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We report three cases of acute myocardial infarction caused by left anterior descending (LAD) artery occlusion presenting as ST elevation in the inferior. Therefore, coronary angiography showed an occlusion of the LAD coronary artery. Our cases show the rare occurrence of left coronary circulation dominance affecting inferior leads. These cases show an unusual and very rare form of left dominance coronary circulation where LAD is wrapped around the apex and continuing as a posterior descending artery. This would make inferior myocardial infarction because of occluded LAD or determine as wrapped LAD.

Background: The posterior descending artery is the most common vessel chosen for an endarterectomy, while endarterectomy to the posterior descending artery is associated with decreased graft patency. The purpose of this study was to describe a distal anastomosis support (DAS) technique and retrospectively investigate the effect of DAS on the mid-term graft patency. Methods: Between January 2016 and December 2018, 200 patients with a PDA severe lesion who underwent off-pump coronary artery bypass (OPCAB) with CE (OPCAB + CE group, n = 95) and OPCAB + CE with DAS for anastomosis of PDA grafted by saphenous vein (SVG) (OPCAB + CE + DAS group, n = 105) were evaluated retrospectively. All patients came back to follow-up visit 6th, 12th, 24th, and 36th postoperative month. The primary endpoint is the graft failure (FitzGibbon B or O) of SVG-PDA on the follow-up CTA or CAG. Results: There was no significant difference in perioperative outcomes. We found significantly improved cumulative graft patency in OPCAB + CE + DAS group at 36 months after operation (84.6% vs 76.5%, p = 0.02). In multivariate Cox regression analysis, plaque length larger than 2 cm (hazard ratio [HR], 13.108, 95% confidence interval [CI], 2.842–60.457, p = 0.001), and peak TNI ⩾70× ULN within 48 hours of surgery (HR, 3.778, 95% CI, 1.453–9.823, p = 0.006) were independent predictors of graft failure, whereas PDA diameter greater than 1.5 mm (HR, 0.231, 95% CI, 0.081–0.654, p = 0.006), and DAS use (HR, 0.336, 95% CI, 0.139–0.812, p = 0.015) were significant protective factors. Conclusions: Concomitant DAS conferred superior mid-term patency of SVG-PDA. Adding the DAS procedure to OPCAB + CE may be a promising surgical option for patients with a PDA severe lesion, especially when PDA diameter less than 1.5 mm and plaque length greater than 2 cm.

The prevalence of congenital coronary artery anomalies is approximately 1% in the general population. They are a common cause of sudden death in younger persons. The origination of the posterior descending artery (PDA) from left anterior descending (LAD) artery is an extremely rare anomaly. We present a case of a 54-year-old female who presented with diabetic ketoacidosis with co-existing non-ST elevation myocardial infarction, therefore, had an invasive angiogram that identified the anomalous origin of PDA from LAD. It is vital to define coronary anatomy as anomalies dictate which cardiac intervention should be attempted in cases of ischemia.

This paper presents two cases of human hearts (a 75-year-old woman and an 88-year-old man) with double posterior descending arteries (PDA) of various sizes originating from the right coronary artery, mainly supplying the interventricular septum as well as the posterior walls of both heart ventricles in a different scope. In the analysis of the arterial vasculature, a range of aspects were considered, such as the point of exit of the right coronary artery, the course of the vessel, the range of the blood supply of the interventricular septum and both ventricles, as well as selected morphometric parameters that were simultaneously compared with one another. These atypical changes presented based on the example of the analyzed cases will certainly constitute a valuable source of information for cardiac surgeons and interventional cardiologists in planning operations.

