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Background Atrial fibrillation (AF) is a common disease and can lead to cardioembolic stroke. Stroke prevention according to the CHA2DS2VASc score is achieved via oral anticoagulation. In recent years, interventional occlusion of the left atrial appendage (LAA) has become a common alternative. Besides showing non-inferiority in large trials compared with warfarin interventional LAA occlusion can lead to serious adverse events with most of them occurring peri-interventionally. Case summary A 75-year-old man with AF and recurrent gastrointestinal bleedings was referred for an interventional closure of the LAA. The intervention was successful with an ABBOTT® Amulet device. Four months later, the patient had to be resuscitated. Return of spontaneous circulation occurred after 10 min. On hospital arrival, echocardiography revealed a pericardial tamponade and 2 L of blood were drained. A coronary angiogram revealed a lesion with active leakage of contrast agent in the proximal circumflex artery. The patient was transferred to the cardiac surgery department immediately. Intra-operatively a perforation of the tissue at the basis of the LAA close to the left main coronary artery was discovered. The occluder was excised and the LAA was closed by endocardial sutures. Discussion In this report, we review the literature concerning interventional LAA occlusion and the reported cases of LAA perforation. Retrospectively, it remains unclear whether the perforation caused the resuscitation or was induced by it. To our knowledge, this is the first reported case of a laceration of a coronary artery by an occlusion device.

We present the case of an 80-year-old man who presented with symptomatic severe aortic stenosis and coronary artery disease (proximal left anterior descending artery, proximal circumflex artery, and first marginal branch). Surgical risk was considered high (Society of Thoracic Surgeons score 8.3%)

Wellens’ syndrome, also regarded as left anterior descending coronary T-wave syndrome, is an electrocardiography (EKG) pattern that indicates critical proximal left anterior descending artery (LAD) stenosis. It is characterized by deeply inverted T-waves or biphasic T-waves in the anterior precordial chest leads in a patient with unstable angina. Patients typically present with symptoms consistent with acute coronary syndrome. We present a unique case of Wellens’ syndrome with no angiographic findings of significant stenosis in the proximal LAD but with significant occlusion of the proximal circumflex artery and initial presentation with a chief complaint of epigastric pain and syncope. Physicians need to recognize these characteristic EKG changes during the pre-infarction stage, as they represent myocardial necrosis. Many of these patients eventually develop extensive anterior myocardial infarction with marked left ventricular dysfunction and death if coronary angiography and coronary revascularization are not performed within a few weeks. If Wellens’ is seen, patients should undergo urgent cardiac catheterization.

Key points Coronary wave intensity analysis (WIA) is an emerging technique for assessing upstream and downstream influences on myocardial perfusion. It is thought that a dominant backward decompression wave (BDWdia ) is generated by a distal suction effect, while early-diastolic forward decompression (FDWdia ) and compression (FCWdia ) waves originate in the aorta. We show that wave reflection also makes a substantial contribution to FDWdia , FCWdia and BDWdia , as quantified by a novel method. In 18 sheep, wave reflection accounted for ∼70% of BDWdia , whereas distal suction dominated in a computer model representing a hypertensive human. Non-linear addition/subtraction of mechanistically distinct waves (e.g. wave reflection and distal suction) obfuscates the true contribution of upstream and downstream forces on measured waves (the 'smoke and mirrors' effect). The mechanisms underlying coronary WIA are more complex than previously thought and the impact of wave reflection should be considered when interpreting clinical and experimental data. Abstract Coronary arterial wave intensity analysis (WIA) is thought to provide clear insight into upstream and downstream forces on coronary flow, with a large early-diastolic surge in coronary flow accompanied by a prominent backward decompression wave (BDWdia ), as well as a forward decompression wave (FDWdia ) and forward compression wave (FCWdia ). The BDWdia is believed to arise from distal suction due to release of extravascular compression by relaxing myocardium, while FDWdia and FCWdia are thought to be transmitted from the aorta into the coronary arteries. Based on an established multi-scale computational model and high-fidelity measurements from the proximal circumflex artery (Cx) of 18 anaesthetized sheep, we present evidence that wave reflection has a major impact on each of these three waves, with a non-linear addition/subtraction of reflected waves obscuring the true influence of upstream and downstream forces through concealment and exaggeration, i.e. a 'smoke and mirrors' effect. We also describe methods, requiring additional measurement of aortic WIA, for unravelling the separate influences of wave reflection versus active upstream/downstream forces on coronary waves. Distal wave reflection accounted for ∼70% of the BDWdia in sheep, but had a lesser influence (∼25%) in the computer model representing a hypertensive human. Negative reflection of the BDWdia at the coronary-aortic junction attenuated the Cx FDWdia (by ∼40% in sheep) and augmented Cx FCWdia (∼5-fold), relative to the corresponding aortic waves. We conclude that wave reflection has a major influence on early-diastolic WIA, and thus needs to be considered when interpreting coronary WIA profiles.

Extreme angulation of coronary artery takeoff represents a challenge for wiring and device advancement in percutaneous coronary intervention (PCI). This anatomic feature is particularly adverse in cases of chronic total occlusion (CTO) of the ostial-proximal segment of the target vessel. In this setting, the retrograde approach can help getting access to the occlusion. However, difficulties might arise at the critical step of wire externalization, due to the need to overcome the extreme ostial angle. Here, we describe a case of successful CTO PCI of the proximal circumflex artery, which presented an extreme angle at its takeoff. Due to inability to perform antegrade wiring of the occlusion, the retrograde approach was undertaken via epicardial collaterals from the right coronary artery. Since conventional attempts at re-entering the antegrade guiding catheter failed due to the aforementioned extreme angle, the retrograde wire was snared in the mid left anterior descending artery, and externalization was performed. This case demonstrates the usefulness of coronary snares in the CTO operator's toolkit and shows how such devices can be used to safely and successfully complete challenging retrograde procedures.

