COMBINED REPLACEMENT OF THE AORTIC VALVE AND ASCENDING AORTA IN JEHOVAH'S WITNESSES: REPORT OF TWO CASES

Two Jehovah's Witnesses with large ascending thoracic aortic aneurysms and aortic insufficiency secondary to annuloaortic ectasia underwent successful combined replacement of the aortic valve and the ascending aorta. One patient received a composite graft containing an aortic valve prosthesis, which necessitated supravalvular coronary ostia reimplantation; the other patient underwent separate aortic valve and left supracoronary ascending aneurysm replacement, with reimplantation of the right coronary ostium into the graft. No blood or blood derivatives were administered. Both patients had uneventful recoveries and continue to do well. To our knowledge, they represent the first reported cases of successful combined replacement of the aortic valve and ascending aorta in Jehovah's Witnesses.     

Robotically assisted coronary endarterectomy

Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a completely endoscopic fashion, but diffusely diseased target vessels may pose a technical challenge. We present a case in which coronary endarterectomy was performed on the left anterior descending coronary artery during a two-vessel totally endoscopic coronary artery bypass procedure. A 52-year-old woman presented with intermittent substernal pain. Preoperative studies showed diffuse disease in the left coronary artery system. Bilateral internal mammary arteries were harvested robotically using a skeletonized technique in a completely endoscopic fashion. Cardiopulmonary bypass was achieved via peripheral cannulation, and the heart was arrested with intermittent cold antegrade hyperkalemic blood cardioplegia delivered via an ascending aortic occlusion balloon catheter. The first obtuse marginal anastomosis was performed. The left anterior descending coronary artery was diffusely diseased and heavily calcified. An end-to-side anastomosis was attempted to the right internal mammary artery with unsatisfactory results. A localized coronary endarterectomy was performed, and an extended anastomosis was completed using the right internal mammary artery. The patient recovered uneventfully and was discharged home on postoperative day 6. Diffuse coronary artery disease was once thought to be a prohibitive challenge for minimally invasive coronary bypass procedures. This case demonstrates that local coronary endarterectomy is feasible and safe in robotic totally endoscopic coronary artery bypass surgery.     

Transcatheter aortic valve implantation and hybrid coronary artery revascularization: time to combine them

We report on simultaneous off-pump coronary artery bypass grafting to the left anterior descending artery, modified transapical aortic valve implantation, and stenting of the circumflex and right coronary arteries in an 84-year-old patient. The poly-morbid patient with a logistic EuroSCORE of 85% experienced recent myocardial infarction; the left ventricular ejection fraction was reduced to 20%. Postoperative recovery was fast and short. The strategy described is the next logical step in broadening the indication for transcatheter aortic valve interventions.     

POST-TRAUMATIC APICAL LEFT VENTRICULAR ANEURYSM IN A PATIENT WITH LEFT VENTRICULAR APICAL-ABDOMINAL AORTIC CONDUIT: CASE PRESENTATION

A patient with a small aortic annulus had an apico-aortic conduit implanted for aortic stenosis approximately three years before being admitted to our institution. Four months after sustaining a steering wheel injury to the chest, he developed chest pain and palpitations. X-ray films and left ventriculograms revealed a large apical aneurysm of unknown duration. At surgery, it was noted that the proximal portion of the conduit had been sewn directly to the myocardium without the use of a rigid or soft apical outlet prosthesis incorporating a sewing ring. The aneurysm was resected along with a small proximal segment of the conduit graft. A polished Pyrolite(R) rigid inlet tube with a sewing ring and graft extension was inserted into the residual left ventricular apex, and continuity was reestablished with the abdominal segment of the conduit. It is postulated that the aneurysm was caused by either the direct anastomosis of the fabric graft to the apical myocardium at the original operation (with subsequent disruption and aneurysm formation prior to the steering wheel injury), or was the result of fixation of the heart at the diaphragm by the conduit, with increased vulnerability to deceleration injury at the direct left ventricular apex myocardium-fabric graft site.     

Anomalous right coronary artery originating from the left sinus of Valsalva in a Yucatan minipig

A 39.2-kg, castrated male Yucatan minipig (Sus scrofa domestica) was presented for enrollment in a coronary artery study. Angiography revealed an anomalous right coronary artery originating from the left sinus of Valsalva. The left anterior descending, left circumflex, and anomalous right coronary arteries were implanted with metallic stents without complications. The minipig remained on the study for 3 mo until it reached its predetermined study endpoint, during which time it showed no clinical signs of disease. Histologic examination of the implanted coronary arteries revealed no differences between the normal (left anterior descending and left circumflex arteries) and the anomalous right coronary artery. Swine are important models for coronary research. Although several cases of anomalous human coronary arteries have been documented, the current case is the first report of a coronary artery anomaly in a minipig.     

