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Case 32
Published in Andrew Solomon, Julia Anstey, Liora Wittner, Priti Dutta, Clinical Cases, 2021
Andrew Solomon, Julia Anstey, Liora Wittner, Priti Dutta
Mrs Lewis is seen by the cardiology team who take her for an urgent angiography. The angiography shows 60% stenosis in the obtuse marginal artery. Mrs Lewis is transferred to the local cardiothoracic centre for a coronary artery bypass graft. She makes a good recovery from her surgery and is discharged directly from there, with cardiology and cardiothoracic follow-up.
Subacute stent thrombosis in a patient with COVID-19 pneumonia
Published in Baylor University Medical Center Proceedings, 2021
Mohamed Ayan, Swathi Kovelamudi, Malek Al-Hawwas
Urgent coronary angiography showed 100% thrombotic occlusion of the second obtuse marginal artery, a severe lesion in the mid left anterior descending artery, and distal occlusion of a nondominant right coronary artery (Figure 2a). He had successful PCI with a 3.0 × 38 mm Resolute Onyx drug-eluting stent to the second obtuse marginal artery (Figure 2b). He was loaded with 600 mg of clopidogrel in the catheterization lab and started on 75 mg of clopidogrel daily. Heparin infusion was restarted after PCI per intensive care unit protocol for the COVID-associated hypercoagulability state. Three days after PCI, he had worsening hemodynamics and developed ST-segment depressions in lateral leads (Figure 1c) with a rising troponin level after it had trended down after PCI (34 ng/mL from 7 ng/mL after PCI). Urgent coronary angiography revealed complete occlusion of the second obtuse marginal artery from stent thrombosis (Figure 2c). Balloon angioplasty reestablished Thrombolysis in Myocardial Infarction (TIMI)–3 flow; however, a new 3.0 × 34 mm Resolute Onyx stent was placed because of significant residual filling defect (Figure 2d).
A case of spontaneous coronary artery dissection presenting with acute anterior wall myocardial infarction in a young adult male – an increasingly recognized rare disease
Published in Journal of Community Hospital Internal Medicine Perspectives, 2018
Mohamed Taha, Htun Latt, Jaafar Al-Khafaji, Mohamed Ali, Richard Seher
Emergent coronary angiography revealed total occlusion of the left anterior descending artery at its origin (LAD) with an evidence of spontaneous dissection as the cause of the occlusion (Figures 2 and 3). The right coronary artery was patent and free of disease. Left ventriculogram revealed severe left ventricular dysfunction with elevated left ventricular end-diastolic pressure and akinesis of the mid to distal anterior wall and apex. Left ventricular ejection fraction (LVEF) was estimated at 41%. An apical thrombus was also discovered during echocardiogram. The LAD occlusion was successfully treated with primary percutaneous transluminal coronary angioplasty (PTCA) and placement of a drug-eluting stent (4.0 × 38 mm Xience Alpine stent, Figure 4). Post-intervention there was still an evidence of thrombosis in the obtuse marginal artery and the diagonal artery which was addressed with aspiration thrombectomy. The procedure was uneventful with complete resolution of the chest pain thereafter.
A ‘recurrent’ coronary artery
Published in Acta Cardiologica, 2022
Meenu Bagarhatta, Ritu Agarwal, Rengarajan Rajagopal
Anatomically, the course of an artery is described as ‘recurrent’ when the artery originates at a distal location and courses proximally to supply an organ (for instance radial recurrent artery). The coronary arteries are seen to arise from the aortic sinuses and usually run distally without any retrograde course to supply the myocardium. Fifty-year-old lady with history of rheumatic mitral disease presented with progressive breathlessness and chest discomfort. Coronary CT angiogram performed pre-operatively to mitral valve repair, showed no obstructive atherosclerotic coronary disease. Mitral valve was thickened with sub-valvular deformity and aortic valve was tricuspid and normal. The left main and right coronary arteries were seen to arise from respective aortic sinuses. The left main coronary artery (LMCA) (marked with ‘*’ in Figure 1) had a long course with the first lateral branch supplying the territory corresponding to obtuse marginal artery (basal anterolateral and inferolateral segments). Left circumflex artery (LCx) originated from this artery with ‘recurrent course’ along the LMCA (black arrow in the Figure 1) to the proximal left atrio-ventricular groove. There were no other segments of severe angulation. This pattern of origin and course of LCx could be described as a ‘recurrent’ course of left circumflex artery and has not been described previously in literature. Such segments of severe angulation have altered flow dynamics and may be prone to development of spontaneous arterial dissections and acute coronary events. Segments of such tortuosity also pose difficulties during interventional procedures while introducing sheaths and stents.