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Angiographically, a “dual LAD” is described as two distinct arteries supplying the vascular territory of the LAD in parts, identified as the short LAD/LAD1 and the long LAD/LAD2. Using an easy-to-understand three-step approach, Jariwala et al unveiled a novel classification strategy for dual LAD systems in an attempt to decrease ambiguity in diagnosis and management of the anomaly. As part of our research, we looked at a wide range of published cases and case series in the literature, and also those reported from our hospital. In our novel classification system, we divide dual LADs into three main groups based on their origin and vascular territory, each of which is further divided into subgroups based on the course of LAD1/LAD2 and the variable feature that is a distinguishing attribute of the type of anomaly to be specified. A review of 144 publications in the world literature revealed 340 patients eligible for the study. The median age was 58.8 years (SD - 11.42; range - 29e89) with male predominance (3.3:1). Cases in Group I comprised 60.6% of the total cases, followed by Group II (36.2%), and Group III (3.2%). Subgroup I-A was the most common in terms of dual LAD, followed by subgroup II-A. Acute coronary syndrome (45.5%) and chronic coronary syndrome (55.8%) were the most common clinical presentations in patients with significant coronary artery disease (30.8%).
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Myocardial bridging (MB) is a relatively uncommon congenital anomaly where a segment of the coronary artery dips inside the myocardium and takes a tunneled course under a bridge of the myocardium. This leads to the compression of the coronary artery during systole resulting in hemodynamic changes and their clinical manifestations. However, it is an incidental finding but can present with multiple complications like myocardial ischemia, infarction, and sudden death, primarily when associated with other risk factors like left ventricular hypertrophy of the heart. Therefore, a careful examination of the heart is essential for evaluating the clinical significance of the MB. Here, we presented a case of a 30-year-old young female who had a sudden death, and her histological examination of the heart showed MB of left anterior descending coronary artery (LAD).
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@#Objective To investigate the perioperative results and safety of minimally invasive direct coronary artery bypass grafting (MIDCAB) treatment of anterior descending artery disease through a small left thoracic incision assisted by thoracoscopy. Methods The clinical data of 92 patients who received MIDCAB in our hospital from May 2014 to October 2018 were retrospectively analyzed, including 72 (78.26%) males aged 42-78 (61.2±7.48) years, and 20 (21.74%) females aged 30-80 (61.30±12.26) years. The perioperative complications, blood product use, left heart function changes, ventilator use time, ICU stay, hospital stay and other indicators were analyzed. Results Two (2.17%) patients were transferred to thoracotomy, 5 (5.43%) patients received blood products during the operation, 2 (2.17%) were subjected to secondary thoracotomy to stop bleeding, 4 (4.34%) had postoperative hypoxemia and 1 (1.08%) was reintubated. The ventilator use time was 3-227 (22.35±35.39) hours, the ICU stay was 16-777 (78.85±108.62) hours, and the postoperative hospital stay was 2-36 (8.86±6.05) days. One (1.08%) patient died in hospital. Conclusion MIDCAB for anterior descending artery disease has good perioperative results, especially for solitary anterior descending artery disease, which can reduce the use of blood products, and shorten the time of ventilator use after operation, ICU stay and hospital stay.
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In countries like India rheumatic heart disease (RHD) is still a common problem, and with improvements in diagnosis and treatment, the lifespan of these patients is increased. With increase in the lifespan, these patients may develop coronary artery disease (CAD) and present as acute coronary syndrome (ACS). In some cases especially RHD with severe mitral stenosis (MS), thrombus that develop in left atrium may embolize in one of the coronary arteries, leading to acute coronary syndrome. We report a case of 51 year old female who was a known case of rheumatic heart disease and now presented with acute coronary syndrome. Patient was hemodynamically unstable and underwent percutaneous balloon mitral valvotomy (PBMV) and percutaneous coronary intervention (PCI) simultaneously. We here discuss the possible complications that need to be addressed in such scenario and how can we approach such cases. This is first of such intervention at our institute and also there are very few such records available online. Patient tolerated the procedure well with significant clinical improvement.
