Coronary artery aneurysm presenting as STEMI

While percutaneous coronary intervention (PCI) is a commonly performed procedure, it still has many serious complications. Coronary artery pseudoaneurysms can form after PCI and can progress to cardiac tamponade. We report the case of an 80-year-old male who presented for an inferior wall ST elevation myocardial infarction, had drug-eluting stents placed to the right coronary artery (RCA), and subsequently suffered a RCA pseudoaneurysm with hemopericardium. He eventually underwent pseudoaneurysm repair with off pump coronary artery bypass graft. There is no established treatment protocol, and involvement of a multidisciplinary team improves outcomes.

Background: Patients with acute inferior wall ST elevation myocardial infarction (STEMI) with right ventricular infarction (RVI) involvement have a worse prognosis. However, most patients in the previous studies were treated with intravenous fibrinolysis and they were in the Caucasian populations. Objective: To compare the in-hospital mortality rate of patients with acute inferior wall STEMI with and without RVI treated with primary percutaneous coronary intervention (PPCI). Materials and Methods: The present study was a retrospective descriptive study that enrolled patients with acute inferior wall STEMI treated with PPCI in King Chulalongkorn Memorial Hospital between January 1, 2007, and December 31, 2016. Results: Among 452 acute inferior wall STEMI patients treated with PPCI, 99 patients had RVI. The in-hospital mortality rate was 23.2% compared with 5.1% in patients without RVI (p<0.001). Patients with RVI had a significantly higher incidence of cardiogenic shock at 48.5% versus 15.6% (p<0.001), lower left ventricle ejection fraction at 51.15±17.27% versus 55.79±12.46% (p=0.037), higher incidence of complete heart block at 33.3% versus 11.9% (p<0.001), and ventricular tachycardia at 15.2% versus 5.9% (p=0.003). After adjustment for age, female gender, cardiogenic shock on admission, left ventricular ejection fraction (LVEF), ventricular tachycardia, and complete heart block, the RVI had a tendency to be the poor predictor for in-hospital death (adjusted HR 1.96; 95% CI 0.73 to 5.23; p=0.18). Nevertheless, the RVI was the significant independent predictor for 1-year mortality (adjusted HR 2.12; 95% CI 1.03 to 4.36; p=0.041). Conclusion: Patients with acute inferior wall STEMI and RVI treated with PPCI had higher in-hospital mortality compared to no RVI. The RVI tended to have worse outcomes than those without RVI. Keywords: Acute inferior wall STEMI; Right ventricular infarction; Mortality

BackgroundSpontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome in younger females with no pre-existing history of coronary artery disease. Recurrent SCAD is common after a first episode and can involve the same coronary artery or present as a new dissection unrelated to the initial lesion. Current recommendations advise for a conservative approach in the absence of haemodynamic compromise and flow limitations. Conversely, there are no clear guidelines for the management of early recurrent SCAD.Case summaryA 52-year-old woman with history of obesity, asthma, and prediabetes presented with chest pain and electrocardiogram (ECG) showing inferior wall ST-elevation myocardial infarction (STEMI). Coronary angiography revealed proximal right coronary artery (RCA) dissection and distal left anterior descending artery (LAD) dissection, while left ventriculogram showed Takotsubo cardiomyopathy (TC). Angiography revealed no flow limitations so conservative management was pursued. She returned within a couple of days with recurrent chest pain and ECG showing similar findings of inferior STEMI. Repeat angiography confirmed progression of the proximal RCA SCAD with resolution of distal LAD SCAD. Since flow through the distal RCA was still preserved, conservative medical management was continued. She presented a third time for palpitations only and another repeat coronary angiogram showed healing RCA SCAD.DiscussionManagement of early recurrent SCAD continues to be a clinical dilemma. In addition, our patient had features of TC which shares a similar clinical risk factor profile with SCAD thus it may be prudent to further investigate for TC in patients presenting with SCAD and have suggestive features of TC on history and echocardiography.

Coronary artery anomalies, particularly an anomalous right coronary artery (RCA) originating from the left anterior descending (LAD) artery, are rare and can present with unusual patterns of myocardial infarction. We discuss the case of a 49-year-old male with diabetes and hypertension who presented with chest pain, tachycardia, and hypotension. Electrocardiography showed ST-segment elevations in V1-V6, II, III, aVF, and V1R-V4R, indicating an anterior, inferior, and right ventricular ST-elevation myocardial infarction. Coronary angiography revealed a thrombotic occlusion of the proximal LAD artery and an anomalous RCA originating from the mid-LAD. This case highlights the challenges and poor prognosis associated with anomalous RCA from the LAD, emphasizing the challenges with fluid resuscitation and heart blocks.