Introduction: Coronary arterial dominance is defined by the vessel which gives rise to the posterior descending artery (PDA). The prevalence of right dominance is 80- 85%, left dominance is 8% and codominance is 7% among the general population. The coronary dominance in African Americans is not well known. The aim of this study was to investigate the coronary dominance in African Americans. Previous studies showed that left dominance and codominance are associated with increased post-percutaneous coronary intervention (PCI) in-hospital mortality in patients with acute coronary syndrome (ACS). Methods: A retrospective analysis of coronary angiograms performed in our facility was done. A total of 556 cases were reviewed from 2018 to 2019. All the data was collected from the electronic medical records. Patients were categorized by race, gender, age, and comorbidities. Angiograms were reviewed and coronary dominance was determined by the vessel which supplied the PDA. Results: From the 556 charts reviewed, 430(77%) cases were performed in African Americans. Of the 430 patients, 220(51%) were male and 210(49%) were female. Mean age was 62.6 years. 370(86%) patients had hypertension, 171(39.7%) had diabetes, 28(6.5%) had peripheral vascular disease, 149(34.6%) had heart failure, 33(7.6%) had history of stroke. 28(6.5%) were on dialysis, 201(46.7%) had dyslipidemia, 14(3.2%) had HIV, 43 (10%) had atrial arrhythmias, 237(55.1%) had history of tobacco use and 21(4.8%) had history of cocaine use. In 390(90.7%) patients, left main coronary artery bifurcated into left anterior descending coronary artery (LAD) and left circumflex artery (LCX). In 40(9.3%) patients, left main coronary artery trifurcated into LAD, LCX and ramus intermedius artery. Among these patients, 303(70.4%) had right coronary dominance, 38(8.8%) had left coronary dominance and 89(20.7%) had codominance. 7 patients had ectasia of the coronary vessels and 8 patients had anomalous origin of coronary vessels. Conclusions: Our study showed that African Americans have higher prevalence of codominance compared to general population. It is important to identify it at the time of coronary angiogram since it has been associated with increased post PCI in-hospital mortality in patients with ACS.

Hyperdominant left anterior descending artery (LAD) is a rare anomaly in which the LAD gives rise to the posterior descending artery. Our case report describes an extreme case of hyperdominant LAD supplying the anterior, inferior, and partially the lateral walls of the left ventricle. It is crucial that physicians be aware of the possibility of extreme LAD dominance. A proximal occlusion of such a vessel might have catastrophic consequences with atypical presentation on electrocardiogram.

Single coronary artery (SCA) is a rare anomaly with an incidence of 0.01%–0.004% in general population. We present a rare case of SCA, which is L1 subtype of Lipton's classification of SCA, and accounts for only 0.016% of the population undergoing coronary angiogram. The patient presented with acute inferior myocardial infarction, on further evaluation she was found to have SCA. The right coronary artery was arising as a branch from the proximal left anterior descending artery (LAD) with distal LAD continuing as posterior descending artery and posterior left ventricular branch, and with a critical stenosis in left circumflex artery and LAD. She underwent successful multivessel angioplasty with good results.

The posterior descending artery (PDA) supplying the posterior one-third of the inter-ventricular septum usually arises from the right coronary artery (RCA) or the left circumflex artery (LCX). PDA arising from the left anterior descending artery (LAD) is an extremely rare anomaly. Here we report a rare type of left dominant circulation in which a large LAD is continuing as PDA after winding round the apex in the presence of a diminutive RCA. Such a large LAD continuing as PDA is referred as "hyperdominant" or "superdominant". A 32-year-old male chronic smoker presented with acute onset retrosternal pain of 4 h duration with profuse sweating in primary health center with electrocardiography (ECG) changes in inferior leads and was thrombolysed with intravenous streptokinase 15 lacs IU over one hour and was referred to our center for further management and coronary intervention. Coronary angiogram revealed PDA as a continuation of the LAD beyond the crux and a non-dominant right coronary as well as LCX. The LAD had plaque in mid-LAD course. Intravascular ultrasound study (IVUS) showed insignificant plaque in mid-LAD (30%). Hence, we decided to keep him on medical therapy only. Cardiol Res. 2018;9(4):253-257 doi: https://doi.org/10.14740/cr738w