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BACK GROUND OF STUDY:A detailed awareness of branching pattern of left main coronary artery is of immense help for various diagnostic and therapeutic measures on coronary arteries, in this era of increasing coronary artery disease. MATERIALS & METHODS: Fifty human hearts were included in the study group. The LMCA and its branches were studied in detail after removing the epicardium and subepicardial fat. RESULTS: This dissection study on the ramification of LMCA could detect bifurcation , trifurcation and quadrifurcation in 76%, 22% and 2% respectively.
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Background: The anatomical variations of left coronary artery [LCA] determine the course in the pathogenesis ofatherosclerosis, mechanical stress and hemodynamic change.Aim: To study the gross anatomy of left coronary artery [LCA] in terms of its origin, termination, branchingpattern, dominance pattern, external diameter at origin, length of main trunk of left coronary artery, variationsand/ anomalies if present.Materials and Methods: After an ethical approval, 150 adult human cadaveric hearts were collected fromDepartment of Anatomy, B.V.D.U. Medical College and Hospital, Sangli and Pune. The careful dissection wascarried out to note details about left coronary artery and data was analyzed using SPSS software.Results: The origin of left coronary artery was observed in the left posterior aortic sinus 100%. The incidence ofbifurcation, trifurcation and quadrifurcation was 69.33, 28% and 2.67% respectively. SA nodal artery was directlyarising from main trunk of left coronary artery in 2 hearts (1.33%). Circumflex branch of left coronary artery gaveSA nodal artery, AV nodal artery and posterior interventricular artery in 18.66%, 16% and 16% hearts respectively.In one case (0.66%), we found a hyperdominant left anterior descending artery which continued as posteriorinterventricular artery [PDA] occupying entire posterior interventricular sulcus and terminated at crux of theheart by giving AV nodal artery. Hence left dominance was observed in total 16.66% cases. The mean externaldiameter of left coronary artery at its origin was 5.02 ±1.0328. Length of main trunk of left coronary artery wasranging from 4 mm to 22 mm with mean length of 11.66±3.529 mm.Conclusion: Short or long main trunk of left coronary artery, small diameter of main trunk, additional terminalbranches of left coronary artery, left coronary artery dominance, Mouchet’s posterior recurrent interventricularartery, hyperdominanant left anterior descending artery are the significant anatomical factors which decide theextent of coronary insufficiency, its functional impact and may create challenges during the interventionalcoronary care.
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Aim: This current study is done to throw light upon the, distribution and termination of right coronary artery andleft anterior descending branch of left coronary artery and to correlate the clinical significance of the variationsobservedMaterials and methods: 30 human hearts from the embalmed cadavers from Department of Anatomy, GreatEastern Medical School were collected during routine dissection. The heart is taken out after incising the fibrouspericardium and great vessels .The course of right and left coronary arteries were traced from the Ostia. Thespecimens were duly numbered, preserved in 5% formaldehyde solution. Photographs of each specimen weretaken by digital camera and the arterial pattern is coloured red digitally and labeled.Results: In the present study the right coronary artery terminates at crux or beyond the crux in 57%, before cruxin 23% and right border in 13%. Left anterior descending artery terminates beyond apex in the lower 1/3rd of theinter-ventricular groove in 87% and at the apex in 13%.Conclusion: Right and left coronary arteries showed significant variation in their mode of termination. Betteranatomical knowledge about the branches of coronary artery and its variation is essential for cardiologists andinterpretation of coronary angiograms by radiologist.