Coronary malperfusion complicating Type A aortic dissection is relatively rare. The diagnosis of Type A aortic dissection as the cause of coronary ischemia is a challenge. The mechanism of coronary malperfusion has been proposed. We report a 45-year-old man presenting with acute inferior wall ST segment elevation myocardial infarction who was finally diagnosed to have Type A aortic dissection complicated by hemopericardium and cardiac tamponade. Coronary spasm is the most likely cause of transient myocardial ischemia in this patient and should be considered as another possible cause of coronary malperfusion in patients with Type A aortic dissection.

Atrioventricular (AV) blocks are of concern with the use of beta blockers in inferior wall myocardial infarction (MI). Ivabradine lowers heart rate with a lesser risk of AV blocks. To compare ivabradine with metoprolol in acute inferior wall MI in terms of feasibility, tolerability, and efficacy. It was a prospective double-blind single-center randomized controlled study. Of 1032 patients with acute inferior wall MI, 468 eligible patients were randomized in 1:1 manner to ivabradine (group A) and metoprolol (group B). Intention to treat analysis of 426 patients (group A-232 and group B-232) was performed. The primary endpoint was 30-day incidence of major adverse cardiovascular events including death, reinfarction, complete heart block (CHB), and heart failure. Secondary endpoints included 30days incidence of recurrent angina, readmission, first- or second-degree AV block, and tachyarrhythmias. Both the drugs decreased the mean heart rate to 62.22±2.95 (group A) vs 62.53±3.59 (group B) beats per minute (P=0.33). Ejection fraction improved in both the groups (5.15±1.93% in group A vs 5.52±2.18% in group B, P=0.065). The two groups did not differ significantly in their primary endpoints in terms of death (group A=1.72% vs group B=1.72%, OR=1.00, 95% CI=0.25-4.05, P=1.00), reinfarction (group A=0.86% vs group B=0.86%, OR=1.00, 95% CI=0.14-7.16, P=1.00), heart failure (group A=4.31% vs group B=2.59%, OR=1.70, 95% CI=0.61-4.75, P=0.31), or CHB (0% vs 2.59%, OR=0.07, 95% CI=0.00-1.34, P=0.08). There were no significant differences in the secondary endpoints of recurrent angina, readmission, and tachyarrhythmias except for more first- and second-degree AV blocks with metoprolol (12.93% vs 2.59%, OR=5.59, 95% CI=2.28-13.72, P=0.0002). Ivabradine is well tolerated and equally effective as metoprolol in acute inferior wall ST elevation myocardial infarction patients for lowering the heart rate with lesser risk of AV blocks.

The Diagnosis

This study evaluated the 30-day clinical outcome of patients with acute inferior wall ST-elevation myocardial infarction (AIW-STEMI) from occlusion of the left circumflex artery (LCX) vs the right coronary artery (RCA) undergoing primary percutaneous coronary intervention (PCI). The clinical outcomes of AIW-STEMI caused by RCA and LCX occlusion may be different for patients undergoing primary PCI. Between May 2002 and September 2009, 646 consecutive patients with AIW-STEMI undergoing primary PCI were enrolled. Of these patients, 520 (80.5%) with AIW-STEMI caused by RCA occlusion were categorized into group 1, whereas the remaining 126 (19.5%) whose AIW-STEMI was caused by LCX occlusion served as group 2. The results demonstrated that the frequency of advanced congestive heart failure, respiratory failure requiring mechanical ventilatory support, and 30-day mortality were remarkably higher in group 2 than in group 1 (all P < 0.01). Conversely, the incidence of right ventricular infarction and complete heart block were notably higher in group 1 than in group 2 (all P < 0.001). Additionally, the peak level of creatine kinase-isoenzyme MB was significantly higher, whereas the left ventricular ejection fraction was notably lower in group 2 than in group 1. Multivariate analysis demonstrated that advanced CHF, high serum creatinine level, low systolic blood pressure, low left ventricular ejection fraction, and LCX as the infarct-related artery were significantly and independently predictive of 30-day mortality (all P < 0.05). The 30-day prognostic outcome was less favorable in LCX-related AIW-STEMI compared with RCA-related AIW-STEMI undergoing primary PCI.