The feasibility of coronary artery bypass grafting using an internal thoracic artery (ITA) depends on the length of the graft with respect to the optimal route to reach the coronary target. The goal of this study was to assess the gain in length afforded by skeletonization and to evaluate the lengths of different pathways of the ITAs to the left coronary arteries. The left and right ITAs were dissected out from 20 specimens and measured before and after skeletonization. Distance between the origin of the right ITA and the base of the left atrial appendage, corresponding to the proximal circumflex artery, was measured for both the transverse pericardial sinus and preaortic routes. Skeletonization gave a significant gain of length for both ITAs. Analysis showed no significant correlation between the ITA length and the height, weight, and BMI of specimens. We found no association between the length of the sternum and the length of skeletonized RITA or LITA. The anterior route of the skeletonized right ITA was shorter than the transverse pericardial sinus route in 18 cases. The average length to the circumflex artery territory was 132.8 ± 23.5 mm in front of the aorta and 150.5 ± 18.8 through the transverse pericardial sinus with a gain of length of 17.7 mm (p

BACKGROUND Aorto-ostial lesions as well as bifurcation lesions still provide challenges in percutaneous coronary intervention (PCI), as meticulous stent placement is needed. The Szabo-technique, which uses a second wire to anchor the stent at the ostium, may be helpful here. In this article, we will provide detailed information on the technique including video material as well as procedural and long-term follow-up data of a cohort of patients treated with this technique. METHODS A retrospective single-centre study was performed in patients undergoing Szabo-PCI from 2014 to 2016 (N.=28). RESULTS Indications for PCI were elective in 53% and urgent/emergent in 47%. Target vessel was the ostial right coronary artery in 43%, the ostial left main artery in 7%, the proximal left anterior descending artery in 29% and the proximal circumflex artery in 21% of the cases. Primary success rate was 86%. In the other 14%, delivery of the stent failed due to a high-grade calcification. There were no periprocedural complications. During the follow-up time (mean 308 days) there was one case of cardiovascular and one case of non-cardiovascular death without any stroke events. In one case target lesions revascularisation was necessary. CONCLUSIONS The Szabo-technique offers a feasible and safe approach for PCI of ostial and bifurcation lesions. Calcified lesions seem to be a challenging aspect.

Coronary artery aneurysms are a rare finding and even more any coronary dilation having a diameter 1.5 times greater than the adjacent artery qualified as giant. No established treatment protocol exists. We report the case of a 75-year old man with a clinical symptom of chest pain on exertion, worsening in the last 6 months, who was diagnosed with a giant left main aneurysm. Surgical ligation of the proximal left anterior descending artery and first diagonal and triple bypass, using saphenous vein graft to vascularize the proximal circumflex artery, left anterior descending artery and first diagonal, was performed.

Coronary stent dislodgement or embolization before deployment is a rare but serious complication in interventional cardiology. A 60-year-old male presented with unstable angina five years after coronary artery bypass surgery. There was a stenosis (70%) in the obtuse marginal branch of the circumflex artery. During percutaneous coronary intervention, a sirolimus-eluting stent was stripped from its balloon mainly because of significant proximal angulation and incarcerated within the proximal circumflex artery. A smaller balloon dilatation catheter was advanced and pushed through the inside of the slipped stent. Using this technique, the stent could be advanced into the lesion and was successfully deployed. To our knowledge, this is the first case report on sirolimus-eluting stent dislodgement.

Background Injury to the circumflex artery after mitral valve (MV) repair or replacement is a recognized complication of this procedure. We designed an echocardiographic method to visualize the course and flow of the circumflex artery, to detect iatrogenic injury to this structure intraoperatively, as well as to predict the coronary dominance pattern in MV surgery patients. Methods After Ethics Committee approval, a prospective study was undertaken in 110 patients undergoing minimal invasive MV repair. Intraoperative transesophageal echocardiography was used to visualize the circumflex artery using a combination of B-mode imaging and color Doppler with different Nyquist limits. The course of the circumflex artery and the coronary sinus and their corresponding diameters were documented at the proximal and distal ends of both vessels. Preoperative angiographic data were used to determine the coronary dominance type. Results The course of the circumflex artery could be detected proximally in 109 patients (99%), to the point of intersection with the coronary sinus in 99 patients (90%), and distal to this intersection in 95 patients (86%) using our technique. Three patients had evidence of iatrogenic aliasing (circumflex stenosis) or "no flow" (circumflex occlusion) on transesophageal echocardiography examination after repair and therefore underwent surgical or percutaneous correction. All 3 of these patients had an uncomplicated postoperative course thereafter with no evidence of perioperative myocardial infarction. All remaining patients with normal circumflex examinations after repair did not show any clinical evidence of myocardial infarction or unstable hemodynamics postoperatively. The 95% confidence interval for the diameter of the proximal circumflex artery was 4.5 mm to 5.6 mm for the left dominant type patients and 3.8 mm to 4.2 mm for the right dominant and balanced type patients ( p = 0.01). Conclusions The early recognition of iatrogenic injury of the circumflex artery is feasible with intraoperative transesophageal echocardiography examination, and may lead to treatment before extensive myocardial infarction occurs. We suggest that visualization of the circumflex artery with our technique should be performed more frequently in patients undergoing MV surgery.

A52-year-old Native American man with a history of hypertension, hyperlipidemia, and tobacco abuse presented ith C6-7 myelopathy for cervical fusion. A review of systems evealed a history of chest tightness with exertion for which he nderwent a preoperative cardiac evaluation. A nuclear stress est revealed a subtle reversible defect in the basal anterior wall f the left ventricle (LV) and a moderate-sized fixed defect in he basal and midinferior walls of the LV, with a possible ocalized pericardial or pleural effusion. A cardiac cathetrization showed a 60% to 70% proximal circumflex artery cclusion, 60% to 70% obtuse marginal 1 lesion, and a

A 74-year-old woman showed electrocardiographic signs of severe lateral ischemia with no hemodynamic consequence after mitral valve repair for severe mitral regurgitation. An angiogram showed interruption of the proximal circumflex artery. The patients then underwent an on-pump beating heart marginal branch revascularization. A new angiogram performed before discharge showed a widely patent graft. (J Card Surg 2010;25:163-165)

There exists an extensive literature describing the clinical and morphologic characteristics of coronary artery fistulas [1, 2]. The angiographic and echocardiographic appearances of the two cases in the reports that follow highlight the confusion in the current literature with regard to differentiating coronary arteriovenous fistulas and the entity known as the aorto-right atrial tunnel [3, 4]. The aorto-right atrial tunnel is a very rare anatomic condition in which the communication arises directly from the aorta, with dilation of the corresponding sinus of Valsalva [4]. The ‘‘tunnel’’ consists of a dilated and tortuous vessel originating from either the left, or noncoronary, sinus with variable entry to the right atrium. The coronary arteries arise independently of the aorto-right atrial tunnel, and no branching vessels (coronary artery) arise from the tunnel itself. Two-dimensional echo cardiography can differentiate a coronary arteriovenous fistula by visualizing both coronary origins separately away from the tunnel. They manifest as a dilated main coronary artery with proximal and distal branches that distribute into the myocardium [4, 5]. The sinus of Valsalva has normal morphology.

Cardiac computed tomography allows for improved, noninvasive and accurate visualization of coronary artery anomalies. The case of a single coronary artery with origin from a single ostium in the right sinus of Valsalva with an anomalous course of the left coronary artery anterior to the pulmonary trunk is presented. The unusual distal reconstitution of a normal anatomical course at the junction of the mid and distal left anterior descending artery with occlusion of the proximal circumflex artery has not, to the authors' knowledge, been previously described.