Background: The use of sequential anastomoses in coronary artery bypass grafting (CABG) is still controversial. This study aimed to evaluate the mean blood flow (MBF) rate and pulsatility index (PI) of single and sequential saphenous vein grafts to the posterior descending artery (PDA) in the same patient during off-pump CABG (OPCABG). Methods: Sequential saphenous vein grafts were used to bypass the diagonal artery (Diagonal) (side-by-side), obtuse marginal artery (OM) (side-by-side) and PDA (end-to-side). The anastomoses of Diagonal and OM were temporarily occluded with bulldog clamps, making the sequential graft a “single” graft to PDA. The MBF and PI of this “single” graft to PDA were measured with transit-time flow measurement (TTFM). Then the bulldog clamps were removed and the MBF and PI of sequential graft to PDA were measured again and compared to those of the “single” graft in the same patient. Anastomoses were evaluated with coronary CT angiogram at 6 months. Results: A total of 128 patients with triple vessel disease were enrolled (96 men; mean age, 66.0±8.0 years; range, 54–80 years). The MBF of the “single” vs. sequential graft to PDA was 20.6±9.1 vs. 21.4±10.1 mL/min (P=0.472). The PI of ‘single graft’ vs. sequential graft to PDA was 1.7±0.6 vs. 1.7±0.5 (P=0.941). The patency of all grafts was good in all patients after 6 months of follow-up. Conclusions: There were no hydrodynamic differences between single and sequential grafts to PDA in OPCABG.

Introduction: There is considerable variation in the arterial supply of diaphragmatic surface of the heart. Diaphragmatic myocardial infarction is one of the more common consequences of coronary artery disease. The aim of this study was to assess the incidence of anatomic variants of origin and termination of Posterior Descending Artery (PDA) and to determine the type of coronary dominance in North Indian population. Subjects and Methods: This prospective study was carried out on 50 routine subjects of different age groups who came to the Department of Radiodiagnosis, King George’s Medical University UP, Lucknow in the year 2010- 2011 with known or suspected coronary artery disease. All the cases were investigated on a 64 slice Multidetector Computed Tomographic (MDCT) scanner, using retrospective Electrocardiographic gating. Endeavour was made to determine the incidence of sites of origin and termination of PDA as well as to determine the type of coronary dominance. Results: PDA arose from Right Coronary Artery (RCA) in 39 (78%) cases and from Left Circumflex (LCx) artery in 11(22%) cases. The PDA was found to terminate in the upper 1/4 of Posterior Inter-Ventricular Groove (PIVG) in 18 (36%) cases, in upper 1/2 of PIVG in 19 (38%) cases, in upper 3/4 of PIVG in 10 (20%) cases and at the apex of the heart in 1 (2%) case. None of the female had termination of PDA at the apex. Termination of PDA could not be determined in 2 (4%) cases. Right dominance was seen in 36 (72%) cases, Left dominance in 11 (22%) cases. and Co-dominance in 3 (6%) cases. Conclusion: Posterior descending artery most commonly terminated after traversing the upper half of posterior inter-ventricular groove. The incidence of left coronary dominance was more in females, it was approximately twice the incidence found in males. Co-dominance was observed only in male subjects.

The origin of the posterior descending artery [PDA] from the left anterior descending artery [LAD] or its branches is a rare coronary anomaly. The critical coronary lesions before the origin of the PDA in this circumstance can lead to large ischemia or infarction, which can be fatal. Coronary angiography is the investigation of choice. These patients should undergo early revasculazation.

Patient Initials or Identifier Number Mr. C ### Relevant Clinical History and Physical Exam Mr. C, 64 y/o male came to my clinic for progressive angina with exertion and improved after rest for 1 year. Two days ago, sudden angina while sitting last for 1 hour. Past history: Diabetes mellitus

Dabigatran etexilate is a recently approved direct thrombin inhibitor (DTI), which is superior to warfarin in the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF). However, dabigatran use is associated with an increased risk of myocardial infarction (MI) compared to warfarin. The mechanisms for this association effect remain speculative. We present a case of an acute MI and cardiac arrest in a patient with chronic AF who had been recently switched from warfarin to dabigatran. Urgent coronary angiography, at St. Michael’s hospital (Toronto, Canada), revealed evidence of thromboembolism to the distal posterior descending artery. The patient was treated medically and switched back from dabigatran to warfarin. He did well and was discharged after an uneventful stay in the coronary care unit.