金钱豹和猪獾冠状动脉的解剖

为了阐明金钱豹(Panthera pardus)和猪獾(Arctonyx collaris)心冠状动脉的分支分布特征及血供情况,为心脏生物学及动物学研究提供结构基础资料,利用血管铸型和组织透明方法观察研究了金钱豹与猪獾心左、右冠状动脉的分支分布.结果表明,金钱豹和猪獾的心均由左右冠状动脉营养.金钱豹左冠状动脉分为室间隔支、前降支和旋支.前降支又分出左室上支、左室中支和左室下支.右冠状动脉沿途分出右室前支、右室后下支和右室后上支.猪獾左冠状动脉分为前降支和旋支.前降支又分出室间隔支和左室前支,旋支又分出左缘支和左室后支.其右冠状动脉沿途分出右室前支、右缘支和右室后支.金钱豹和猪獾心的室间隔均由发自左冠状动脉的独立的室间隔支营养,二者左右冠状动脉在膈壁的分布属于均衡型.     

Variations in coronary artery anatomy: Normal versus abnormal

We offer a comprehensive classification of coronary artery anomalies, together with angiographic examples of each entity. Minimal requirements for normality include the following criteria: (1) the dual aortic origin is from right and left coronary ostia; (2) the course of the right coronary artery follows the right atrioventricular groove; (3) the course of the left coronary artery follows the left atrioventricular groove and anterior interventricular groove; (4) the posterior descending branch originates from either the right or left coronary artery; (5) the major coronary branches flow epicardially; and (6) the coronary arteries terminate at the myocardial capillary level. This conception of "normal" coronary arteries has determined the classification of abnormalities presented here. Early and correct diagnosis of anomalies that may compromise the myocardial blood supply is stressed, and possible surgical solutions are offered. Selective coronary angiography is the technique of choice for precise visualization of the coronary artery system.     

Extensive right coronary artery thrombosis

A 65-year-old man presented with a non-ST-elevation acute coronary syndrome. His medical history was unremarkable. Apart from a brother, who sustained a myocardial infarction at the age of 40, no cardiovascular risk factors were present. Coronary angiography revealed normal left anterior descending and circumflex arteries. The right coronary artery was subtotally occluded with an extensive thrombus running into the posterolateral branch (figures 1A and B). Despite appropriate medical treatment, intermittent chest pain persisted. The patient underwent a percutaneous coronary intervention with mechanical removal of the thrombus by aspiration followed by balloon dilatation.     

Primary percutaneous coronary intervention in the left main stem of a monocoronary artery

In a 71-year-old female with evolving anterior wall myocardial infarction, coronary angiography revealed a monocoronary artery which arose from the right sinus of Valsalva. Originating from a short common trunk, the left main stem showed a thrombotic lesion that occluded the left anterior descending coronary artery while the circumflex artery was obstructed. Intracoronary administration of abciximab, followed by stenting of the transition between the left anterior descending coronary artery and the main stem, and final kissing balloon inflation of the bifurcation resulted in an excellent angiographic result and favourable clinical outcome. (Neth Heart J 2009;17:274–6.)     

Modified heart-lung preparation for the evaluation of systolic and diastolic coronary flow in rats

A modified heart-lung preparation of the rat, which permits measuring systolic and diastolic coronary flow separately and enables coronary compliance to be evaluated, is described. The systemic circulation was substituted by a shunt circuit, and the elastic properties of the arterial tree were mimicked by a rubber balloon. Systolic and diastolic coronary flow was evaluated from the pulmonary and aortic flow signal. Integrated phasic pulmonary flow represented right ventricular stroke volume. Integrated phasic systolic aortic flow represented left ventricular stroke volume minus that volume flowing into the coronary arteries during systole, because the aortic flow probe had to be inserted distal to the origin of the coronary vessels. Because right and left ventricular stroke volume was identical under steady-state conditions, the difference between systolic pulmonary and systolic aortic flow resulted in systolic coronary flow. Diastolic coronary flow was measured by means of the retrograde flow through the aortic flow probe. Coronary compliance was calculated according to Frank's windkessel model from coronary resistance and from central diastolic aortic pressure, which decayed exponentially after switching out the rubber balloon and the shunt circuit. It could be shown that the proportion of systolic to diastolic coronary flow depends on coronary compliance.     