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Objective To explore the potential relationship between left coronary bifurcation angle and plaques forming in left anterior descending artery by dual-source CT angiography.Methods One hundred patients who underwent dual-source CT angiography in our hospital from January to May during 2016 and had plaques in left anterior descending artery were retrospectively studied,while 100 patients with normal image were as negative controls.There were 57 male and 43 female at the mean age of (57.54 ±-8.38) years in negative controls,and 64 male and 36 female at the mean age of (62.08 ± 13.94) years in patients with left anterior descending artery plaques.The left coronary bifurcation angle was measured by multi-planar reconstruction (MPR) and maximum density projection (MIP) techniques.Results The left coronary bifurcation angle in negative control group were range from 41.25°to 112.14°,at the mean age of 69.45 ° ± 18.71 °,while range from 54.14 ° to 128.12 o,at the mean age of 85.65 °-± 15.96 ° in plaque group.The bifurcation angle in plaque group was larger than those in negative control group(P ＜ 0.05).Conclusion Dual-source CTA could objectively evaluate left coronary bifurcation angle and plaque character.The left coronary bifurcation angle had an important influence on the formation of left anterior descending artery plaque.
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Objective To study the clinical value of intraoperative epicardial echocardiography ( IEE) in assessing graft-left anterior descending artery ( LAD ) of off-pump coronary artery bypass grafting ( OPCABG) . Methods IEE was used to detecte graft vessels anastomosis in 53 patients with OPCABG-LAD . Two-dimensional grey ultrasound and color Doppler ultrasound was used to show whether there was abnormal echo in proximal and distal lumen , measuring diameter and rate of stenosis . Pulse Doppler ultrasound was used to observe the blood flow spectrum . Intraoperative transient blood flow meter (TTFM) was employed to measure the pulsatility index and flow volume . Results Among the 53 patients with OPCABG-LAD ,38 cases were left internal mammary artery graft (LIMA) ,15 cases were saphenous vein graft (GSV) . Pulsatility index and flow volume showed normal by TTFM . The detection rates of graft vessels-LAD anastomosis in proximal and distal segment were 100％ using IEE , including 10 cases anastomotic plaques and 10 cases proximal plaques . Comparison of blood flow parameter of graft by IEE and TTFM in operation ,there was no significant difference in LIMA grafts ( P =0 .091) ,but the correlation was statistically significant ( r = 0 .809 , P < 0 .001 ) ;the difference in GSV grafts had no statistical significance ( P = 0 .821 ) ,but the correlation was statistically significant ( r = 0 .684 , P = 0 .005 ) . Conclusions IEE clearly displays the lumen of graft vessel and LAD ,and measures the hemodynamic indexes . It provides an intuitive ,accurate and convenient method for detecting the patency of the graft vessels during OPCABG .
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Objective To investigate the risk factors of major adverse cardiac events (MACE) in patients with intermediate coronary stenosis in proximal left anterior descending artery (ICS-PLAD) and to assess the predictive value of risk factors model for MACE in patients with ICS-PLAD.Methods Totally 221 patients with ICS-PLAD (≥50％ and ＜70 ％ diameter stenosis by angiography) were retrospectively studied.The risk factors of MACE in patients with ICS-PLAD were explored by binary logistic regression analysis.The predictive value of risk factors model for MACE in patients with ICS-PLAD was evaluated by receiver operator curves (ROC).Results Compared with No MACE group,the MACE group had more patients with diabetes(DM),hypertension and number of stenotic vessels ≥ 2,had higher body mass index (BMI),low density lipoprotein cholesterol(LDL-C)and triglycerides(TG) (P all ＜ 0.05).Binary logistic regression analysis showed that the independent risk facts were TG (OR =2.447,P =0.000,95％ CI:1.608-3.725),LDL-C (OR =1.971,P =0.006,95 ％ CI:1.219-3.187) and number of stenotic vessels ≥ 2 (OR =6.596,P =0.000,95 ％ CI:2.995-14.526).The area under the ROC (AUG) of risk factor model for the prediction of MACE in patients with ICS-PLAD were 0.794 (P =0.000).Conclusion Patients with ICS-PLAD,with DM,hypertension,number of stenotic vessels ≥2,obesity,high LDL-C or high TG,had higher MACE rate.TG,LDL-C and number of stenotic vessels ≥2 were the independent risk factors of MACE in patients with ICS-PLAD.The risk factors model has some clinical value for the prediction of MACE in patients with ICS-PLAD.