Transthoracic echocardiography (TTE) has been described as an accurate technique for noninvasive evaluation of coronary flow reserve (CFR) of the left anterior descending artery (LAD) and posterior descending artery (PDA). Aim of this study was to find out whether serial measurement of CFR in LAD and PDA using TTE allows detection of stenosis elimination after intracoronary intervention and is a marker of successful procedure.The study group comprised 14 patients with single-vessel coronary disease (stenosis 82+/-14%) of the LAD (9 patients) or right coronary artery (RCA, 5 patients) scheduled for stent implantation. All patients underwent dipyridamole stress echo with CFR evaluation of either distal LAD or PDA 1 day before and 6-9 days after successful stent implantation. CFR was calculated as the ratio of hyperemic to basal peak diastolic velocity. A CFR value of2.0 was considered abnormal.Adequate Doppler signals to measure CFR were obtained in 13 patients (93%). Abnormal pre-procedure CFR value was revealed in 12 assessed patients (92%). Significant increase of CFR due to a decrease of coronary flow velocity at rest and its more pronounced hyperemic rise was found in all patients after stent implantation (CFR: 1.28+/-0.52 before and 2.53+/-0.37 after stenting; p0.001). Using a cut-off value of CFR more or equal 2.0 to identify absence of significant coronary artery disease, TTE detected successful stent implantation with a sensitivity of 91.7% and specificity of 100% for both LAD and RCA. CFR was still abnormal in only 1 patient with pre-procedure90% LAD stenosis.TTE is a feasible technique for serial CFR evaluation in LAD and PDA. Cut-off CFR value more or equal 2.0 is a sensitive and specific criterion of successful stent implantation in LAD and RCA.

Purpose: To compare volume-targeted acquisition with whole-heart acquisition in 1.5-T free-breathing 3D coronary magnetic resonance angiography (MRA) with parallel imaging. Materials and Methods: The major coronary arteries were imaged in 36 subjects using the whole-heart and volume-targeted acquisitions with comparable imaging parameters. The quantitative and semiquantitative data derived from these two acquisition methods were analyzed statistically, with P < 0.05 considered significant. Results: Both the right coronary artery (RCA) / left circumflex artery (LCX)- and the left main (LM) / left anterior descending (LAD)-targeted acquisitions had similar results in navigator efficiencies and apparent signal-to-noise ratio (SNR) in comparison with whole-heart acquisition. Apparent contrast-to-noise ratio (CNR) of the volume-targeted imaging was significantly higher than that of the whole-heart imaging. The imaging time required for a whole-heart scan was significantly longer than each of the RCA/LCX- and LM/LAD-targeted acquisitions. However, the sum of scanning times derived from volume-targeted imaging was significantly longer than that of whole-heart acquisition. Both RCA/LCX- and LM/LAD-targeted acquisition yield higher vessel sharpness and overall image quality in comparison with whole-heart acquisition. The lengths of the major coronary arteries were not significantly different for the whole-heart and volume-targeted approaches. The whole-heart method was obviously superior to the volume-targeted method in terms of visualization of the posterior descending artery. Conclusion: For current 1.5-T navigator coronary MRA, volume-targeted and whole-heart acquisitions have their own advantages and the choice of methods may vary in accordance with the different aims of clinical practice. J. Magn. Reson. Imaging 2013;38:594–602. © 2013 Wiley Periodicals, Inc.

