Duplication of the right coronary artery in a patient with hypertrophic cardiomyopathy and myocardial bridging.

Hypertrophic cardiomyopathy is a genetic myocardial disorder. In such patients, myocardial bridging is the most frequent encountered coronary arterial anomaly. Patients may, however, on occasion, present with other much rarer malformations of the coronary arteries. Duplication of the right coronary artery is a very rare anomaly. We have now encountered a patient with hypertrophic cardiomyopathy in whom we found myocardial bridging of the anterior interventricular coronary artery and duplication of the right coronary artery. To the best of our knowledge, this association has not previously been described.

Relationship between fragmented QRS complexes in leads V4-V6 and left ventricular apical thrombus formation in patients presenting with first acute anterior myocardial infarction.

OBJECTIVE: The present study was an investigation of the relationship between fragmented QRS (fQRS) and left ventricular apical thrombus (LVAT) in patients presenting with first acute anterior myocardial infarction (MI). METHODS: Consecutive 148 patients (mean age: 60.1±10.1 years; male: 75.6%) with first acute anterior MI who underwent primary percutaneous coronary intervention (PCI) were included. Study population was divided into 2 groups based on presence of LVAT. fQRS was defined as presence of various RSR' patterns, which included additional R wave or notching of R wave or S wave, and presence of more than 1 R in 2 contiguous leads corresponding to major coronary artery territory on 12-lead electrocardiogram. Patients with bundle branch block were excluded from the study. RESULTS: Of these, 32 (21.6%) had LVAT. Patients with LVAT had higher prevalence of fQRS (53.1% vs. 22.4%; p<0.001) and lower rate of successful PCI (75% vs. 94%; p=0.002) compared with patients without LVAT. More patients in LVAT group had left ventricular ejection fraction of <30% (87.5% vs 65.5%; p=0.010). Groups were similar with respect to other baseline characteristics (p>0.05 for all). Presence of fQRS was independent predictor of LVAT (odds ratio [OR], 2.795; 95% confidence interval [CI], 1.058-7.396) in multivariable logistic regression analysis. CONCLUSION: Presence of fQRS in leads V4-V6 is independently associated with LVAT in patients presenting with first acute anterior MI.

Impact of Coronary Collateral Circulation on In-Hospital Death in Patients with Inferior ST Elevation Myocardial Infarction.

Objectives. Coronary collateral circulation (CCC) may limit the size of right ventricular (RV) infarcts but does not fully explain the relationship between CCC and clinical adverse events in patients with inferior STEMI. In this study, it was aimed to assess the relationship between preintervention angiographic evidence of CCC and clinical outcomes in patients with inferior STEMI who have undergone percutaneous coronary intervention. Methods. A total of 235 inferior STEMI patients who presented within the first 12 hours from the symptom onset were included. CCC to the right coronary artery (RCA) before angioplasty were angiographically assessed, establishing two groups: 147 (63%) patients without CCC and 88 (37%) with CCC according to presence of CCC. Results. RV infarction, complete atrioventricular block, VT/VF, cardiogenic shock, and in-hospital death were noted less frequently in patients with CCC than in those without CCC. Absence of CCC to RCA was found to be the independent predictor for in-hospital death among them (odds ratio 4.0, 95% CI 1.8-12.6; p = 0.03). Conclusion. Presence of angiographically detectable CCC was associated with better in-hospital outcomes including RV infarction, complete AV block, cardiogenic shock, and VT/VF in patients with inferior STEMI.

Use of a 0.014 in. guidewire for cannulation of left coronary ostium with a difficult anatomy.

We report a case with a difficult left coronary anatomy in which we were not able to cannulate the left coronary ostium with the standard catheters. However, cannulation was successful with the help of a 0.014 in. angioplasty guidewire.

Double right coronary artery with atherosclerosis: a rare coronary artery anomaly.

We report the case of a patient with double right coronary artery, a very rare anomaly discovered incidentally and having atherosclerotic lesions in both right coronary arteries.

Myocardial injury after apparently successful coronary stenting with or without balloon dilation: direct versus conventional stenting.

Direct stenting (i.e., stenting without balloon predilation) is a novel approach to the percutaneous treatment of coronary artery lesions. This approach, by reducing aggression to the vessel wall and immediately sealing the dissections created by balloon inflation by the endoprosthesis, may also significantly lower the rate of procedural ischemic complications. Our purpose was to measure cardiac troponin T (cTnT), creatine kinase and its isoform CKMB after apparently successful elective stent implantation with conventional stenting (CS) or direct stenting (DS) and to compare the procedural myocardial injury between these 2 approaches. Enzyme levels were measured before and 16 hours post-procedure. A second-generation commercial ELISA cTnT assay (Boehringer Mannheim Corporation) was used to measure cTnT with a cut-off of 0.1 ng/dl. There was no abnormality in any of the 3 enzymes in either group before the procedure. Although the incidence of cTnT was elevated in 4 of 37 patients (10.8%) in the DS group and in 5 out of 23 patients (21.7%) in the CS group at 16 hours post-procedure, these values did not reach statistical significance (p > 0.05). Creatine kinase and CKMB levels were not elevated in any of the patients. CTnT and CKMB measurements are needed to detect this minor myocardial damage. Randomized studies with larger patient populations should be conducted to compare the two different approaches.