Coronary embolisation is a very rare complication of the clinically widespread method of percutaneous transluminal coronary angioplasty (PTCA). The well-documented case of a 64-year-old male patient is presented comparing angiographic and morphological findings. The occluded left anterior descending artery (LAD) was successfully dilated during PTCA. Simultaneously the circumflex artery showed acute occlusion. The patient fell into cardiac shock and died after attempted resuscitation and agonal installation of extracorporeal circulation. The autopsy revealed severe residual stenosis of the proximal LAD by parietal thrombosis and occlusion of the proximal circumflex artery by an unattached intraluminal thrombus (0.8 x 0.3 x 0.2 cm) which had been dislocated during PTCA. Autopsy thus confirmed the clinical presumption of coronary embolism and, in addition, disclosed a previously unknown perforation of the femoral artery which had occurred during agonal installation of extracorporeal circulation and contributed to death via severe retroperitoneal hemorrhage. The case is discussed under the aspects of clinical quality control by forensic pathological investigations.

We report two cases of coronary-to-bronchial artery communication responsible for coronary steal. In both cases the anastomosis originated from the proximal circumflex artery and developed because of bronchiectasis. In both cases closure of the anastomosis was achieved successfully by embolization. To date, the patients remained free from symptoms.

But Mouse, thou are not alone, In proving foresight may be in vain: The best laid schemes of mice and men, Often go awry, And leave us nought but grief and pain, For promised joy! — —Robert Burns, “To a Mouse” (1785) Reimer et al1 have been widely acclaimed for helping to usher in the reperfusion era in the treatment of ST-elevation myocardial infarction (STEMI). Using a dog model of proximal circumflex artery ligation for different periods of time, they demonstrated that a “wave of cell death” develops first in subendocardial myocardium and progressively spreads to midepicardial and subepicardial myocardium over hours. Transmural infarct size was 38% after 40 minutes, 57% after 3 hours, 71% after 6 hours, and 85% after 24 hours of ischemic injury. The presence of a subepicardial zone of ischemic but viable myocardium that might be salvaged by early reperfusion established the anatomic justification for fibrinolytic therapy and primary percutaneous coronary intervention to modify infarct size in patients with STEMI. Article p 2909 Interestingly, the article that immediately followed the Reimer et al article in the November 1977 issue of Circulation was by the same group and was entitled “Infarct Size Reduction by Propranolol Before and After Coronary Ligation in Dogs.”2 Using the same animal model, they randomized dogs to intravenous propranolol before coronary occlusion, intravenous propranolol 3 hours after coronary occlusion, or saline infusion and euthanized the dogs at 24 hours without restoring reperfusion. Pretreatment with propranolol decreased transmural infarct size from 85% to 52%, whereas delayed treatment was about half as effective, decreasing infarct size to 71%. Whether other pharmacological or mechanical interventions added to reperfusion therapy can further reduce myocardial infarct size has been a major area of preclinical and clinical investigation for 3 decades.3 There have been dozens of …

A 79-year-old man, who had sustained nonpenetrating chest trauma 1 month previously, was admitted for dyspnea. Echocardiography demonstrated prolapse of the noncoronary aortic cusp with severe regurgitation. Aortography showed no intimal flap in the ascending aorta. Coronary arteriography showed dissection extending from the left main trunk to the proximal circumflex artery. At surgery, no abnormalities were found in the aortic wall or around the left coronary ostium. Avulsion of the commissure between the right coronary cusp and the noncoronary cusp from its aortic wall attachment was detected. Aortic valve replacement and coronary artery bypass grafting were performed.

Coronary aneurysms are quite uncommon, and those qualifying as giant aneurysms are even more so. Currently, no standardized treatment protocol exists. We report the case of a 46-year-old man presenting with clinical signs and symptoms of acute myocardial infarction who was found to have a giant coronary aneurysm. The patient was initially evaluated with a computed tomography angiogram, which revealed a 9-cm aneurysm of the left circumflex coronary artery. Surgical resection of the aneurysm, ligation of the proximal circumflex artery, and bypass using the left internal mammary artery to vascularize the proximal circumflex artery was performed.

The cardiac conduction system is composed of the sinoatrial node (SAN), the atrioventricular node (AVN), the His bundle, the right and left bundle branches, the fascicles, and the Purkinje fibers. Spreading of the pacemaking impulse from atrial to ventricular myocardium is delayed at the AVN located at the base of the interatrial septum. From the AV node, the propagation of the pacemaking impulse accelerates along the AV bundle and bundle branches, finally activating ventricular muscle via the Purkinje fiber network system. The atrioventricular node (AVN) and bundle (AVB) normally penetrate the right fibrous trigone (central fibrous body) at the atrioventricular junction. The SAN artery comes off of either the proximal right coronary artery (60–70 %) or the proximal circumflex artery. Alternative sources of arterial supply to the atrioventricular-conducting pathway include the descending septal artery, the first septal perforating artery, and anterior atrial branches inclusively the Kugel anastomotic artery. Anatomic structures related to arrhythmias include cavotricuspid isthmus, subthebesian pouch, septal isthmus, and pulmonary veins. Other anatomic arrhythmogenic elements are the ligament of Marshall, lipomatous hypertrophy of the interatrial septum, and cardiac autonomic nervous system.

Coronary vascular intraluminal release of endogenous endothelium-derived substances, such as prostacyclin, may affect downstream cardiac myocyte contractile function. With a “chronic” canine model of endothelialized and deendothelialized internal thoracic artery coronary grafts, we tested the hypothesis that higher basal release of endothelium-derived prostacyclin in internal thoracic artery bypass conduit effluent accelerates functional recovery of postischemic stunned myocardium in the intact circulation. Eleven dogs underwent left internal thoracic artery–left circumflex artery bypass, and the proximal circumflex artery was then ligated. Internal thoracic artery conduit endothelium was denuded by balloon catheter in five dogs before grafting and left intact in six dogs. After 7 days, awake dogs were studied to measure myocardial segment length in the circumflex region with ultrasonic dimension transducers, left ventricular pressure with micromanometers, and circumflex artery flow with an ultrasonic flow probe. Regional contractile function was quantified by the area beneath the linear preload recruitable stroke work relationship at baseline and at intervals after a 15-minute circumflex graft occlusion followed by 3 hours of reperfusion. Heart rate, left ventricular peak pressure, left ventricular end-diastolic pressure, left ventricular peak first derivative of pressure (dP/dt), and circumflex flow were similar (all p not significant) in endothelialized and nonendothelialized dogs during ischemia and reperfusion. Ischemia reduced the preload recruitable stroke work relationship to 44% ± 35% of control values ( p < 0.01) in endothelialized dogs and to 47% ± 18% of control values in nonendothelialized dogs ( p < 0.01) at 15 minutes of reperfusion, indicating a similar ( p not significant) initial degree of injury. During 3 hours of reperfusion, the preload recruitable stroke work relationship returned to 51% ± 17% of control values in endothelialized dogs but to only 35% ± 20% of control values in nonendothelialized dogs ( p < 0.02). Basal intraluminal release of endogenous prostanoids in excised internal thoracic artery conduits was subsequently quantified by ex vivo bioassay of vasoactive properties of conduit effluent on normal coronary artery smooth muscle. Endothelialized conduits induced greater smooth muscle relaxation than did nonendothelialized conduits (67% vs 23%), and this increased relaxation by endothelialized conduits was eliminated by indomethacin, a blocker of prostanoid synthesis. These data indicate that coronary bypass conduit endothelium–derived substances, such as prostacyclin, significantly influence downstream myocardial contractile response to ischemia and reperfusion, independent of alterations in coronary flow in the intact circulation. (J T HORAC CARDIOVASC SURG 1996;111:62-73)