A 70-year-old male came to the emergency room of the authors’ hospital because of sudden cardiac arrest due to inferior wall ST elevation myocardial infarction. His coronary angiography revealed multiple severe coronary spasms in his very long left anterior descending artery. After an injection of intracoronary nitroglycerine, his stenosis improved. The cardiac arrest relapsed, however, accompanied by ST elevation of the inferior leads, while the patient was on diltiazem and nitrate medication to prevent coronary spasm. Recovery was not achieved even with cardiac massage, intravenous injection of epinephrine and atropine, and intravenous infusion of nitroglycerine. The patient eventually recovered through high-dose nicorandil intravenous infusion without ST elevation of his inferior leads. Therefore, intravenous infusion of a high dose of nicorandil must be considered a treatment option for cardiac arrest caused by refractory coronary vasospasm.

Coronary artery fistula (CAF) is uncommon but remains the most frequent hemodynamically significant congenital coronary artery anomaly.1 The majority of fistula is single and drains into the right heart, only 3.5% into the left ventricle.2 A large fistula requires closure to prevent complications such as myocardial ischemia resulting from coronary steal, congestive heart failure, endocarditis and potential aneurysmal dilatation and rupture.3-5 Here we presented a rare case of CAF with multiple origins involving left anterior descending artery (LAD), left circumflex branch (LCX) and right coronary artery (RCA), and draining into the left ventricle, which was successfully closed by coil embolization. CASE REPORT A 61-year-old man who complained of chest pain and fatigue on exertion for two years, was admitted to our hospital in March 2007. Physical examination revealed nothing particular and no continuous murmur audible. A chest X-ray showed a cardiothoracic ratio of 45.5%, and there was normal sinus rhythm with no significant ST-T changes on regular electrocardiogram (ECG). On two-dimensional echocardiography, the RCA was dilated. Doppler echocardiography showed a continuous flow into the left ventricle (LV) beneath the posterior leaflet of the mitral valve (Figure 1). A RCA-to-LV fistula was suspected. Selective coronary angiograms demonstrated a common large tortuous fistula arising from the distal LAD, LCX and RCA draining into the LV. The proximal LAD, LCX and RCA were dilated and tortuous (Figure 2). After careful discussion, a staged transcatheter coil embolism regimen was taken.Figure 1.: Doppler echocardiography shows a continuous flow into the left ventricle beneath the posterior leaflet of the mitral valve.Figure 2.: Selective coronary angiograms show a common fistula arising from the distal LCA and RCA running in the LV.The RCA was engaged with a 7F JR 4.0 (Cordis, USA) guiding catheter. Due to the microcatheter (Cook, Europe) not long enough to reach CAF, we had to shorten the length of JR 4.0 guiding catheter by cutting the proximal of 7F JR 4.0 guiding catheter and connecting to 6F JR 4.0 guiding catheter tail-to-tail. A runthrough 0.3556 mm (0.014') guide wire (Terumo, Japan) and a microcatheter were passed through this guiding catheter to the RCA together, after guide wire removed, 2 larger microcoils (Cook) (6 mm × 5 mm) were placed as anchors and then 2 smaller microcoils (3 mm × 3 mm) were released to embolize the CAF. And then the LCX-CAF was successfully closed with similar method. Briefly, 7F JL 4.0was used to engage the left coronary artery (LCA), a microcatheter was positioned in the distal LCX over the guide wire, and 4 microcoils (two 6 mm × 5 mm, two 3 mm × 3 mm) were used to close LCX-CAF successfully. Repeated angiography 15 minutes later showed satisfactory result of the RCA-CAF and LCX-CAF without residual shunting. A month later, the patient was readmitted for another transcatheter closing for LAD-CAF. Satisfied result in LCX and RCA was verified by repeated coronary angiogram. 7F JL 4.0 was used to engage the LCA, 2 microcoils (3 mm × 3 mm) were used to close LAD-CAF through microcatheter successfully. Complete closure of the coronary artery fistula was confirmed by angiography (Figure 3). The patient is on close follow up. At 6 months, patients did not present with any symptoms of chest discomfort and repeated Doppler echocardiography confirmed persistent occlusion of the fistula with no residual shunt.Figure 3.: Post-intervention selective coronary angiograms show complete occlusion of the fistula.DISCUSSION CAF, an uncommon entity of congenital heart disease, first described by Krause in 1865, was characterized by the involved coronary artery having a normal origin from the aorta with a fistulous communication with the atria or ventricles, or with the pulmonary artery (PA).6 During the embryonic development, sinusoid gap of trabeculae of cardiac muscle is connected to coronary artery. Along with the development of myocardium the sinusoid gap was compressed and degraded to capillary. But if sinusoid gap persisted instead of degraded it would turn to be CAF. The majority of fistula drains into the right heart, with 15% into the pulmonary artery and 7% into the coronary sinus. Congenital arteriosystemic fistula rarely drains into the left heart, only 5% draining into the left atrium and 3.5% into the left ventricle.2 And most of the CAF is single. Here we presented a case of CAF with multiple origins involving LAD, LCX and RCA, and draining into the left ventricle. CAF with large shunt can cause heart failure, myocardial ischemia, arrhythmia, infective endocarditis or aneurysm progressive enlargement and rupture.3-5 In this case with significant shunt, blood may preferentially flow to the coronary fistula at the expense of the other coronary arteries, a phenomenon also known as “coronary steal”. Coronary steal is particularly evident during times of stress and can result in myocardial ischemia to territories not supplied by the arterial fistula. So the patient presented with chest pain. Recently, transcatheter intervention was provided as a new therapeutic approach for characteristics of high efficacy and micro-invasive. Coils, detachable balloons, polyvinyl alcohol foam and occlusive devices have been successfully used in the closure of CAF.7-11 In this case with multiple CAF, which might result in longer operation time, greater contrast volume, it needs to be performed by stage for the sake of safety. Moreover, the location of CAF, which is located in the distal coronary artery and extremely tortuous, inspired us to use coil other than Amplatzer duct occluder or else.10 During implementing the RCA coil embolization, due to the obvious tortuous and the microcatheter can not reach the satisfactory position, we connect a 7F JR 4.0 guiding catheter with a 6F JR 4.0 one, which can effectively shorten the length of guiding catheter and easily send the microcatheter to proper position to release coil. This technology is mainly used in the percutaneous transcoronary angioplasty. The application to CAF embolization is rarely to be reported. In conclusion, we successfully treated a complicated, high-flow coronary artery fistula by transcatheter coil embolization. Catheter embolization is an effective and safe treatment for coronary artery fistula in the strictly selected cases.

