影响

目的研究右冠状动脉不同程度狭窄对左冠状动脉狭窄患者左室射血分数（LVEF）的影响。方法根据左冠状动脉病变部位不同,将1 000例左冠状动脉狭窄患者分为左前降支（LAD）狭窄,左回旋支（LCX）狭窄,左主干（LM）狭窄,左前降支+左回旋支（LAD+LCX）狭窄4个系列。每个系列再根据右冠状动脉（RCA）病变程度不同分为RCA正常组（直径狭窄<50%）、RCA非闭塞组（99%>直径狭窄≥50%）和RCA闭塞组（直径狭窄≥99%）,比较分析3组间LVEF的差异。结果在LAD,LCX,LM,LAD+LCX狭窄时,与RCA正常组LVEF相比,RCA非闭塞组LVEF分别下降0.9%,0.3%,3.4%和2.8%;RCA闭塞组LVEF分别下降10.9%,3.7%,6.5%和5.2%。LAD狭窄时,RCA非闭塞组和RCA闭塞组之间LVEF有统计学差异（P<0.01）。结论右冠状动脉病变可在左冠状动脉狭窄的基础上使左室射血分数进一步下降;当左冠状动脉狭窄为闭塞性病变时,影响更为明显。     

Cabrol shunt for iatrogenic aortic dissection: evaluation with cardiac 64-slice CT

A 63-year-old man was admitted with intractable angina and underwentelective coronary angiography. He had a history of percutaneouscoronary intervention to the left circumflex artery five yearspreviously. Coronary angiography revealed 90% stenosis of theproximal right coronary artery (RCA) (Panel A) and a 3 mmCypher     

Pure right ventricular infarction.

A 76-year-old man with chest pain was admitted to hospital where electrocardiography (ECG) showed ST-segment elevation in leads V1-4, indicative of acute anterior myocardial infarction. ST-segment elevation was also present in the right precordial leads V4R-6R. Emergency coronary angiography revealed that the left coronary artery was dominant and did not have significant stenosis. Aortography showed ostial occlusion of the right coronary artery (RCA). Left ventriculography showed normal function and right ventriculography showed a dilated right ventricle and severe hypokinesis of the right ventricular free wall. Conservative treatment was selected because the patient's symptoms soon ameliorated and his hemodynamics was stable. 99mTc-pyrophosphate and 201Tl dual single-photon emission computed tomography showed uptake of 99mTc-pyrophosphate in only the right ventricular free wall, but no uptake of 99mTc-pyrophosphate and no perfusion defect of 201Tl in the left ventricle. The peak creatine kinase (CK) and CK-MB were 1,381 IU/L and 127 IU/L, respectively. His natural course was favorable and the chest pain disappeared under medication. Two months after the onset, the ECG showed poor R progression in leads V1-4 indicating an old anterior infarction. Coronary angiography confirmed the ostial stenosis of the hypoplastic RCA. This was a case of pure right ventricular free wall infarction because of the occlusion of the ostium of the hypoplastic RCA, but not of the right ventricular branch. Because the electrocardiographic findings resemble those of an acute anterior infarction, it is important to consider pure right ventricular infarction in the differential diagnosis.     

Relation between site of origin of ventricular tachycardia and relative left ventricular myocardial perfusion and wall motion

To assess the relation between the site of origin of ventricular tachycardia (VT) and relative myocardial perfusion and wall motion, 18 patients with a history of recurrent sustained VT underwent cardiac catheterization, invasive electrophysiologic study with endocardial mapping, and resting radionuclide ventriculography. In addition, 6 patients had exercise and redistribution thallium-201 scintigraphy, whereas the remaining 12 patients had resting thallium scans. The site of origin of VT (determined by catheter and intraoperative endocardial mapping) was correlated with relative myocardial perfusion (thallium) and left ventricular (LV) wall motion. All patients had significant (>50% narrowing) coronary artery disease and 16 had LV aneurysms.Twenty sites of origin of VT (28 morphologies) were identified in these 18 patients. Of the 9 patients with multiple VT morphologies, the VT originated at disparate sites in 2 patients. All 18 patients had thallium defects at rest and 3 patients had additional reversible (ischemic) defects on exercise. Of the 20 sites of origin of VT, 16 were at the periphery of the thallium defect, 1 was adjacent to it, and 3 were in the center of it. In the 16 patients with LV aneurysm, there were 18 sites of origin: 15 at the border of the aneurysm, 1 adjacent to it, and 2 within it.The data suggest that in patients with VT and coronary artery disease the site of origin is usually the periphery of a resting thallium defect, and in patients with LV aneurysm the site is the border of the aneurysm.     