Background Abnormal endothelium-dependent coronary response to acetylcholine has been shown in patients with essential hypertension. We tested the hypothesis that flow-dependent dilatation, which has been shown in normal human coronary arteries, is impaired in hypertensive patients. Methods and Results The coronary vasomotor response to maximal increase of blood flow induced by papaverine was studied in 10 control subjects and in 14 hypertensive patients with no other risk factors and angiographically normal coronary arteries. After the injection of papaverine in the midportion of the left anterior descending coronary artery (LAD), the diameter of the proximal LAD (LAD1) was measured by quantitative angiography, whereas that of the proximal circumflex artery (LCx) served as control segment. Estimates of coronary blood flow in the distal LAD (LAD2) were calculated by intracoronary Doppler flow velocity measurements. An increase in LAD2 blood flow of 521±41% ( P P P P P Conclusions Thus, the flow-mediated coronary dilatation is lost in hypertensive patients, and this may impair normal dilatation observed in response to an increase in myocardial metabolic demand.

The Wolff-Parkinson-White (WPW) syndrome was initially described in 1930 as a clinical syndrome of paroxysmal tachycardias in healthy young people that demonstrated “bundle-branch block and short P-R interval”. These tachycardias were eventually determined to be macro-reentrant arrhythmias utilizing accessory pathways. Surgical approaches for transecting these accessory pathways were being developed as early as the 1960s. Since 1984, catheter ablation has developed into a safe and highly effective therapy option, and the treatment of choice for WPW syndrome today. We present a unique case of a patient with previous surgically treated WPW syndrome that serves as a reminder of treatments past and caution for current therapies. A 54-year-old man with a remote history of WPW syndrome, treated in 1989 with surgical cryoablation of a left ventricular free wall accessory pathway, now presented with an hour of sustained palpitations after a triathlon practice session. He was found to have ventricular tachycardia at a rate of 180 bpm on EKG requiring external cardioversion. The troponin I level peaked at 2.59 ng/mL. Left heart catheterization revealed a peculiar truncated 100% occlusion of the proximal circumflex artery with extensive bridging collaterals to the mid circumflex artery, and also confirmed an infero-basal aneurysm. The cause of the ventricular tachycardia (VT) was deemed non-ischemic and he was referred for electrophysiology study. 3D electroanatomic mapping of the left ventricular (LV) endocardial surface was performed, revealing a discrete posterior wall scar. Reentrant VT was repeatedly induced utilizing a zone of slow conduction along the border zone of the scar. Radiofrequency ablation of Purkinje potentials on the LV septum, running alongside the scar border zone, eliminated the VT. The entire endocardial surface of the postero-basal scar was electrically silenced to prevent further VT events. Typically, during the surgical approach of WPW, a wide endocardial (rarely an epicardial) incision was made along the atrial surface of the mitral valve annulus, dissecting deeply and caudally until ventricular myocardium was exposed. Despite the close proximity of the circumflex artery to the epicardial incision line during these surgeries, there are only rare reports of coronary artery complications, generally considered to be either catheter-induced dissections or embolic events. The development of a network of extensive bridging collaterals in our patient supports progressive stenosis of the left circumflex artery from cryoablation thermic injury, leading to scar formation and VT years later. In conclusion, this case reminds us that current ablative therapies are still relatively new, and long-term follow-ups for delayed complications remain a necessity. J Med Cases. 2016;7(6):216-219 doi: http://dx.doi.org/10.14740/jmc2488w

A 37-year-old Asian American man presented with severe stable angina of recent onset over a period of 3 weeks. He was an active policeman, whose only significant past medical history was a prolonged febrile illness with a rash at age 5. Exercise myocardial perfusion stress test was strongly positive with ST depression in inferolateral leads and large reversible perfusion defects in the inferior, inferolateral, and lateral walls of the left ventricle. Cardiac catheterization revealed a large fusiform aneurysm of the proximal left anterior descending (LAD) artery, ectasia of the proximal circumflex artery with 95% narrowing, and an occluded right coronary artery with an occluded proximal aneurysm. (Figure 1). Figure 1. Coronary angiogram showing a proximal aneurysm of the left anterior descending (LAD) artery and ecstatic circumflex artery with severe stenosis inside the ecstatic segment. Coronary CT angiogram showed 3-dimensional extent of the aneurysms, stenoses, and, in particular, the LAD aneurysm's relation to the main pulmonary artery. The LAD aneurysm measured 11.7×17.7×24.2 mm, with a 2.5-mm diagonal artery arising from the side wall. (Figure 2). Figure 2. A, Computed tomography (CT) angiogram showing aneurysms and stenoses. B, CT angiogram showing …

A 43-year-old patient undergoes a transradial percutaneous coronary intervention for a bifurcation lesion of the left proximal circumflex artery and the first obtuse marginal branch (Medina 1,1,1) ([Fig. 1][1]). A 3.5 × 12-mm bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara