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AIM OF STUDY: Breast conserving surgery (BCS) is the standard treatment for stage I and II breast cancer. Multiple studies have shown that recurrences after lumpectomy occur mainly in or near the tumor bed. Use of accelerated partial breast irradiation (APBI) allows for significant reduction in the overall treatment time that results in increasing patient compliance and decreasing healthcare costs. We conducted a treatment planning study to evaluate the role of intensity modulated radiation therapy (IMRT) with regards to three‑dimensional conformal radiation therapy (3DCRT) in APBI. MATERIALS AND METHODS: Computed tomography planning data sets of 33 patients (20 right sided and 13 left sided) with tumor size less than 3 cm and negative axillary lymph nodes were used for our study. Tumor location was upper outer, upper inner, central, lower inner, and lower outer quadrants in 10, 10, 5, 4 and 4 patients, respectively. Multiple 3DCRT and IMRT plans were created for each patient. Total dose of 38.5 Gy in 10 fractions were planned. Dosimetric analysis was done for the best 3DCRT and IMRT plans. RESULTS: The target coverage has been achieved by both the methods but IMRT provided better coverage (P = 0.04) with improved conformity index (P = 0.01). Maximum doses were well controlled in IMRT to below 108% (P < 0.01). Heart V2 Gy (P < 0.01), lung V5 Gy (P = 0.01), lung V10 Gy (P = 0.02), contralateral breast V1 Gy (P < 0.01), contralateral lung V2 Gy (P < 0.01), and ipsilateral uninvolved breast (P < 0.01) doses were higher with 3DCRT compared to IMRT. CONCLUSION: Dosimetrically, IMRT–APBI provided best target coverage with less dose to normal tissues compared with 3DCRT‑APBI.
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Abstracts: Background: Sound knowledge of left coronary artery (LCA) is necessary for performing coronary angiographies and shunt surgeries. Study of origin, course of left coronary artery and its branches helps in judging the area of myocardium supplied by them which in turn helps in judging the size of infarct. Methodology: The present study is done on 76 adult heart specimens obtained from routine dissection conducted for undergraduate students in the Department of Anatomy at Bidar Institute of Medical Sciences, Bidar and also at other nearby medical colleges of Karnataka and Maharashtra. The data obtained is tabulated and analyzed statistically. Results: In our study, in all the cases the Left coronary artery originates from left posterior aortic sinus. Bifurcation of left coronary artery is seen in 81.5%, trifurcation in 14.5% and quadrifurcation in 4% cases. The left anterior descending artery (LAD) terminates by wrapping around apex in 70% cases and the left circumflex artery (LCX) terminates between obtuse border and crux of heart in 52.5% of cases. Conclusion: The present study is done to know origin, distribution, branching and level of termination of left coronary artery in adult human hearts of Hyderabad Karnataka region to provide vital inputs for making a correct diagnosis and planning treatment for procedures like coronary angiography, stenting procedures and surgical myocardial revascularization in extensive myocardial ischemia.
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BACKGROUND: The significant impact of postoperative radiotherapy (PORT) on cardiac morbidity in patients of early breast cancer (EBC) undergoing breast‑conserving surgery has been shown in different studies. The present study was conducted to assess the impact of surgery and the side of involvement on radiation dose to left anterior descending artery (LAD) and Left circumflex coronary artery (LCx). MATERIALS AND METHODS: Totally, 58 patients of EBC were randomly chosen for this dosimetric study and planned with tangential field technique without intensity modulation (IM). Heart, LAD, and LCx (n = 55) were contoured. Dose volume histograms were analyzed to determine the Dmax (maximum dose) and Dmean (mean dose) of LAD and LCx. Student’s t‑test was used for comparative analysis of the means. RESULTS: The mean Dmax of LAD for left (L) EBC was 3.17 Gray (Gy) while for right (R) EBC it was 0.86 Gy (P = 0.007; 95% C.I, 1.14–3.48). The mean Dmean of LAD for L‑EBC and R‑EBC were 1.97 Gy and 0.79 Gy, respectively (P = 0.029; 95% C.I, 0.77–1.60). The mean‑Dmax of LCx for patients with L‑EBC (2.9 Gy; range: 1.2–4.35 Gy) was statistically higher than that for R‑EBC (1.3 Gy; range: 0.7–3.2 Gy) (P = 0.045). The mean‑Dmean of LCx for L‑EBC (2.1 Gy; range: 0.6–3.6 Gy) was also significantly higher than that of L‑EBC (0.9 Gy; range: 0.7–2.1 Gy) (P = 0.03). There was no significant impact of the pattern of surgery on LAD dose, but significance was noted for LCx dose parameters (P = 0.04 and 0.08 for m‑Dmax and m‑Dmean of LCx). CONCLUSION: This pilot dosimetric study confirms the assumption that patients with left‑sided EBC are at higher risk of developing long‑term cardiac morbidity when treated with PORT due to increased dose to LAD.