Three cases of single coronary artery

Single coronary artery has been considered a minor coronary anomaly without clinical importance. With the wide spread of coronary angiography, however, the disease has been reported to develop complications at a high rate, such as angina, myocardial infarction and arrhythmia. We report three patients with single coronary artery with several complications. Case 1: A 56-year-old woman having a past history of diabetes mellitus and myocardial infarction was admitted because of the recently developed frequent attacks of effort angina. Treadmill test was positive and thallium-201 exercise myocardial scintigraphy revealed redistribution in the lateral wall. Ascending aortogram suggested that the right coronary artery (RCA) arose from the left sinus of Valsalva. An injection into the right sinus of Valsalva revealed no coronary ostium. Selective left coronary angiogram resulted in the diagnosis of single coronary artery (Smith's type 2) with 90% stenosis in the left circumflex artery (LCX). Left ventriculogram showed hypokinesis in the anterolateral wall. PTCA performed on this patient revealed clinical and nucleomedical improvement. Case 2: A 48-year-old man experienced chest pain and syncope. Electrocardiogram revealed ST-elevations in II, I and a VF, sinus bradycardia and atrioventricular junctional rhythm. Angiography resulted in the diagnosis of single coronary artery (Smith's type 2) with 75% stenosis in the RCA. Ergonovine test was positive. Case 3: A 69-year-old man complained of chest pain. Electrocardiogram showed complete right bundle branch block, sinus bradycardia and atrioventricular junctional rhythm. Cardiac catheterization revealed that this was also a case of single coronary artery (Smith's type 2) with no significant stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Exercise induced ventricular arrhythmias. Angiographic correlation with the severity of coronary artery disease

We correlated the incidence and degree of exercise induced ventricular arrhythmias (EIVA) with the angiographic severity of coronary artery disease (CAD) in 162 patients with a history of stable effort angina, all showing a positive exercise stress test for myocardial ischemia and a greater than or equal to 70% stenosis of a major coronary artery. Patients were grouped according to the following criteria: presence of electrocardiographic evidence of old transmural myocardial infarction (MI), number of significant coronary stenoses and number of left ventricular (LV) areas showing abnormal segmental wall motion (ASWM). The incidence of EIVA in patients with multivessel CAD was higher than in patients with single vessel CAD, but this difference was not statistically significant. The number of LV areas with ASWM was better correlated with the frequency of EIVA, which was 20.0% in patients with normal LV wall motion, 31.2% in patients with 1 area of ASWM, 54.0% in patients with 2 areas of ASWM (p less than 0.005 vs normal LV wall motion), 74.1% in patients with 3 or more areas of ASWM (p less than 0.001 vs normal LV wall motion and 1 area of ASWM), and 81.8% in patients with LV aneurysm (p less than 0.001 vs normal LV wall motion and 1 area of ASWM, p less than 0.005 vs 2 areas of ASWM). Patients with old MI showed a significantly higher incidence of EIVA than those without MI (p less than 0.001), but this difference was due to the more severe LV asynergy in the MI group. In conclusion, our results show that, in a selected population of patients with CAD, the incidence of EIVA correlates better with the extent of LV segmental wall motion abnormalities than with the number of diseased coronary arteries or the presence of an old transmural MI.     

Isolated coronary stenosis: clinical picture, contractile function of the left ventricle and central hemodynamics

Clinical manifestations of coronary disease, medical history, left-ventricular segmental contractility and central hemodynamics were examined in 54 patients, aged 32 to 45, with an isolated 75-99% stenosis of a major coronary artery. The most common isolated stenosis in the anterior interventricular branch (AIVB) of the left coronary artery is associated with more severe clinical coronary symptoms. Total damage to the coronary channel is twice as great where AIVB is affected as it is with lesions of the right (RCA) or the circumflex (CA) coronary artery. AIVB stenosis results in more serious disorders of left-ventricular segmental contractility and central hemodynamics, with the end diastolic index showing the most dramatic rise. Isolated AIVB stenosis is associated with a higher risk of myocardial infarction, as compared to the RCA or CA stenosis.     

Electrocardiographic changes as a marker of improved subendocardial ischemia in a patient with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) patients sometimes develop subendocardial ischemia without coronary artery stenosis. We report a case of non-obstructive HCM, in which electrocardiographic changes were observed with improvement of subendocardial ischemia. A 76-year-old man presented with chest pain on exertion. The electrocardiogram revealed left ventricular (LV) hypertrophy with repolarization abnormalities. No coronary stenosis was found on computed tomography angiography, but thallium-201 exercise scintigraphy revealed transient LV cavity dilation after exercise, consistent with subendocardial ischemia. His chest symptoms disappeared after starting verapamil. Transient LV cavity dilation improved without a reduction in exercise tolerance, as did electrocardiographic abnormalities without any changes on echocardiography.     