Recent studies have implicated inflammation in the pathogenesis of coronary artery disease and of acute coronary syndromes.1‐3 Systemic markers of inflammation such as C-reactive protein (CRP) are elevated in patients with coronary atherosclerosis, 4 and increase significantly in patients with unstable angina or acute myocardial infarction.5 CRP levels are also powerful predictors of cardiac complications and death in patients with unstable coronary syndromes5 as well as in healthy men and women without a prior cardiac history.6,7 A potential explanation for the high event rate in patients with elevated CRP levels is that a high CRP level is a marker for more severe and extensive coronary artery disease. This study was designed to determine whether CRP correlates with the extent and severity of coronary atherosclerosis as assessed by coronary angiography. ••• This was a prospective trial. Outpatients with stable angina or an abnormal stress test who were referred for diagnostic cardiac catheterization with coronary angiography were screened. Patients with any preexisting condition that may cause CRP elevation were excluded. This included patients with known inflammatory, infectious, or neoplastic diseases, and patients with a history of myocardial infarction or unstable angina or any percutaneous interventional or surgical procedure within 2 weeks. Patients taking corticosteroids, or nonsteroidal anti-inflammatory or immunosuppressive drugs were also excluded, as were patients with a prior history of coronary artery bypass graft surgery. Cardiac catheterization and angiography were performed in the standard fashion. Each coronary angiogram was read by 2 interventional cardiologists who were blinded to CRP results and agreement was reached by consensus. Stenosis severity was determined using calipers. To assess the extent of atherosclerotic involvement, a coronary atherosclerosis score was designed using the following model. The coronary artery tree was divided into 9 segments: the left main coronary artery, the proximal, mid-, and distal left anterior descending artery (the major diagonal branch was considered part of the mid‐left anterior descending artery), the proximal circumflex artery including the first obtuse marginal branch, the circumflex artery distal to the first marginal branch, the proximal and mid‐right coronary artery, and the posterior descending artery. Each of these segments was scored from 0 to 3 depending on the most severe diameter stenosis according to the following system: 0 5 normal, 1 5 stenosis between 1% and 49%, 2 5 stenosis between 50% and 99%, and 3 5 total occlusion. In the case of total occlusion, each of the segments distal to the occlusion was arbitrarily given a score of 1. A coronary atherosclerosis score was generated as the sum of the scores in all segments. In addition, the number of vessels with coronary artery disease in each patient was calculated as the number of vessels with a stenosis $50%. CRP was measured immediately after insertion of

A 47-year-old man was admitted with a massive inferolateral wall infarction due to proximal circumflex artery obstruction. After emergent percutaneous coronary intervention, the patient remained hemodynamically unstable because of severe mitral valve insufficiency due to massive annular dilatation combined with diffuse 3-vessel coronary disease and poor left ventricular function. Mitral valve annuloplasty and concomitant coronary bypass grafting were performed with good recovery initially. On the ward, the patient became …

The effects of pharmacologic vasodilation and reductions in circumflex coronary artery pressure on the ventricular diastolic pressure-segment length and pressure-wall thickness relations were studied in nine conscious dogs equipped with an inflatable cuff on the proximal circumflex artery, a micromanometer in the left ventricle and four sets of piezoelectric crystals to measure wall thickness and endocardial segment length in the left circumflex and left anterior descending artery territories.Adenosine infusion into the circumflex coronary artery increased endocardial and transmural blood flow to that territory (measured by microspheres) by 436% and 487%, respectively (both p < 0.05), and shifted the left circumflex artery territory pressure-wall thickness curve upward (p < 0.05) without affecting the circumflex pressure-segment length, the left anterior descending artery territory pressure-segment length or pressure-wall thickness curves significantly; papaverine also shifted the circumflex region pressure-wall thickness curve upward (p < 0.05).Both with and without vasodilation, moderate reductions in circumflex artery perfusion pressure did not affect the position of the ventricular pressure-wall thickness or the pressure-segment length curve (although during adenosine infusion endocardial blood flow decreased from 436% to approximately 100% of control values). More severe reductions in perfusion pressure (

Calcitonin gene-related peptide (CGRP) is a potent vasodilator, but its effects on in situ ventricular function are unknown. We studied effects of intracoronary CGRP (100, 200, and 600 pmole/min, for 10 min) in 21 open-chest chloralose-anesthetized dogs. Systemic, pulmonary, left ventricular (LVP), central venous, and pulmonary capillary wedge pressures were continuously monitored. Left ventricular wall thickness (WT) and circumflex coronary blood flow were also measured. CGRP was infused into the proximal circumflex artery. During CGRP infusion there were no changes in heart rate, cardiac index, pulmonary artery pressure, or systemic vascular resistance, no percentage change in ventricular WT, and no changes in dWT/dt, peak dP/dt, or the slope of end-systolic points on WT/LVP loops. But there were significant changes in coronary flow (CQ), coronary resistance (CRES) and mean arterial blood pressure (MAP) from control (C)* (P less than 0.05). (table; see text) CGRP is a potent coronary artery vasodilator causing notable dose-dependent decreases in coronary resistance and a rise in myocardial flow, despite a decreased MAP (all P less than 0.05). CGRP does not affect ventricular contractility in vivo.

Aim The study aim was to determine the sequence of changes in both wall thickness and function in ‘at risk’ myocardium (using M-mode and radial strain/strain-rate imaging) induced by reperfusion of an acute transmural infarction, and to relate these changes to the presence or absence of a pressure-limiting stenosis in the infarct related epicardial vessel. Methods Eighteen closed-chest pigs were randomized into two groups (each with nine animals). In Group I, 4 weeks prior to induction of an acute transmural infarct, a copper coated stent was implanted in the proximal circumflex artery (Cx) to create a coronary artery stenosis of between 30 and 95% lumen diameter. At 4 weeks, the stenotic Cx vessel was occluded for 90 min by inflation of a PTCA balloon placed proximal to the stenosis to produce an acute transmural infarction. In Group II (the control group), 90 min Cx occlusion was performed in a normal vessel. In both groups the resulting acute transmural infarction was reperfused after 90 min by removing the PTCA balloon. For both groups, cardiac ultrasound data, including strain/strain-rate imaging, were collected at all stages of the investigation for subsequent offline analysis. Results In both groups, acute reperfusion (TIMI flow 3 or 2), immediately increased infarct zone end-diastolic wall thickness due to the development of oedema. The acute increase in wall thickness was significantly higher in the non-stenotic animals as compared to the ones with a residual stenosis. Neither of the groups showed any tendency to normalize deformation (strain) during the reperfusion period. Conclusion In this experimental study, the measurement of end-diastolic wall thickness was a simple and non-invasive tool to monitor acute infarct reperfusion. It also provided information on the presence of a flow limiting stenosis in the infarct related artery after restoration of the flow. The deformation of the myocardium remained impaired during early reperfusion, whether reflow was at full pressure or low pressure due to a residual stenosis in the infarct related artery.

We occurred in a left main (LM) dissection during primary coronary intervention in a 45-year-old man with anterior acute myocardial infarction. Successful, multiple direct stenting was performed from the ostial to the mid left anterior descending coronary artery (LAD). Nonetheless, an LM dissection involving the proximal circumflex artery (Cx) was still evident at the end of the intervention. Multislice Computed Tomography (MSCT) coronary angiography images showed that LM dissection was definitely long and close to the ostium; moreover, the proximal stent had both excluded the false lumen in the LAD and stabilized the dissection towards the Cx. Two months later, at MSCT coronary angiography the LM dissection was still evident and the patient had remained totally asymptomatic. MSCT coronary angiography can be recommended as a complementary diagnostic tool for the assessment of LM anatomy because of the possibility of three-dimensional reconstructions and consequent clear evaluation of its take-off, course and bifurcation.

