Hybrid myocardial revascularization after previous left pneumonectomy

Previous intrapericardial left pneumonectomy and irradiation necessitated an unorthodox, staged approach to myocardial revascularization in a patient with unstable angina pectoris, left main artery, and three-vessel coronary artery disease. A saphenous vein bypass graft was constructed from the descending thoracic aorta to the left anterior descending coronary artery via left thoracotomy, without cardiopulmonary bypass. Two days later the patient underwent stenting of the left main and circumflex coronary arteries. Recovery was uneventful.     

Forward. An update on jaundice in the newborn

We report a case of acute left main coronary artery subocclusion treated by stenting. The patient had a severe ostial left main coronary artery stenosis and after diagnostic coronary angiography developed subocclusion of the left main coronary artery, with TIMI 1 flow and life-threatening hemodynamic consequences. After two balloon dilatations had failed, a half Palmaz-Schatz stent (7 mm) was successfully deployed at the site of the lesion with immediate improvement of the angiographic and clinical picture. We claim that the placement of a half Palmaz-Schatz stent, hand-crimped on a high-pressure and non-compliance balloon, could provide a means for restoring adequate blood flow in patients who develop an important ischemia after diagnostic coronary angiography of a short, calcified left main coronary artery with severe ostial stenosis. Despite the satisfactory angiographic and clinical findings in these patients, the risk of restenosis and the presence of other multivessel diseases press us towards a more definitive surgical treatment.     

Coronary artery fistula with left atrial myxoma: report of a case

A 64-year-old male was referred for surgical treatment of left atrial myxoma. Preoperative coronary angiography revealed coronary artery fistula from the left anterior descending artery and the circumflex artery draining into the main pulmonary artery. Operative treatment was performed including resection of the myxoma, patch closure of the atrial septal defect, and closure of the fistula with pledgeted mattress sutures from within the main pulmonary artery on cardiopulmonary bypass. His postoperative course was uneventful, and disappearance of the left atrial myxoma and the coronary artery fistula was ascertained by echocardiography and coronary angiography.     

Clinical utility of two-dimensional magnetic resonance angiography in detecting coronary artery disease

AIMS: The accuracy of magnetic resonance angiography in detecting proximal coronary artery stenoses is unclear. We postulated that fast magnetic resonance angiography is capable of (1) imaging proximal coronary arteries, and (2) detecting stenoses of > or = 50% of their luminal diameter. METHODS AND RESULTS: Thirty-five patients, referred for analysis of angina pectoris, underwent both conventional angiography and magnetic resonance angiography of coronary arteries. A fast k-space segmented gradient-echo technique was used during breath-holds. Two observers, blinded to the results of conventional angiography, independently analysed the magnetic resonance studies for (1) length of visualized segments, and (2) presence of signal voids indicative of stenoses. From 140 proximal arteries, 15 (11%) were excluded because of incomplete imaging or degraded image quality. Mean length of the visualized segments was 9 +/- 4 mm for the left main, 62 +/- 16 mm for the left anterior descending, 21 +/- 9 mm for the left circumflex and 89 +/- 32 mm for the right coronary artery. Sensitivity for detecting > or = 50% luminal diameter stenoses was 0.00 for the left circumflex, 0.53 for the left anterior descending coronary artery, 0.71 for the RCA and 1.00 for the left main artery. Specificity varied from 0.73 for the left anterior descending coronary artery to 0.96 for the left circumflex. Inter-observer agreement was 0.90. CONCLUSION: Thus, segmented magnetic resonance angiography is capable of non-invasive imaging of proximal coronary anatomy. Its good accuracy in detecting left main coronary artery disease, intermediate accuracy in detecting right coronary artery and left anterior descending coronary artery stenoses, and low accuracy in detecting left circumflex lesions fit within a range of sensitivities and specificities found by others. Further technical advances are necessary to make the technique clinically robust.     