Apulsed-wave Doppler spectral profile can be used as a modality to objectively assess flows in the descending thoracic aorta.1 The normal profile reveals systolic antegrade flow; however, a small amount of retrograde diastolic flow is physiologic and increases with age and decreasing aortic compliance. The image on the left reveals holodiastolic flow reversal and increased end-diastolic velocity, as seen with the yellow arrow and asterisk, revealing continuous retrograde flow in the descending thoracic aorta. Both increased velocities and holodiastolic reversal correlate with increasing severity of aortic insufficiency, large arteriovenous fistula, patent ductus arteriosus, and systemic to pulmonary artery communications such as Blalock–Taussig shunt.1 A computed tomographic angiography scan, right image, reveals a markedly dilated right coronary artery (RCA) extending in a serpiginous fashion laterally and along the undersurface of the heart. In this plane, the right coronary artery is cut along its short axis revealing a severely dilated coronary sinus (CS) communicating with the right coronary artery via fistula, marked by the red arrow. The continuous pressure gradient from the arterial (high pressure) to venous (low pressure) system explains the flow reversal pattern in the descending aorta while hemodynamically responsible for the decreased diastolic forward flow and left-to-right shunting. The consequences of a significantly increased shunt-flow include volume overload, pulmonary hypertension, and heart failure.2 The fistulous communication with the venous system is responsible for diverting oxygenated blood, leading to myocardial ischemia. Anesthetic management includes avoiding hemodynamic fluctuations as anesthesia-induced hypotension decreases coronary perfusion and potentiates myocardial ischemia while hypertension increases the risk of rupturing a dilated coronary artery.3The authors declare no competing interests.

BACKGROUNDThe high incidence of coronary heart diseases requires early diagnosis to prevent complications. This study aims to assess the mean value of tissue mitral annular displacement (TMAD), using Speckle tracking echocardiography (2D STE) in patients with coronary artery stenosis.METHODS149 patients aged 50 to 76 years were included in this cross-sectional study who were admitted with primary diagnosis of acute coronary syndrome (ACS) to the emergency department. In all patients, the TMAD data were measured using 2D speckle tracking technology.RESULTS149 patients with a mean age of 61.83 ± 7.14 years old were studied. Regarding the involved coronary artery as left anterior descending (LAD), right coronary artery (RCA), or left circumflex artery (LCX), the TMAD data was reduced significantly (P < 0.001) in the relevant walls [base of anterior and anteroseptum (4.46 ± 3.53 mm), base of inferior and inferoseptum (4.91 ± 3.81 mm), and base anterolateral and inferolateral walls (5.53 ± 3.827 mm), respectively.] TMAD in anterior, inferior, and lateral ST-elevation myocardial infarction (STEMI) were 2.64 ± 0.870, 4.78 ± 3.8, and 2.80 ± 0.83 mm, respectively which were significantly reduced compared to the non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (P < 0.001). TMAD in different LV function categories was only reduced in those with LAD lesion and with severe LV systolic dysfunction (2.47 ± 0.834 mm, P < 0.001).CONCLUSIONThe current study describes a significant relationship between TMAD and left ventricular function, ACS type, and the culprit coronary artery. In different types of ACS, the TMAD value was worse in the subgroups of STEMI and in the walls affected by the stenosed coronary artery. This method might be helpful in defining the culprit coronary artery.

