The Role of CT-Guided Optimal Fluoroscopic Viewing Angle for Coronary Engagement After TAVR.

We report the case of an 89-year-old woman with prior transcatheter aortic valve replacement who underwent successful left coronary artery engagement and left circumflex percutaneous coronary intervention using patient-specific computed tomography fluoroscopic projections. (Level of Difficulty: Advanced.).

2 Cases of Spontaneous Coronary Artery Dissection in Neonates.

Spontaneous coronary artery dissection in infants is a rare phenomenon. We present 2 neonates with severe ventricular dysfunction due to coronary artery dissection. Neither patient had evidence of extracardiac fibromuscular dysplasia or other comorbidities that would explain the presentation. (Level of Difficulty: Advanced.).

Case Series of Coronary Artery Anomalies in Athletes: Challenges in Clinical Management and Sports Eligibility.

Coronary artery anomalies include a spectrum of pathologic changes associated with sudden cardiac death in athletes. We highlight the inherent challenges in risk stratification and management of athletes with coronary artery anomalies by presenting 3 cases, each with distinct pathologic coronary anatomy and clinical management decisions. (Level of Difficulty: Intermediate.).

Cardiac Arrest in a Softball Player Following a Collision: Catching the Correct Diagnosis.

Commotio cordis is a rare cause of sudden cardiac arrest from blunt chest trauma; however, it is a diagnosis of exclusion. We present a case of sudden cardiac arrest in a collegiate athlete initially attributed to commotio cordis but in whom further history and workup revealed another rare condition. (Level of Difficulty: Advanced.).

A Ruptured Coronary Artery Aneurysm Secondary to Kawasaki Disease.

Coronary artery aneurysm occurs in 0.3%-0.8% of patients with Kawasaki disease, and cases of rupture are extremely rare. Only 2 cases have been reported in which the patients survived. We report a case of ruptured coronary artery aneurysm that was treated with coronary artery bypass grafting and extracorporeal membrane oxygenation. (Level of Difficulty: Advanced.).

A Late Complication in a Surgically Corrected ALCAPA Patient.

Late complications in surgically corrected ALCAPA patients are rare. We describe an interesting case of a patient with a thrombosed giant right coronary artery aneurysm which was discovered on a chest X-ray. (Level of Difficulty: Intermediate.).

Mid-Right Coronary Artery Spasm Diagnosed by an Ergometrine Provocation Test Through a Saphenous Vein Graft.

Although coronary artery spasm is a cause of acute coronary syndrome (ACS), demonstration of its possible cause in patients with a history of coronary artery bypass grafting remains challenging. We report a case of ACS that successfully provoked coronary artery spasm by pharmacological testing through a saphenous vein graft. (Level of Difficulty: Beginner.).

Anomalous Left Anterior Descending Coronary Artery With Retroaortic Left Circumflex Artery: A Novel Coronary Pattern.

A novel coronary anatomy in the form of anomalous left anterior descending coronary artery from pulmonary artery with a retroaortic left circumflex arising from the right coronary artery is presented. This unreported anatomy was discovered in a 7-month-old girl with failure to thrive. (Level of Difficulty: Intermediate.).

Multiple Late Complications After Takeuchi Repair of Anomalous Left Coronary Artery From the Pulmonary Artery.

Takeuchi repair is a unique surgical approach in anomalous left coronary artery from the pulmonary artery. We present an adult patient with anomalous left coronary artery from the pulmonary artery with multiple late structural complications after Takeuchi repair who was evaluated using multimodality imaging, including newly developed cardiac fusion imaging with computed tomography and echocardiography. (Level of Difficulty: Advanced.).

Fluttering Bioprosthetic Valve Leaflet Detected by Intravascular Ultrasound During Valve-in-Valve Transcatheter Aortic Valve Replacement.

We report fluttering bioprosthetic leaflet, assessed by intravascular ultrasound, during valve-in-valve transcatheter aortic valve replacement, successfully treated by using chimney stenting. Valve-in-valve transcatheter aortic valve replacement is still a challenging situation, particularly in cases with a shallow distance between leaflet and coronary ostium; a multimodality imaging approach helped manage this situation. (Level of Difficulty: Intermediate.).

Allogeneic Mesenchymal Stromal Cell Injection to Alleviate Ischemic Heart Failure Following Arterial Switch Operation.

Cell therapy is a promising tool to prevent and treat heart failure in congenital heart disease. We report the first case of intramyocardial injection of allogeneic mesenchymal stromal cells as rescue therapy in a neonate with ischemic heart failure following arterial switch procedure for isolated transposition of the great arteries. (Level of Difficulty: Advanced.).

Computational fluid dynamics investigation of the novel hybrid comprehensive stage II operation.