Background— Residual or recurrent mitral regurgitation frequently occurs after mitral ring annuloplasty repair for ischemic mitral regurgitation (IMR), because annuloplasty primarily addresses annular dilatation. We describe a subvalvular repair technique addressing posterior papillary muscle (PPM) displacement. Methods and Results— Ten sheep had radiopaque markers placed on the left ventricle (LV) and mitral apparatus. A suture was anchored at the right fibrous trigone, passed through the PPM tip and LV wall, and exteriorized through a tourniquet (STRING-1). A second suture was anchored transmurally in the high septum (anterobasal LV wall) and passed through the PPM and LV wall (STRING-2). Reversible posterolateral ischemia was induced by temporarily occluding the proximal circumflex artery. Under open chest conditions, 3D marker coordinates were obtained with biplane videofluoroscopy at baseline and during acute ischemia before and after tightening of each STRING using transesophageal echocardiography to grade IMR. IMR decreased (mean±SEM, 2.0±0.1 to 1.2±0.1; P P P Conclusions— Basal repositioning of the PPM with STRING-1 reduced acute IMR without concomitant annular reduction. This technique may be a useful adjunct if residual IMR is likely after undersized ring annuloplasty.

To the Editors, We have read with great interest the article by Jeewa and colleagues published in Pediatric Cardiology describing two cases of coronary arteriovenous fistula [1]. The authors reported that the dilated left coronary artery communicated directly with the coronary sinus. The abnormal vessel ran along the atrioventricular groove and entered into the right atrium through a restrictive Thebesian valve. The morphology and location of this dilated vessel suggested the direct connection of the proximal circumflex artery to the coronary sinus. We recently experienced a case quite similar to these cases. A 12-year-old girl was referred to our hospital for a continuous murmur. The echocardiography had shown an appearance similar to that of the reported cases. The aortography also showed that the dilated left circumflex artery appeared to connect with the enlarged coronary sinus (Fig. 1a, b). However, the multidetector-row computed tomography (MDCT) images showed that the coronary sinus was present next to this abnormal vessel (Fig. 1c, d). This dilated vessel originated from left coronary artery and drained directly to the right atrium. We considered that this abnormal vessel could not be the coronary sinus in either our case or Jeewa’s cases. If the vessel was the coronary sinus, the coronary perfusion would not be workable because the blood pressure in the coronary sinus can be much higher than in the peripheral coronary arterial branches. It was quite difficult to distinguish the coronary sinus from the abnormal dilated vessel draining into the right atrium using echocardiography or conventional angiography. Although fistulas between the circumflex coronary artery and the coronary sinus are rare [2], it is quite important and essential to make a precise diagnosis. In these cases, MDCT is a promising tool for precise depiction and determination of the optimal treatment.

Heparin accelerates coronary collateral development in various animal models of myocardial ischemia. The purpose of this study was to clarify the beneficial effect of heparin on canine collateral development. Seventeen adult mongrel dogs were instrumented for measurements of a subendocardial segment length in the central area perfused by the left circumflex coronary artery, its flow, and left ventricular pressure. A pulsed Doppler flow probe and an externally inflatable pneumatic occluder were placed around the proximal circumflex artery. After the recovery from surgery, 2-min circumflex coronary artery occlusions were repeated eight times at 58-min intervals daily. After excluding seven dogs with well-developed preexisting collateral circulation, ten dogs were randomized into two groups with (n = 5) and without (n = 5) heparin treatment. The total occlusion time until adequate collateral development (an index of collateral growth) was 164+/-34 (SD) min in dogs with heparin treatment, being significantly less than 289+/-49 min in dogs without heparin (p

We present a case of severe proximal circumflex artery tortuosity with two 90 degrees bends and then a tight stenosis in the mid part of first obtuse marginal branch. Conventional method used to cross the lesion by wire failed. However, a commercially available new wire with ability to change the degree of tip angulation (Pilot wire, USCI Bard) was then used successfully to cross the stenosis. In addition, the wire straightened the tortuosities and provided good trackability to the balloon. Thus, this new wire is a valuable addition to the angioplasty armamentarium.

Mitral regurgitation (MR) was evaluated by color Doppler echocardiography during percutaneous transluminal coronary angioplasty (PTCA) in 28 patients with one-vessel artery disease (left anterior descending artery in 11, right coronary artery in 8, and circumflex artery in 9) and normal left ventricular function. In all three groups, left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) decreased significantly during artery occlusion in comparison with baseline values (no differences among various groups). Anterior and inferior akinesia/dyskinesia was observed in all patients during left anterior descending and right coronary artery occlusion, respectively. Lateral akinesia/dyskinesia was induced by occlusion of the circumflex artery in six patients (all with proximal lesions [p0.05 vs the other two groups]) and the right coronary artery in one. Only the six patients with circumflex artery occlusion showed PTCA-related MR (2+ in two). LVEF and WMSI were similar during artery occlusion in patients with and without MR. Neither mitral leaflet prolapse nor anulus dilation occurred during PTCA in any of the patients. Our data show that during brief occlusion of the proximal circumflex artery, functional MR (usually mild) frequently occurs in relation to specific lateral akinesia/dyskinesia.

To assess feasibility, sensitivity, and specificity of transesophageal echocardiography (TEE) in visualizing proximal left coronary artery segments (entire left main, proximal left anterior descending, and circumflex) and in identifying proximal coronary stenosis, 160 consecutive patients were studied. Each patient underwent TEE before coronary angiography; the echocardiographic images were digitized and reviewed in a continuous cineloop format. The entire proximal left coronary artery was adequately imaged in 111 patients (70%). A stenosis was considered to be present at TEE if hyperreflecting plaques narrowing the coronary lumen were observed. TEE suggested the presence of a stenosis in 6 of 6, 50 of 63, and 13 of 24 patients with stenosis detected at angiography on the left main, left anterior descending, and circumflex, respectively, and 2 of 105, 5 of 48, and 14 of 87 patients without angiographically detectable coronary stenosis in corresponding coronary segments. Thus, sensitivity and specificity of TEE in identifying stenosis of the left main coronary artery, proximal left anterior descending artery, and proximal circumflex artery were 100% and 98%, 79% and 89%, 54% and 84%, respectively. In conclusion, TEE identification of the proximal left coronary artery is feasible in most patients. Accuracy in identifying significant proximal stenosis varies from segment to segment and is higher for the left main coronary artery.