Right Internal Mammary Artery Implantation into Right Ventricular Myocardium for Revascularization of the Entire Heart: Experimental Data and Preliminary Report

The left internal mammary artery implant combined with epicardiectomy and free omental graft provides three extra-coronary sources of blood. This operation tested in dogs with 92% main-stem occlusion of three coronary arteries protected 75% of the animals. Applied clinically in over 100 patients, the operation resulted in 90% improvement. To obtain complete myocardial revascularization, the right internal mammary artery has been used as a fourth source of extra-coronary blood. In 57 animals, the right internal mammary arteries were implanted into the anterior walls of the right ventricle; in 80% this vessel formed anastomoses with the right coronary tree, and in 65% with the right and left coronary arteriolar systems. Six patients are described who underwent right internal mammary artery implantation; five of these in addition had the combined operation of left internal mammary artery implant, epicardiectomy and free omental graft. All patients had completely blocked right coronary arteries; in addition, five had advanced disease of the left coronary arterial tree.     

Different accumulation of elements in the rami of the coronary arteries of Thai

To analyze the accumulation of elements in the rami of the coronary arteries, the authors determined element contents in both the coronary arteries and their rami of the Thai by inductively coupled plasma-atomic emission spectrometry. The subjects consisted of 13 men and 6 women, ranging in age from 34 to 83 yr. It was found that a higher accumulation of calcium and phosphorus occurred in the proximal sites of coronary arteries such as the anterior descending, right coronary, left coronary, and circumflex arteries than the distal sites such as the diagonal, lateral, conus, acute marginal, and posterior descending arteries. The accumulation of calcium and phosphorus in the anterior descending and right coronary arteries of the Thai increased remarkably in the fifties, thereafter decreased, and increased again in the eighties. It should be noted that a very high accumulation of calcium and phosphorus in the coronary arteries occurred in the fifties. In regard to relationships among the average contents of elements in the coronary arteries and their rami, it was found that there were very significant direct correlations between calcium and phosphorus contents, between calcium and magnesium contents, and between phosphorus and magnesium contents. These results suggested that as calcium and phosphorus increased in the coronary arteries and their rami, magnesium increased simultaneously in all of the coronary arteries and their rami.     

Kawasaki disease causing saccular aneurysms of the coronary arteries

A 22-year-old man was referred for treatment of a 45 mm saccular aneurysm of the right coronary artery (RCA) and a 15 mm saccular aneurysm of the left anterior descending artery (LAD). The patient developed Kawasaki disease in 1998. The aneurysms were diagnosed in 2002. The RCA showed thrombus formation. Until now the patient had remained asymptomatic. He now presented with effort angina. On coronary angiography and magnetic resonance imaging, an occluded aneurysm of the proximal RCA (45 mm) was seen with a second aneurysm more distally (22 mm).     

ASCENDING AORTIC ANEURYSM RESECTION EIGHT MONTHS AFTER TRIPLE CORONARY ARTERY BYPASS: CASE REPORT

This report involves the surgical treatment of a patient who underwent saphenous vein triple coronary artery bypass and subsequently developed an ascending aortic aneurysm and aortic insufficiency. Although the implantation of vascular structures into synthetic grafts is commonplace, this case is unique in that it involves the successful implantation of an aortic island containing the origin of the coronary arteries.     

Catheter-based antegrade intracoronary viral gene delivery with coronary venous blockade

The purpose of this study is to evaluate the feasibility of percutaneous antegrade myocardial gene transfer (PAMGT). A consistent and safe technique for in vivo gene transfer is required for clinical application of myocardial gene therapy. PAMGT with concomitant coronary venous blockade was performed in 12 swine. The myocardium was preconditioned with 1 min of occlusion of the left anterior descending and left circumflex arteries. The anterior interventricular vein was occluded during left anterior descending artery delivery, and the great cardiac vein at the entrance of the middle cardiac vein was occluded during left circumflex artery delivery. With arterial and venous balloons inflated (3 min) and after adenosine (25 mug) injection, PAMGT was performed by antegrade injection of an adenoviral solution (1 ml of 10(11) plaque-forming units in each coronary artery) carrying beta-galactosidase or saline through the center lumen of the angioplasty balloon. In one set of animals, PAMGT was performed with selective coronary vein blockade (n = 9); in another set of animals, PAMGT was performed without coronary vein blockade (n = 5). At 1 wk after gene delivery, the animals were killed. Quantitative beta-galactosidase analysis was performed in the left and right ventricular walls. PAMGT was successfully performed in all animals with and without concomitant occlusion of the coronary veins. Quantitative beta-galactosidase analysis showed that PAMGT with coronary blockade was superior to PAMGT without coronary blockade. beta-Galactosidase activity increased significantly in the beta-galactosidase group compared with the saline group: 1.34 +/- 0.18 vs. 0.81 +/- 0.1 ng (P 相似文献   

False-negative myocardial scintigraphy in balanced three-vessel disease,revealed by coronary pressure measurement

In nuclear perfusion imaging of the myocardium, a false-negative test result in patients with balanced three-vessel disease is a well-known pitfall. This paper describes a patient with typical chest pain and a negative myocardial perfusion scintigram. At coronary angiography, intermediate stenoses in the left anterior descending (LAD), left circumflex (LCX), and right coronary (RCA) arteries were present. Fractional flow reserve, measured by coronary pressure measurement, was 0.54, 0.56, and 0.66 respectively for the LAD, LCX, and RCA, unequivocally demonstrating the presence of balanced three-vessel disease. The patient underwent successful bypass surgery and remained event-free thereafter.     