Surgical angioplasty of the main coronary arteries in children

OBJECTIVE: To determine the safety and efficacy of surgical angioplasty of the coronary arteries in children. METHODS: We performed 9 surgical reconstructions of the left main coronary artery and 1 of the right coronary artery ostium in 10 children (mean age 5.7 years; range 2 months-15 years). The basic diseases included the following: congenital atresia of the left coronary artery (n = 2) and atresia of the right coronary artery in a patient with an aortoventricular tunnel (n = 1); stenosis of the left main coronary artery (1) in a patient with Williams syndrome (n = 1), (2) in a patient with familial hypercholesterolemia (n = 1), (3) after the arterial switch operation for transposition of the great arteries (n = 3), (4) after reimplantation of an anomalous left main coronary artery from the pulmonary artery (n = 1), and (5) by compression after a réparation à l'étage ventriculaire procedure (n = 1). Myocardial viability was assessed by single photon emission computed tomography (thallium 201; 7/10). The coronary artery stem was enlarged with a saphenous (n = 5), a pericardial (n = 4), or a polytetrafluoroethylene patch (n = 1). RESULTS: There was 1 hospital death and 9 patients are alive (mean follow-up 46 +/- 30 months; range 12 months to 10.5 years). Eight of 9 survivors had a selective coronary artery angiogram and had normal coronary artery ostia. Two patients had stenosis of the left anterior descending coronary artery, 1 of whom underwent successful internal thoracic artery grafting. CONCLUSIONS: Surgical angioplasty of the coronary stems restores physiologic coronary perfusion and conserves bypass material. It can be performed safely in children and provides encouraging midterm results.     

Total occlusion of the left common coronary artery--a case report

Total chronic occlusion of the left main coronary artery is an unusual finding. After a review of the literature, the authors present a case report of a patient with stable angina and total occlusion of the left main coronary artery, right coronary with atherosclerotic lesions and normal ventricular function.     

Interprosthetic fracture of the femoral shaft

Acute occlusion of the left main coronary artery is usually responsible for cardiogenic shock, severe arrhythmias or sudden death. Despite the widespread use of emergency coronary angiography in acute myocardial infarction, occlusion of the left main coronary artery is rarely observed and its treatment remains controversial. The authors report the case of a young man with a previous history of radiotherapy for Hodgkin's disease, admitted for acute myocardial infarction due to complete thrombosis of the left main coronary artery treated as an emergency by percutaneous transluminal angioplasty and implantation of a Palmaz Schatz stent. There were no complications of the procedure and the patient was asymptomatic one year later.     

The addition of antibiotics to fibrin glue

Coronary artery bypass grafting is the treatment of choice for significant left main coronary artery disease. A patient with an occluded left main coronary artery in the setting of myocardial infarction, who was given streptokinase and subsequently managed with intracoronary stenting, is reported.     

Anomalous coronary artery with tetralogy of Fallot and aortopulmonary window

Anomalous origin of the left main coronary artery from the pulmonary artery is rarely associated with other conditions. We report the case of an infant born with tetralogy of Fallot and aortopulmonary window who at the time of surgical repair was found to have an anomalous left main coronary artery originating from the right pulmonary artery.     

Chronic total occlusion of the left main coronary artery

Total chronic occlusion of the left main coronary artery is a rare angiographic finding in a catheterization laboratory. After reviewing the coronary angiographies performed in our laboratory between 1986 to 1995, we found a prevalence of 0.04%. These patients presented unspecific symptoms similar to other kinds of coronary artery disease. In all cases, the right coronary artery was dominant with extensive collateral circulation to the left coronary artery. Ventricular function was normal in 50% of the cases. Probably, in these unusual cases, the best therapeutic approach is surgical revascularization.     