Background: The hybrid comprehensive stage 2 (HCS2) procedure is a novel palliative operation applicable to a select subset of single ventricle patients with adequate native antegrade aortic flow to the upper body. Flow to the descending aorta, through the pulmonary outlet and ductal arch, is influenced by a stented intrapulmonary baffle connecting the branch pulmonary arteries. We used computational fluid dynamics (CFD) to elucidate the hemodynamic characteristics of this reconstruction. Methods: We used multiscale CFD analysis of a synthetic, patient-derived HCS2 anatomic configuration with unsteady laminar flow conditions and a non-Newtonian blood model to quantify the resultant hemodynamics. The 3-dimensional CFD model was coupled to a 0-dimensional lumped parameter model of the peripheral circulation to determine the required boundary conditions. Results: For the specific anatomy studied, the intrapulmonary baffle did not obstruct flow from the pulmonary trunk to ductal arch as long as the distance between the anterior pulmonary artery wall and baffle wall exceeded ∼7 mm. Vortex shedding off of the baffle wall did not develop, because of the short distance to the ductal arch. The stented baffle experienced significantly uneven "inward" loading from the systemic side. Pulmonary outlet flow separation distal to the baffle produced a low-speed recirculation region. Conclusions: Hemodynamic patterns in this complex anatomy are generally favorable. Low flow recirculation could be mitigated by preoperative shape optimization. Calculated inward stresses on the pulmonary baffle can be used in the future to study baffle stent deformation, which is expected to be small.

Anomalous Origin of a Right Coronary Artery from the Pulmonary Artery in a Middle-Aged Woman.

A 53-year-old female patient presented for evaluation of a murmur. The examination revealed a 2/6 systolic ejection murmur in the left upper sternal border. Transthoracic echocardiography with color Doppler showed increased blood flow around the apex of the right ventricle. Further imaging revealed the right coronary artery emerging from the pulmonary artery. (Level of Difficulty: Beginner.).

Echocardiographic Diagnosis of Bland-White-Garland Syndrome in an Asymptomatic Adult.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital defect and usually diagnosed within the first 2 months of life. Only 10% of patients survive to adulthood largely in part to the formation of extensive collaterals from the right to left coronary arteries. We present a case of ALCAPA diagnosed in an asymptomatic adult through a transthoracic echocardiogram (TTE). (Level of Difficulty: Beginner.).

A Novel Biological Strategy for Myocardial Protection by Intracoronary Delivery of Mitochondria: Safety and Efficacy.

Mitochondrial dysfunction is the determinant insult of ischemia-reperfusion injury. Autologous mitochondrial transplantation involves supplying one's healthy mitochondria to the ischemic region harboring damaged mitochondria. The authors used in vivo swine to show that mitochondrial transplantation in the heart by intracoronary delivery is safe, with specific distribution to the heart, and results in significant increase in coronary blood flow, which requires intact mitochondrial viability, adenosine triphosphate production, and, in part, the activation of vascular KIR channels. Intracoronary mitochondrial delivery after temporary regional ischemia significantly improved myocardial function, perfusion, and infarct size. The authors concluded that intracoronary delivery of mitochondria is safe and efficacious therapy for myocardial ischemia-reperfusion injury.

Mitral Valve Repair and Anomalous Origin of Circumflex Artery: To Ring or Not to Ring.

We describe a case of an adult patient with mitral valve regurgitation and the anomalous origin and course of the left circumflex coronary artery. Use of a ringless procedure or a microinvasive approach, such as transapical neochordae implantation, would have possibly avoided a life-threatening post-operative complication. (Level of Difficulty: Advanced.).

Prognostic value of proximal left coronary artery flow velocity detected by transthoracic Doppler echocardiography.

BACKGROUND: Lesions in the proximal left coronary artery (LCA) are associated with a poor prognosis compared with other lesional sites. Transthoracic Doppler echocardiography (TTDE) can help to detect proximal LCA flow, and an accelerated coronary flow velocity (CFV) indicates the presence of proximal LCA lesions. This study aimed to investigate the prognostic value of CFV in the proximal LCA measured by TTDE. METHODS: We enrolled 1472 consecutive hemodynamically stable patients with known or suspected heart disease whose CFV was successfully detected using TTDE accompanied by routine echocardiography between 2008 and 2011. The primary outcome was cardiac death (acute myocardial infarction, heart failure, or sudden cardiac death) and patients were followed up over a median of 6.3 years. RESULTS: Overall, 42 cardiac deaths (3%) were observed. An increased CFV was significantly associated with the outcome in several models based on potential confounders (age, rate pressure product, Framingham Risk Score, diabetes, coronary artery disease, hemoglobin, brain natriuretic peptide, estimated glomerular filtration rate, left ventricular mass, left ventricular ejection fraction, and E/e'). Using a receiver operating characteristic curve analysis, the optimal cut-off value for the CFV to the association of the outcome was 37 cm/s (area under the curve, 0.70; sensitivity, 82%; specificity, 62%). In sequential Cox proportional hazards models, the CFV added incremental prognostic information to the clinical and basic echocardiographic parameters (chi-squared: 110.7 to 146.6, P < 0.01). CONCLUSIONS: An increased CFV in the proximal LCA was associated with cardiac death, incremental to the clinical and basic echocardiographic parameters.