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Anterior ST elevation myocardial infarction can present with a specific electrocardiographic (ECG) pattern without ST segment elevations, known as De Winter sign. Recognizing this ECG pattern is important since it is considered an equivalent to ST elevation myocardial infarction (STEMI), hence may require thrombolysis when primary PCI facilities are not available or delayed. We report a28 year old male who presented to us with de winters ecg pattern. Subsequent coronary angiogram showed Proxmial left anterior descending (LAD) artery occlusion.
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No abstract available.
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Aged , Humans , Male , Angina Pectoris/diagnosis , Coronary Angiography , Coronary Artery Disease/complications , Coronary Stenosis/complications , Coronary Vessel Anomalies/complications , Percutaneous Coronary Intervention/instrumentation , Stents , Treatment OutcomeABSTRACT
Objective To explore the double blood vessels bridge application and efficacy in multiple localized narrow of the anterior descending coronary artery.Methods The clinical data of 106 patients with multiple localized narrow of the anterior descending coronary artery were retrospectively analyzed.The patients were divided into two groups according to the operation methods.Fifty-six patients (improvement group) were conducted double blood vessels bridge on the anterior descending coronary artery,50 patients (control group) were conducted a single blood vessel bridge on the anterior descending coronary artery.Results The age,sex,body mass index,left ventricular ejection fraction,extracorporeal circulation time,endotracheal intubation time,length of hospital stay between two groups had no significant difference (P ＞ 0.05).One case in improvement group occurred angina pectoris,left ventricular size was (51 ± 6) mm,left ventricular ejection fraction was (60.8 ± 8.0)％.Nine cases in control group occurred angina pectoris,left ventricular size was(43 ± 6) mm,left ventricular ejection fraction was(55.1 ± 10.0)％.There was significant difference between two groups(P ＜ 0.05).Conclusion Double blood vessels bridge is safe and effective in multiple localized narrow of the anterior descending coronary artery.
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Background To investigate the effects of collateral coronary circulation on the outcome of the patients with anterior myocardial infarction (NII) with left anterior desending artery occlusion abruptly.Methods Data of 189 patients with acute anterior MI who had a primacy percutaneous coronary intervention (PCI) in the fast 12 h from the onset of symptoms between January 2004 and December 2008 were retrospective analyzed.Left anterior descending arteries (LAD) of all patients were occluded.LADs were reopened with primary PCL According to the collateral circulation,all patients were classified to two groups:no collateral group (n＝111),patients without angiographic collateral filling of LAD or side branches (collateral index 0) and collateral group (n＝78),and patients with angiographic collateral filling of LAD or side branches (collateral index 1,2 or 3).At one year's follow-up,the occurrence of death,reinfarction,stent thrombosis (ST),target vessel revascularization and readmission because of heart failure were observed.Results At one year,the mortality was lower in patients with collateral circulation compared with those without collateral circulation (1% vs.8%,P＝0.049),whereas there were no differences in the occurrence of reinfarction,ST,target vessel revascularization and readmission because of heart failure.The occurrence of composite of endpoint was lower in patients with collateral circulation compared with those without collateral circulation (12% vs.26%; P＝0.014).Conclusions Pre-exist collateral circulation may prefigure the satisfactory prognosis to the patients with acute anterior MI after primary PCI in the fast 12 h of MI onset.