Tracking the MEN1 gene

Combined carotid endarterectomy and coronary artery bypass grafting was performed in 52 patients between January 1982 and September 1994. Forty-nine patients had stable or unstable angina and three had symptom-free coronary artery disease detected by stress testing. Thirty-one patients had triple-vessel disease and 17 had left main trunk or left main equivalent coronary artery disease. Five patients had symptom-free carotid artery disease, 12 had non-specific neurological symptoms, and 35 had transient ischaemic attacks. Carotid endarterectomy was performed first, followed by coronary artery bypass grafting. There were three postoperative deaths, two cardiac and one neurological, for a mortality rate of 5.8%. One patient suffered a permanent neurological deficit (1.9%). It is concluded that combined carotid endarterectomy/coronary artery bypass grafting can be performed in selected patients with acceptable neurological morbidity, although cardiac mortality was not eliminated by the combined approach.     

Interventional coronary revascularization in a patient with chronic dissection of the ascending aorta

In a 74-year-old patient who had undergone coronary artery bypass grafting 8 years earlier, angiography was performed for recent onset of angina pectoris. Surprisingly, angiography revealed chronic dissection of the ascending aortic vessel with occlusion of a saphenous vein graft and partial thrombosis of the false lumen. Additionally, there was significant progression of coronary artery disease with new stenoses in both the ostium and body of the saphenous vein graft to the right coronary artery and a high grade left main coronary artery stenosis. Because any surgical intervention was refused by the patient, an interventional therapeutic strategy with percutaneous transluminal dilatation and stenting of both the bypass graft and the left main coronary artery was planned and successfully performed. This is the first report of a complex intervention and revascularization procedure carried out in a patient with type A aortic dissection. Thus, selected cases of chronic type A dissection my be amenable to interventional coronary revascularization in acute coronary syndromes.     

Anatomic variations of the coronary arteries

PURPOSE: To study the coronary arteries and their main branches showing the aspects of source, trajectory and anastomoses of these vessels at the subepicardial level. METHODS: The study was carried out on 110 adult human hearts, of both sexes, fixed in 10% formaldehyde solution. The pericardium was removed to expose the coronary arteries and their branches at the subepicardial level. RESULTS: In 38.18% of the cases the left coronary artery presented a trifurcation into anterior interventricular, circunflex and left marginal branches (35.70%) and into anterior interventricular, circunflex and lateral branches (64.30%). In 60% of the hearts examined, the left coronary artery presented a bifurcation into anterior interventricular and circunflex branches. In 1.82% of the cases these two branches arise directly from the aorta. An anastomosis, at the subepicardial level, between the anterior and posterior interventricular branches was observed in 56.36% of the hearts. In 88.18% the posterior interventricular branch arised from the right coronary artery, whereas in 11.82% this vessel arises from the circunflex branch. Anastomoses between the right coronary artery and the circunflex branch were found in 10% of the hearts (crux cordis). The dominance of the right coronary artery was present in 69.09% of the cases, of the left coronary artery in 11.82% and in 19.09% of the hearts had balanced distribution. CONCLUSION: The coronary arteries and their main branches present a great quantity of variations with regard to source, trajectory and anastomoses. This knowledge is important for the interpretation of coronary angiography and surgical myocardial revascularization.     

Pediatric case of the day. Hinman syndrome (nonneurogenic bladder [NNNB], detrusor-sphincter dyssynergia)

Two cases of spontaneous left main coronary artery dissection are reported. This condition is rare and may present as an urgent surgical dilemma. The presentation, diagnosis, and management of primary left main coronary artery dissection are reviewed. Causative factors and underlying pathology are clarified. Prompt diagnosis and surgical intervention with temporary ventricular support is safe and effective.     