Sidebranch occlusion after coronary stenting with or without balloon predilation: direct versus conventional stenting.

Direct stenting (DS) is a novel approach in percutaneous treatment of coronary artery lesions. Several studies confirmed the safety and feasibility of the procedure with success rates greater than 90%. However, the data regarding the incidence of sidebranch occlusion (SBO) after DS are scarce. The purpose of this study was to evaluate SBO (> 1 mm) after DS and compare it to conventional stenting (CS) with balloon predilation. The study population consisted of 151 patients (88 underwent DS, 63 underwent CS) with 185 sidebranches jailed by the stent (110 in DS group, 75 in CS group). SBO was observed in 20 out of 110 patients in the DS group (18.2%) and 18 out of 75 patients in the CS group (24%). Although the incidence of SBO was higher in the CS group compared to the DS group (24% vs. 18.2%, respectively), these values did not reach statistical significance (p > 0.05). Most of the SBOs were observed in cases with type D sidebranch morphology (p < 0.001) and in cases with sidebranch ostial diameter stenosis 50% (p = 0.019). None of the other clinical and angiographic variables predicted the SBO. To the best of our knowledge, this is the first report comparing incidence of SBO between two different PCI methods (CS vs DS). Randomized studies with larger patient populations should be conducted to compare this approach with conventional stenting.

Conventional versus direct stenting in AMI: effect on immediate coronary blood flow.

There are no data regarding the potential benefits of direct stenting in the setting of AMI. The aim of this study was to evaluate the impact of direct stenting on the angiographic results and compare it to conventional stenting performed in the setting of AMI. We reviewed our institutional interventional database and identified 44 patients who had undergone stenting in the setting of AMI (29 primary and 15 rescue angioplasty). Patients were then divided into two groups; group A consisted of patients who had undergone conventional stenting (23 patients) and group B those who had undergone direct stenting (21 patients). Angiographic success was defined as TIMI flow grade 2. The baseline TIMI 0-1 flow was higher in group A compared to group B (74% vs. 24%; p < 0.05). TIMI flow rates before stenting (after balloon predilation in group A and after guidewire crossing in group B) and angiographic success (TIMI flow 2) after stenting were similar in both groups (p > 0.05). However, the final TIMI 3 flow were significantly better in group B after stenting (65% vs. 95%; p < 0.05). Although there was no no re-flow in group B, three patients in group A had no re-flow after balloon predilatation of lesions with baseline TIMI 2 flow. There was a statistical tendency to a higher TIMI 3 flow in patients treated with direct stenting in the setting of AMI. Direct stenting strategy in thrombus containing lesions seems to be a safe and feasible approach in avoiding no re-flow.

Covered stent graft for primary PTCA of an aortocoronary vein graft.

Covered stent graft by entrapping the thrombus between the vessel wall and stent might be helpful in preventing distal embolization and "no reflow" in a high-risk patient cohort. We here present a case with successful restoration of coronary flow in a highly thrombogenic milieu (acute myocardial infarction) with implantation of two covered stent grafts which by entrapping the thrombus avoided the distal embolization and "no reflow" in a totally occluded saphenous vein graft (SVG). However, stent length should be longer than the measured lesion length since choosing the exact diameter will not cover the plaque elongification secondary to the dilation process which is specifically significant in SVGs because of the softness of the plaque.

Frequency of cardiac troponin-t elevation after successful direct stenting.

Direct stenting (stenting without balloon predilation) is a novel approach in percutaneous treatment of coronary artery lesions. This approach may also significantly lower the rate of procedural ischaemic complications by reducing aggression to the vessel wall and immediately sealing the dissections created due to balloon inflation by the endoprosthesis. However, the incidence of minor myocardial infarction after direct stenting is unknown. The purpose of this study was to measure cTnT, creatine kinase and its isoform, CK-MB after apparently successful elective stent implantation without balloon predilation. Enzyme levels were measured just before and 16 hours after the procedures. A second-generation commercial ELISA cTnT assay (Boehringer Mannheim Corporation) was used to measure cTnT with a cutoff of 0.1 ng/dl. There was no abnormality in all three enzymes before the procedure. CTnT was elevated in 6 patients (13.6%), CK and CK-MB were elevated in 1 (2.3%) patient at 16 hours after the procedure. Both CK and CK-MB elevation were observed in the patient with side branch occlusion. In all others cTnT measurements in addition to CK-MB measurements are needed to detect this minor myocardial damage. To the best of our knowledge this is the first report evaluating the incidence of myocardial injury after direct stenting. Direct stenting by avoiding balloon-induced complications may decrease procedural myocardial necrosis. Randomized studies with larger patient populations should be conducted to compare this approach with conventional stenting. CTnT measurements in addition to CKMB measurements are essential in detecting this minor myocardial damage.

Recanalization of an occluded major side branch after stenting with intracoronary adenosine.

Adenosine is a powerful direct coronary vasodilator with a very short half-life that has been shown to be effective in avoiding and reversing no reflow. We report an immediate successful recanalization of an occluded major side branch after stenting with acute intracoronary adenosine administration. The beneficial effect of adenosine may imply that the side branch occlusion (SBO) in this case could be due to spasm or distal embolization of the atherosclerotic debris ending up with no flow. We believe that adenosine could be helpful in at least some cases of SBO and therefore may be worth attempting.