Coronary artery thrombosis is a phenomenon physicians have studied throughout the years. The different risk factors that play a role in the formation of an atherosclerotic plaque leading to coronary artery blockage are vast and can affect the patient significantly if not examined and diagnosed carefully. The objective of this case report is to highlight this unusual occurrence of repeated coronary artery thrombosis. A 54-year-old Caucasian female presented to the emergency department with a one-day history of sharp chest pain in the substernal area that radiated between her shoulder blades and left arm. Despite being on dual antiplatelet therapy, an electrocardiogram (ECG) showed an inferior ST-elevation myocardial infarction (STEMI). Her medical history was extensive with factor V Leiden deficiency, hyperhomocysteinemia, recurrent deep vein thrombosis (DVT), and a family history of myocardial infarction. The patient was taken to the cardiac catheterization lab based on these characteristics. The patient was diagnosed with a 100% thrombosis in the distal right coronary artery (RCA), which was stented nine months before this current presentation. The patient had been compliant with all her medications from her previous stent placement. A new drug-eluting stent (DES) was inserted, and the patient was placed on prasugrel and apixaban. This was a very interesting topic for a case report due to the time frame of repeat thrombosis in a coronary artery with a DES and the patient’s underlying hypercoagulable state. There are few cases of same vessel restenosis post-DES placement. Our case highlights the need for further research into the prevalence of genetic risk factors in coronary artery thrombosis and the need to investigate the efficacy of different anticoagulation therapies in patients with factor V Leiden thrombophilia.

A 58-year-old male was presented with an ST-elevation inferior myocardial infarction. Emergency medical services administered 325 mg of aspirin and sublingual nitroglycerin en route to the emergency room. In the emergency room, the patient received 600 mg of clopidogrel and a heparin bolus. Coronary angiography revealed complete occlusion of the distal right coronary artery with thrombus. Intravenous eptifibatide was given at the start of the percutaneous coronary intervention (PCI). Intravascular ultrasound demonstrated significant soft atheroma and ruptured plaque in the distal right coronary artery at the crux. A drug-eluting stent was deployed with an excellent angiographic result. Postintervention, the patient’s chest pain and ECG demonstrated complete resolution of the previous ischemic changes. Approximately 11 hours after being treated in the emergency room, the patient developed recurrent chest pain. He was restarted on eptifibatide and heparin, and repeat coronary angiography demonstrated total occlusion at the origin of the right coronary artery stent (Figure 1). Figure 1. Coronary angiogram demonstrating an occluded mid right coronary artery because of stent thrombosis. Thrombectomy was performed, removing huge amounts of atherothrombotic material (Figure 2). Intravascular ultrasound did not demonstrate stent edge dissection or stent malapposition. Figure 2. Coronary thrombus material extracted from the right coronary artery after thrombectomy. A drug-eluting stent with 1-mm overlap with the distal edge of the previous stent was deployed. The patient was felt to have failed clopidogrel therapy and was transitioned to prasugrel therapy. The patient was screened for genetic variants in CYP2C19 , the gene encoding the cytochrome P450 enzyme CYP2C19 that metabolizes clopidogrel. A Luminex assay using a polymerase chain reaction was used to test for the presence or absence of CYP2C19 * 17 , * 4 , * 8 , * 6 , * 9 , * 3 , * 10 , * 2 , * 7 , and * …

Right coronary artery intervention is usually accomplished with a Judkins right (JR) coronary guide catheter. Abnormal right coronary artery take-off from the right coronary sinus poses difficulty in engaging the right coronary artery with a conventional JRguide catheter. We report a rare case of primary percutaneous intervention of the right coronary artery which was performed with a multipurpose catheter as the patient had an extremely low-lying coronary artery from the coronary sinus where conventional catheters could not engage the right coronary artery in an octogenarian with acute inferior wall ST-elevation myocardial infarction in cardiogenic shock.