This report describes the case of a 26-year-old male diagnosed with angina on exertion. A diagnostic coronary angiography revealed significant luminal narrowing at the middle third of the left anterior descending artery and proximal circumflex artery. The patient underwent implantation of sirolimus-eluting stents. Eight months after implantation of the stents, a follow-up coronary angiography showed intrastent coronary artery aneurysms. We suggest that the implantation of the sirolimus-eluting stent caused late formation of a coronary artery aneurysm. (Korean Circulation J 2007;37:127-129)

In complex coronary bypass procedures it is often desirable to target the left circumflex coronary distribution at a site other than the obtuse marginal and terminal branches. Reluctance to bypass into the circumflex artery in the atrioventricular groove is due to difficulty in exposure and possible injury to the coronary sinus. Herein is presented our technique for exposure and anastomosis into the proximal circumflex artery, which avoids these pitfalls. This technique has been consistently simple to perform with excellent results.

Recently, Williams et al’ reported that acute administration of estrogen attenuates the coronary vasoconstrictor response to acetylcholine in atherosclerotic cynomolgus monkeys. These observations suggest that estrogen plays a fundamentally important role in the relationship between coronary vascular endothelium and vascular smooth muscle. This study examines the influence of current estrogen replacement therapy in postmenopausal women on endothelial-dependent and independent vasomotor responsiveness to acetylcholine. Ten postmenopausal women with exertional angina undergoing routine diagnostic coronary angiography or percutaneous transluminal coronary angioplasty were studied. The protocol was approved by the Clinical Research Practices Committee and each subject gave informed consent before the study, Four women were taking estrogen replacement therapy (PremarinB 0.625 to 1.25 mglday or topical estradiol 0.1 mg). None of the women were taking progesterone. All of the women had minimal coronary artery narrowings in the proximal portion of the left anterior descending or a nondominant circumflex coronary artery. Vasoactive medications were withheld for 12-24 hours before the procedure. A 3Fr infusion catheter was positioned in the proximal left anterior descending or proximal circumflex artery through the guiding catheter. After the baseline angiogram was recorded, 3 consecutive 2-minute infusions of acetylcholine were administered into the proximal coronary artery. The$ow rate (0.8 mllmin) was calculated to deliver a final estimated blood concentration of 10s, 10m7 and 10m6 M. After each acetylcholine infusion, repeat angiography was performed in an identical fashion to baseline. After the third acetylcholine in& sion and angiogram, a 50 pg bolus of nitroglycerin was administered and a final coronary angiogram was recorded. Heart rate, blood pressure and appropriate electrocardiographic leads were monitored during the infusions to verify the absence of any changes in hemodynamic status or evidence of &hernia. Proximal and midvessel segments of the coronary artery distal to the tip of the infusion catheter were analyzed without knowledge of the estrogen status using a quantitative coronary angiography method (Gammasonits, Chicago, Illinois). When possible, coronary segments from the noninfused half of the left coronary distribution

Coronary bypass grafts using the internal mammary artery usually have an excellent record of success and long term patency. We report a 42 year old man who initially presented with a history of atypical left sided chest pain, who had coronary artery bypass surgery for a severe stenosis in his proximal left anterior descending coronary artery (LAD) and moderate stenosis of his proximal circumflex artery, with his LIMA being grafted to his mid-LAD and a saphenous venous graft to the proximal LAD. He subsequently developed multiple stenoses in the LIMA graft which required coronary augioplasty and stenting, on more than one occasion, in view of very rapid restenosis within the LIMA graft. Keywords: graft patency; left internal mammary artery grafts; restenosis; stenosis

The Animal Models for Protecting Ischemic Myocardium Study was undertaken for the purpose of developing reproducible animal models that could be used to assess interventions designed to limit infarct size. This paper describes the results obtained in an unconscious dog model and in a conscious dog model, developed in three participating laboratories. The unconscious dog model, involving reperfusion after 3 hours of ischemia in open-chest dogs, was intended to determine whether therapy followed by early reperfusion would limit infarct size more than reperfusion alone. The conscious dog model used chronically instrumented dogs and permanent coronary occlusion to better mimic myocardial infarction in man. In both models, the proximal circumflex artery was occluded, and the primary experimental endpoint was infarct size, as measured by histological techniques 3 days after the initial occlusion. Infarct size was analyzed in relation to baseline variables including the anatomic area at risk, collateral blood flow to the subepicardial zone of ischemia and hemodynamic determinants of myocardial metabolic demand. Most of the variation in infarct size in control dogs could be related to variation in the area at risk, collateral blood flow, and rate pressure product. Using multivariate analysis and groups of 15 dogs, an intervention that limited infarct size by 10-13% of the area at risk would have been detected 50% of the time. Larger treatment effects would be detected more readily, and smaller effects often would be missed, unless group sizes were larger. Two drugs, verapamil and ibuprofen, were evaluated in both models, with experimental group sizes averaging 13 and 20 dogs, in the unconscious and conscious models, respectively. Three of 15 verapamil-treated dogs in the unconscious model study had much smaller infarcts than expected from baseline parameters. With these exceptions, neither drug limited infarct size in either model.

Computerized tomography was evaluated as a technique for imaging and measuring the effect of an intervention on acutely ischemic myocardium. Because cell edema occurs with acute myocardial ischemia and decreases the X-ray attenuation coefficients (tissue density) of myocardium, computerized tomographic images were used to quantitate the effect of hyperosmotic mannitol on ischemia-induced edema. Canine hearts were arrested and scanned after (1) temporary occlusion of the proximal circumflex artery followed by reflow of blood, or (2) continued occlusion of the distal left anterior descending coronary artery. X-ray attenuation values (Hounsfield units) were linearly related to tissue wet/dry weight ratios (r = 0.87, P less than 0.001). After 2 hours of occlusion of the left anterior descending coronary artery the hearts that received mannitol manifested a significant reduction (P less than 0.05) in the volume of left ventricular wall involved with edema. Although the area of edema measured with computerized tomography tended to be smaller in the hearts treated with mannitol than in untreated hearts subjected to a 6 hour occlusion of the left anterior descending coronary artery, the size of the lesion was variable and did not differ significantly from that in untreated hearts. With either short periods of circumflex arterial occlusion followed by blood reflow or with 2 or 6 hours of prolonged occlusion of the left anterior descending coronary artery, the difference in mean attenuation coefficients between the ischemic and nonischemic areas of myocardium in mannitol-treated and untreated hearts was significantly less. These results indicate that computerized tomography in the arrested heart can detect and quantitate the lesion of early acute myocardial ischemia and can quantitate the effect of drug intervention.