Background: Coronary artery bypass graft (CABG) failure may result in a wide range of problems. Objectives: The aim of the present study was to evaluate failure rate and risk factors in coronary bypass grafts. Patients and Methods: In this cross-sectional study, 250 post-CABG patients in Baqiyatallah hospital, Tehran, Iran in 2004 2014 were evaluated. Graft failure rate and predisposing factors were evaluated. Results: In this study, 250 patients with the mean age of 64.50 ± 7.63 years were evaluated. LIMA (left internal mammary artery) to LAD (left anterior descending artery) was patent in 187 patients (82.6%), SVG (saphenous vein graft) to OM (obtuse marginal artery) in 159 patients (81.9%), SVG to RCA (right coronary artery) in 49 patients (50.5%) and SVG to PDA (posterior descending artery) in 90 patients (68.2%). Lowest patency was in the right coronary artery and maximum patency in the left anterior descending artery. LIMA/SVG patency rates in 1 5 years, 5 10 years and over 10 years after CABG were 77.4%/92.7%, 81.5% / 71.6% and 100%/92.7%, respectively. Male gender, BMI > 30, diabetes, hypertension, hyperlipidemia and smoking were related to higher graft failure rate (P = 0.001). Conclusions: The LIMA grafts had the highest late patency rate, but were associated with a high rate of short-term occlusions. Also we found that patients with successful CABG and patent coronary were those who had less predisposing factors.

Background: Coronary artery anomalies are not common, but could be very serious. Objectives: This study determines the frequency of coronary anomalies and normal variants by multi-detector-row computed tomography (MDCT). Patients and Methods: The results of cardiac MDCT study in 2697 consecutive patients were analyzed retrospectively. Acquisition was performed by a 64-detector row CT machine. Imaging results were assessed by experienced radiologists. Results: Myocardial bridging was by far the most frequent coronary variant (n = 576, 21.3%). Eighty-three subjects (3.1%) showed other coronary anomalies and variants. Anomalies of origination and course of the left main coronary artery (LMCA) were detected in 1.09% of the subjects. The frequency of these anomalies in the right coronary artery (RCA), left circumflex artery (LCx), left anterior descending artery (LAD), posterior descending artery (PDA) and obtuse marginal (OM) artery were 1.24%, 0.33%, 0.1%, 0.07% and 0.03%, respectively. The single coronary pattern was seen in 0.18% and coronary fistulas in 0.07%. Conclusion: Based on the fact that coronary CT-angiography using MDCT can display different coronary anomalies, this study shows similar results to other reports on the subject. Future advances in the performance of CT machines will further improve the quality of CT-based cardiac imaging.

The assumption that atherosclerosis accumulates in the proximal coronary arteries and that distal segments are spared has yet to be systematically shown in vivo.We used intravascular ultrasound to analyze complete proximal, mid, and distal segments from 75 diseased left anterior descending arteries (LADs) and 61 diseased right coronary arteries (RCAs) (including either the posterolateral [PLA; n = 38] or posterior descending artery [PDA; n = 23]) to document that distal coronary arteries are more often free of disease vs proximal vessels. External elastic membrane, lumen, and plaque and media areas were measured every 0.4 mm (median), and plaque burden (plaque and media/external elastic membrane) and percentage of normal (plaque and media thickness0.3 mm) cross sections/segment were determined.Left anterior descending artery plaque was heaviest in proximal and mid segments, diminishing significantly in distal segments; plaque burden was 46% ± 9% in proximal, 39% ± 8% in mid, and 31% ± 9% in distal LAD (P.0001), with 93% (median) of distal LAD cross sections being normal compared with 21% of mid and 0% of proximal cross sections (P.0001). Right coronary artery plaque gradient was less pronounced vs the LAD; plaque burden was 37% ± 13% in proximal, 40% ± 10% in mid, and 36% ± 10% in distal RCA, followed by 31% ± 11% in PDA and 33% ± 10% in PLA. This was supported by the median percentage of normal cross sections/segment: 0% proximal, 0% mid, and 23% distal RCA sections plus 100% PDA and 48% PLA sections.Intravascular ultrasound data indicated a proximal-to-distal LAD plaque gradient; significant disease was uncommon in the distal LAD. Conversely, the proximal-to-distal RCA plaque gradient was less distinct than the LAD, although disease in the PDA was still reduced compared with proximal segments.