THE SIGNIFICANCE OF TOTAL PROXIMAL ANTERIOR DESCENDING VESSEL OCCLUSION

A series of 100 consecutive patients demonstrating total occlusion of the proximal left anterior descending coronary artery by cineangiography were analyzed. Forty-five showed occlusion proximal to the first septal branch. Collaterals to the anterior descending vessel were present in 83 cases. Left ventriculography revealed normal contractility in 16 cases and localized aneurysms in twenty-two. In 18 instances the left anterior descending lesion was the only occlusion demonstrated. Double and triple vessel involvement was present in 35 and 45 respectively. Normal EKGs were seen in 22 cases and signs of transmural anterior infarction in forty-two. Neither the development of ventricular aneurysm nor the presence of anterior wall infarction by EKG appeared to be influenced by the site of occlusion with respect to the septal branch. All the patients with normal left ventricular contractility had demonstrable collaterals.     

Measurement of the flow in coronary artery bypass grafts

The aim of our study was to measure the flow in coronary artery bypass grafts and to compare the flow between two groups of patients. In group A the arterial revascularization was performed with both internal thoracic arteries using as a Y graft and in group B conventional revascularization using left internal thoracic artery (ITA) attached to the left anterior descending artery (LAD) and venous grafts to the other branches of the left coronary artery was performed. The flow in all grafts was measured at six time points during the operation. The cumulative flow at the end of the operation in the group A (arterial Y graft) was 51.8 +/- 24.5 ml/min and in group B (conventional technique) it was 96.8 +/- 41.1 ml/min (p < 0.05). The flow in left ITA to LAD was similar in both groups (27.3 +/- 15.9 ml/min and 26.3 +/- 16.1 ml/min in group A and B). The flow in right ITA (25.2 +/- 18.4 ml/min) was significantly lower than in venous grafts (72.5 +/- 45.5 ml/min). The calculated flow reserve was 2.2 in group A and 2.1 in group B. We found that the cumulative flow in arterial Y graft was lower in comparison with conventional revascularization. This is due to the lower flow in the right ITA branch of the Y graft compared to venous grafts. However based on clinical results, we can postulate that the flow in the Y graft is sufficient to meet the demand of the myocardium originally supplied by the left coronary artery.     

Dynamic capacitance of epicardial coronary arteries in vivo

The dynamic capacitance of epicardial coronary arteries (i.d. greater than or equal to 0.4 mm) in vivo was assessed from the volume stiffness and volume of these arteries. The volume stiffness was derived from the pressure wave front velocity as determined in dogs by measuring the delay time between the pressure pulses recorded proximal and distal to a segment of the anterior descending branch of the left coronary artery. The pressure pulse was generated elsewhere in the arterial system during diastole. The volume of the epicardial coronary arteries was calculated from the lengths and diameters as measured in araldite casts, making corrections for in-vitro/in-vivo differences in dimensions. The dynamic capacitance of the right coronary artery, and the anterior descending and circumflex branches of the left coronary artery at an arterial pressure of 13.3 kPa and a frequency between 7 and 30 Hz was found to be 0.0024 +/- 0.0013, 0.0062 +/- 0.0028 and 0.0079 +/- 0.0035 mL/kPa (mean +/- SD), respectively. The total capacitance of the epicardial coronary arteries was calculated to be (0.007 mL/kPa)/100 g, which is small as compared to the total capacitance of the coronary vasculature, including the intramyocardial compartment, which is in the order of (0.5 mL/kPa)/100 g [1].     

Distributing and delivering vessels of the human heart

The branching characteristics of the right coronary artery, acute marginal, posterior descending, left anterior descending, circumflex, and obtuse marginal arteries are compared with those of diagonal branches, left and right ventricular branches, septal, and higher-order branches, to test a newly proposed functional classification of the coronary arteries in which the first group rank as distributing vessels and the second as delivering vessels. According to this classification, the function of the first type is merely to convey blood to the borders of myocardial zones, while the function of the second is to implement the actual delivery of blood into these zones. This functional difference is important in the hemodynamic analysis of coronary heart disease, as it provides an assessment of the role of a vessel within the coronary network and hence an assessment of the functional importance of that vessel in a particular heart. Measurements from casts of human coronary arteries are used to examine the relevant characteristics of these vessels and hence to test the basis of this classification.