Relationship between regional ventricular asynergy and the anatomic lesion in coronary artery disease

The percentage of left ventricular (LV) asynergy was measured in patients with isolated narrowing or obstruction of the right coronary artery (RCA), the anterior descending branch of the left coronary artery (LAD), or a combination of these lesions.Incomplete obstruction of a vessel was not associated with important asynergy. Isolated obstruction of the LAD caused asynergy of the distal two-thirds of the anterior wall and apex of the LV and 46 per cent asynergy. Isolated obstruction of the RCA caused asynergy of the middle or basal thirds of the diaphragmatic surface and 15 per cent asynergy. Double-vessel disease produced a combination of the individual lesions, and total obstruction of both arteries caused extensive asynergy.In each patient the extent of asynergy was modified by the underlying coronary artery anatomy and the collateral circulation. Ejection fraction was related to the percentage of LV asynergy.     

右冠状动脉病变对左冠状动脉狭窄患者左心室功能的影响

目的　探讨右冠状动脉病变对左冠状动脉狭窄患者左心室功能的影响及其机制。方法　对比分析左冠状动脉狭窄患者在合并与不合并右冠状动脉病变时的左心室射血分数。结果　与相应部位单纯左冠状动脉狭窄患者相比 ,合并右冠状动脉病变患者左心室射血分数均呈不同程度地下降 ,其中在左前降支、左前降支 +左回旋支狭窄基础上合并右冠状动脉病变时左心室射血分数下降有统计学意义 (P <0 .0 5或 0 .0 1) ,左主干合并右冠状动脉狭窄患者下降幅度最大 ,但无统计学意义。结论　右冠状动脉病变可在单纯左冠状动脉狭窄的基础上使左心室收缩功能进一步恶化 ;当左冠状动脉狭窄部位为左前降支、左主干或左前降支 +左回旋支时 ,对左心室收缩功能影响更为严重     

Evaluation of therapeutic interventions of sustained monomorphic ventricular tachycardia guided by an electrophysiologic study: a case report

Therapeutic evaluation of sustained monomorphic ventricular tachycardia (VT) using electrophysiologic study (EPS) is presented in a case of refractory VT. A 54-year-old man with a history of recurring syncope underwent coronary angiography which revealed total occlusion of the posterior descending branch of the right coronary artery. Left ventriculography showed a left ventricular aneurysm at the cardiac apex. Ejection fraction of the left ventricle was 36%. He had four VTs of different QRS morphologies in 12 lead electrocardiograms. According to our programmed ventricular stimulations, single or double, and rarely triple, extra stimuli were administered after eight basic stimuli at two basic cycle lengths. Rapid ventricular pacing, up to 210 bpm, was then added. The stimuli were delivered to two different sites in the right ventricle and to at least one site in the left ventricle. When the entire protocol could not induce VT, isoproterenol was given intravenously, and the same protocol was repeated. No drug could prevent VT attacks, even after the surgical resection of two VT foci, VT was still inducible. Postoperative drug therapy could not prevent VT induction in EPS. However, changes in the mode required for VT induction were observed. Among 47 patients with sustained monomorphic VT treated in our hospital, 24 had EPS to evaluate the efficacies of therapeutic interventions, such as drugs and surgery. In 14 patients, no VT was induced by the entire VT induction protocol. Among the remaining 10 patients, four showed changes in the VT induction mode, but VT recurred in their clinical courses even after their treatments.(ABSTRACT TRUNCATED AT 250 WORDS)     

Spontaneous coronary artery dissection causing myocardial infarction and left ventricular aneurysm.

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial infarction (MI). A 66-year-old Japanese man, who had had an anterior wall MI caused by SCAD of the left anterior descending coronary artery, developed left ventricular aneurysm 5 years later, with depressed left ventricular function and thrombus observed on echocardiography. Left endoventricular circular patch plasty according to Dor's technique was performed without coronary artery bypass grafting, because of the absense of significant coronary artery stenosis on the preoperative coronary angiogram. The clinical course of SCAD in the late phase is generally favorable, but because the prognosis of SCAD is uncertain, patients with SCAD should be carefully followed.     

A pitfall of fractional flow reserve associated with the presence of collateral circulation

An 82-year-old man had a severe stenosis in the proximal left anterior descending artery (LAD) and an intermediate stenosis in the distal right coronary artery (RCA). The territory of mid to distal LAD was perfused via an angiographically well-developed collateral circulation from the distal RCA. Fractional flow reserve (FFR) in the distal RCA was 0.84. After successful coronary intervention for the proximal LAD, repeat FFR in the distal RCA was 0.96. In this case, the severity of the stenosis in the donor artery was overestimated by using FFR due to the presence of well-developed collateral circulation.