The left Kugel's artery is an uncommon but sometimes important collateral between the proximal circumflex artery and whatever artery supplies the crux of the heart. It passes anterior to the mitral valve ring, coursing in the interatrial septum, to anastomose usually with the atrioventricular node artery. The left Kugel's artery was prospectively identified on coronary arteriograms in 3.6% of patients with significant disease in dominant circumflex or right coronary arteries with associated collateral circulation. It was occasionally as large as 1 mm in diameter. The angiographic anatomy of this vessel is described.

The relationship between inducible ventricular tachycardia in the convalescent phase of myocardial infarction and subsequent spontaneous ventricular fibrillation is uncertain. Thirty conscious instrumented dogs underwent programmed ventricular stimulation 5 days after anterior infarction; 15 had inducible ventricular tachycardia and 15 were noninducible. Following programmed ventricular stimulation, the application of a 150 uA current to the intima of the proximal circumflex artery initiated intimal damage, thrombosis, and acute ischemia of the posterolateral wall. After 20 minutes of ischemia, 73% inducible and 15% noninducible animals developed ventricular fibrillation (p less than 0.005) without previous hypotension. At 24 hours, 7% inducible and 85% noninducible animals survived (p less than 0.001). Anterior infarct size (percentage of left ventricular mass) was much larger in inducible (24.7 +/- 1.7%) than in noninducible (5.3 +/- 1.1%) (p less than 0.001) animals. Inducible ventricular tachycardia following infarction was highly predictive of spontaneous ventricular fibrillation during a later ischemic episode in this model. The mass of previously injured myocardium was a critical determinant of both.

The reported high incidence of coronary atherosclerosis in many transplant series led us to critically review our experience in 83 patients who have had selective coronary angiography at ≥1 years after transplantation. Angiograms were reviewed for evidence of coronary vascular disease, and quantitative analysis of multiple coronary artery segments was performed in serial films. Qualitative analysis revealed only 3 of 83 patients with any angiographic abnormality at follow-up, 1 with minimal luminal irregularities in the right coronary artery at 1 year, a second with a 50% diameter stenosis of the proximal left anterior descending artery and minimal irregularity of the proximal circumflex artery at 1 year and a third patient who developed a new 30% diameter eccentric proximal right coronary artery stenosis at 3-year follow-up. The cumulative incidence of graft vascular disease assessed angiographically was therefore 2% at 1 year and 4% at 3 years. Quantitative analysis, however, showed a significant decrease in coronary artery luminal diameter over time. The mean left main coronary artery diameter decreased from 5.4 ± 0.9 mm at 1 year to 4.7 ± 0.8 mm at 3 years (p = 0.0007). A significant reduction in luminal diameter also was found in the following segments (measurements are given 1 vs 3 years): proximal left anterior descending artery (4.4 ± 0.7 vs 4.0 ± 0.5 mm, p = 0.003), mid-left anterior descending (2.7 ± 0.5 vs 2.5 ± 0.4 mm, p = 0.009), proximal circumflex (3.9 ± 0.6 vs 3.6 ± 0.7 mm, p = 0.0003), mid-circumflex (3.0 ± 0.6 vs 2.8 ± 0.7 mm, p = 0.005) and proximal right coronary artery (4.0 ± 0.7 vs 3.7 ± 0.6 mm, p = 0.05). In addition, 7 of 8 hearts obtained at autopsy or retransplant showed significant degrees of diffuse fibrointimal hyperplasia, unsuspected from angiography performed as recently as 7 days earlier. Thus, although segmental coronary vascular disease was uncommon in these patients, diffuse vascular disease may be insidious, progressive and undetectable by current angiographic techniques.

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. In contrast to findings in patients manifesting only typical exertional angina, the hemodynamic findings during spasm were those of a hypodynamic state. Left ventricular systolic pressure decreased from 138.9 ± 6.0 (mean ± standard error of the mean) to 113.2 ± 6.2 mm Hg; left ventricular end-diastolic pressure did not change significantly. Myocardial lactate extraction during spasm was invariably markedly reduced: −53.19 percent ± 15.44 ( P The respective roles of medical and surgical intervention are uncertain. Only 3 patients had a completely satisfactory pharmacologic response to nitrates alone or in combination with propranolol, and the condition of 5 others was partially improved; the remaining 21 patients were judged intractable to medical management. Coronary bypass surgery was performed as the ultimate recourse in 18 patients. However, short-term results reveal that only nine (50 percent) showed improvement, four (22 percent) had myocardial infarction during or after surgery and four (22 percent) died. These studies confirm that coronary arterial spasm is a definite pathogenetic factor in a variety of acute myocardial ischemic syndromes. The incidence and full clinical significance of this functional disorder remain to be determined.

Detailed information on the roentgenographic anatomy of the human coronary arterial system was worked out through study of anatomic literature, 3 dimensional vinylite corrosion casts of human coronary arteries, and cine arteriograms taken with selective injection of the right and left coronary arteries by the Sones technique.The left anterior oblique projection was found best for the right coronary artery and its branches, the left main, distal anterior descending artery, the anterior descending branches, the proximal circumflex artery, and some of the proximal circumflex branches.The right anterior oblique projection is also necessary because it is the only view that shows the proximal anterior descending and septal arteries well. It is often helpful for the midportion of the circumflex artery and its branches.The posteroanterior projection is less satisfactory and cannot be considered an adequate substitute for either oblique projection. It is sometimes helpful as a supplement and has been recently incl...

Smoking "crack" is currently popular; this results in rapidly peaking, high blood levels of cocaine. Our purpose was to investigate the effects of rapid cocaine administration. Hemodynamics, myocardial blood flow, and left ventricular cavity end-systolic and end-diastolic areas were measured in pentobarbital-anesthetized dogs before and 15 minutes after (1) a bolus intravenous injection of cocaine (n = 6), or (2) a 10-minute infusion of cocaine (n = 6), or (3) saline (n = 6) administration. In both treated groups cocaine caused a significant reduction in heart rate and left ventricular dP/dt compared with baseline measurements, and an increase in left ventricular end-diastolic pressure. Cocaine also caused dilation of the left ventricle and a fall in regional myocardial blood flow. In nine other dogs, proximal circumflex artery diameter, assessed by angiography, and regional myocardial blood flow were measured before and 3 to 5 minutes after cocaine (n = 7) or saline (n = 2). In treated animals, circumflex artery diameter was reduced 15 +/- 4% (range 2% to 29%, p less than 0.01 versus baseline) after cocaine. We conclude that in this model, rapid administration of cocaine depresses left ventricular function, causes left ventricular dilation, and is associated with coronary artery vasoconstriction and reduced myocardial blood flow.

Origin of a septal perforating artery from a proximal portion of the left coronary system other than the left anterior descending artery was seen on coronary angiography in 18 out of 800 patients over a 14-month period. It arose from the first diagonal artery in 12 patients, the proximal circumflex artery in 2, and the first marginal artery in 4. The angiographic appearance and clinical significance of this finding are described.