Spectrum of coronary arterial spasm. Clinical, angiographic and myocardial metabolic experience in 29 cases

A relationship of coronary arterial spasm to variant angina pectoris, subendocardial ischemia, major ventricular arrhythmias and myocardial infarction has been demonstrated. In 29 patients, spasm was angiographically observed in normal-appearing coronary arteries (7 patients) as well as superimposed on various degrees of coronary atherosclerotic obstruction (22 patients). All patients experienced an atypical anginal syndrome;16 patients also experienced typical exertional angina. Coronary spasm appeared to be a major contributory factor in eight occurrences of myocardial infarction and in 11 incidents of ventricular tachycardia, ventricular fibrillation and heart block. Coronary spasm in the 29 cases was distributed in the following fashion: left main trunk, 6 cases; right main trunk, 12 cases; proximal left anterior descending artery, 13 cases; proximal circumflex artery, 1 case; distal left anterior descending artery, 1 case; and distal circumflex artery, 2 cases. In 5 cases coronary spasm was noted at multiple sites.     

Complete occlusion of the left main coronary artery and the importance of coronary collateral circulation

Study of four patients who survived complete occlusion of the left main coronary artery forms the basis of conclusions concerning the functional significance of coronary collateral circulation. Each of these patients had prominent collateral circulation from the right coronary artery. Global left ventricular function was maintained to the extent that congestive heart failure did not occur; the biplane ejection fraction was normal in the two patients where measurement was possible. The peak rate of systolic wall thickening by roentgen videometry in anterior left ventricular segments was normal in one patient and mild to moderately depressed in another. Experience with the patients described herein indicates that coronary collateral flow can provide critically needed circulatory support for the patient with coronary artery disease.     

Stenosis at the origin of an anomalous left main coronary artery arising from the pulmonary artery in a symptom-free adolescent girl: transesophageal echocardiographic findings

We report an unusual finding of ostial stenosis of an anomalous left main coronary artery originating from the pulmonary artery in a symptom-free adolescent girl. Transesophageal echocardiography with Doppler color imaging correctly identified all of the salient features of this anomaly including proximal stenoses of the right and left coronary arteries. These findings were subsequently confirmed at cardiac catheterization.     

Repair of anomalous connection of the left coronary artery to the pulmonary artery using native aortic and pulmonary tissue flaps

A modified repair technique in anomalous connection of the left coronary artery to the main pulmonary artery is reported in which transfer of the origin of the vessel into the aortic root is facilitated by augmentation with native aortic and pulmonary tissue flaps. This modification reduces tension on the anastomosis and may enhance the likelihood of successful transfer of the left coronary artery into the aortic root.     

Adenoid squamous carcinoma of the conjunctiva--a clinicopathological study of 14 cases

Idiopathic or congenital coronary artery ectasias and aneurysms are uncommon forms of coronary artery disease. The prognosis and optimal management of such patients remains unknown. The authors describe the case of an otherwise healthy 30-year-old man with concomitant severe right coronary artery ectasia and left main coronary artery aneurysm who sustained a mild anterior myocardial infarction. There was no obstructive coronary artery disease, and no cause for the lesions could be identified. Chronic anticoagulation and antiplatelet therapy were initiated with resolution of symptoms.     

High-grade coronary stenosis due to a bronchogenic cyst

A 32-year-old woman without preceding illness or significant cardiovascular risk factors was admitted to hospital because of a syncope after physical exertion. Transoesophageal echocardiography, performed to exclude aortic dissection, showed as an incidental finding a cystic space-occupying mass, 5 x 6 cm in diameter, dorsal to the aortic root and main pulmonary artery. Exercise ECG had S-T segment depressions of about 0.3 mV, associated with anginal symptoms, so that inadequate coronary artery flow on exertion was suspected. Subsequent coronary angiography demonstrated a funnel-shaped 80% stenosis at the origin of the main left coronary artery, while all other coronary arteries were normal and smooth-walled. A causal connection between the two findings was assumed and quickly undertaken surgical intervention revealed an intrapericardial bronchogenic cyst which, presumably as a result of its size and location, had pressed on the main stem of the left coronary artery and caused the stenosis of its ostium. The cyst was completely resected and angioplasty of the coronary artery ostium was performed to ensure its patency. 3 months postoperatively the patient underwent an exercise test of up to 125 Watt without signs of ischaemia. This case presents a previously unreported complication of a bronchogenic cyst.