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A small subset of patients with TOF present later in life with unsuspected or untreated disease. Tetralogy of Fallot in adults represents a special group with peculiar problems related to the effects of prolonged cyanosis over the heart and other organs .Older age has been considered as incremented risk factor for surgical mortality and long-term survival in patients with TOF. Based on this assumption, indication for surgery after long-standing cyanosis has caused controversy. There are few reports that studied this issue have proved some benefit in repairing adults with TOF .The greatest benefit of complete repair at this age is the functional improvement. We report a male patient with TOF with tight lesion of the left anterior descending coronary artery diagnosed at age 40 years and successfully underwent total correction along with CABG. This patient was the oldest documented in Bangladesh undergoing successful corrective surgery for TOF with CABG.
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During coronary artery bypass surgery, there are several discrete maneuvers that facilitates localization of the invisible left anterior descending coronary artery. In some cases with intramyocardial left anterior descending artery, long-term patency of a bypassed graft may depend on anastomosing the internal mammary artery graft to the more proximal and superficial site of the intramyocardial left anterior descending artery. We describe an easy technique to locate the proximal superficial left anterior descending artery with a distal coronary arteriotomy and retrograde insertion of a coronary probe.
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Arteries , Coronary Artery Bypass , Coronary Vessels , Mammary Arteries , TransplantsABSTRACT
Avaliar a incidência de oclusäo de ramos secundários em pacientes com lesäo única da artéria descendente anterior, em que a angioplastia coronária foi aplicada pela primeira vez e com sucesso. Duzentos e treze casos com ramos secundários em pacientes com lesäo única da ar considerados " em risco" por estarem envolvidos na lesäo (grupo I - GI; 85 casos - 39,9%); ou por terem sido atingidos pela insuflaçäo do baläo (grupo II - GII, 128 casos - 61,5%). Corresponderam a: GI - 54 ramos septais (S) e 31 ramos diaggonais (Dg), sendo que 36% tinham evidência angiográfica de doença ostial; GII - 77 S e 51 Dg, com 7,8% de doença ostial. Oclusäo de 7 (3,3%) ramos secundários " em "em risco", 4 (4,7%) do GI e 3 (2,3%) do GII. Na evoluçäo clínica destes 7 casos observaram-se angina de peito em 57% e alteraçöes isquêmicas discretas ao eletrocardiograma em 28.6%. Näo houve qualquer alteraçäo enzímica. A oclusäo foi clinicamente silenciosa em 43% dos casos. A oclusäo de ramos secundários é de baixa incidência, ocorre com maior freqüência nos septais, que nascem da lesäo e nos que têm doença ostial, sendo silenciosa em quase metade dos pacientes ou acompanhada de alteraçeos isquêmicas.
Purpose: To evaluate the incidence and clinical presentation of the occlusion of such secondary branches in patients with single vessel coronary artery disease in the left anterior descending artery, who underwent a first elective and successful PTCA. Material and Methods: Two hundred and thirteen side branches of 121 patients considered to be at risk. They were divided into group I (GI85 side branches, 39.9%), if they originated from the atherosclerotic site; and group II (GII120 side branches, 61.5%), if their origin would be involved during the balloon inflation. In the GI there were 54 septal branches and 3.1 diagonal branches, and 36& had angiographic evidence of ostium disease. GII was constituted by 77 septal and 51 diagonal branches, and 7.8% of them had evidence of ostium disease. Results: Seven side branches (3.3%) at risk occluded, 4 from GI (4.7%) and 3 (2.3%) from GII. As for the clinical presentation, 57% of them had angina, where as 28.6% showed minor abnormalities in the ECG. No patient elevated its serum CK-MB, and silent occlusion cccurred in 43% if them. Conclusion: Occlusion of side branches is a low incidence phenomenon, which happens more often in septal branches with ostium disease that originates from the atherosclerotic site; that about half of the patient had silent occlusion (43%) or mild ischemic manifestations