Iatrogenic complications present a major challenge to the interventional cardiologist. We describe a case of extensive right coronary artery dissection caused by engagement of a 0.035″ guidewire. Attempts to reopen the flush-occluded posterior descending artery using conventional methods were unsuccessful. However, the vessel was successfully restored with the use of intravascular ultrasound guidance and we describe the steps involved in this technique. (J Interven Cardiol 2012;25:170–173)

The optimal technique for bifurcation stenting of distal Left main (LM) lesions remains unestablished and controversial. Some techniques with superior stent apposition, such as culotte technique were supposed to be associated with lower rate of stent thrombosis. However, with culotte technique, the double-stent layer at the carina and in the proximal part of the bifurcation, may lead to difficult or improper rewiring of the side branch before final kissing balloon postdilatation (KBP). We describe a case of distal LM disease associated with distal left circumflex (LCX) and posterior descending artery stenosis. During LM stenting using culotte technique, improper rewiring of LCX before final KBP caused malapposition of the inner sent layer at the mid part of LM. Despite the optimal angiographic result, intravascular ultrasound (IVUS) was able to detect stent malapposition and guided further management to achieve complete stent apposition. The present case indicates that IVUS is an essential tool for LM stenting particularly when applying double stent strategy requiring final rewiring before KBP. Moreover, we suggest that some tools, such as Crusade and Venture catheters, can be used to ensure proper rewiring and hence, prevent subsequent stent malapposition, which may lead to catastrophic complications such as early and late LM stent thrombosis. V C 2011 Wiley-Liss, Inc.

Rationale and Objectives To compare computer-generated interpretation of coronary computed tomography angiography (cCTA) by commercially available COR Analyzer software with expert human interpretation. Materials and Methods This retrospective Health Insurance Portability and Accountability Act‑compliant study was approved by the institutional review board. Among 225 consecutive cCTA examinations, 207 were of adequate quality for automated evaluation. COR Analyzer interpretation was compared to human expert interpretation for detection of stenosis defined as ≥50% vessel diameter reduction in the left main, left anterior descending (LAD), circumflex (LCX), right coronary artery (RCA), or a branch vessel (diagonal, ramus, obtuse marginal, or posterior descending artery). Results Among 207 cases evaluated by COR Analyzer, human expert interpretation identified 48 patients with stenosis. COR Analyzer identified 44/48 patients (sensitivity 92%) with a specificity of 70%, a negative predictive value of 97% and a positive predictive value of 48%. COR Analyzer agreed with the expert interpretation in 75% of patients. With respect to individual segments, COR Analyzer detected 9/10 left main lesions, 33/34 LAD lesions, 14/15 LCX lesions, 27/31 RCA lesions, and 8/11 branch lesions. False-positive interpretations were localized to the left main (n = 16), LAD (n = 26), LCX (n = 21), RCA (n = 21), and branch vessels (n = 23), and were related predominantly to calcified vessels, blurred vessels, misidentification of vessels and myocardial bridges. Conclusions Automated computer interpretation of cCTA with COR Analyzer provides high negative predictive value for the diagnosis of coronary disease in major coronary arteries as well as first-order arterial branches. False-positive automated interpretations are related to anatomic and image quality considerations.

Coronary flow reserve (CFR) in the left anterior descending artery (LAD) can be reduced in nonischemic dilated cardiomyopathy (DCM). The aim of this study was to assess the prognostic value of CFR in LAD and in the posterior descending artery (PD) in DCM patients.Seventy-two DCM patients (44 men, mean age 64 ± 13 years) underwent dipyridamole (0.84 mg/kg in 6 minutes) stress echo. CFR was defined as the ratio between maximal vasodilation and rest peak diastolic flow velocity in LAD and PD.CFR was abnormal in LAD in 42 out of 72 patients and in PD in 31 out of 55. All patients completed the clinical follow-up, and 56 patients completed the echocardiographic follow-up. During median follow-up of 42 months, 33 events (7 deaths, 26 major cardiac events) occurred. Event rate was markedly higher for patients with reduced CFR compared with DCM patients with normal CRF in LAD (0 vs 19 events; P.001) and in PD (1 vs 13 events; P.001). CFR in LAD and in PD were significantly related to the change in end-systolic volume during follow-up (r = -0.481, P.001; and r = -0.407, P = .028; respectively). Preserved CFR in both LAD and PD was associated with better (P.0001) event-free survival compared with abnormal CFR (log rank: 28.1; P.0001).In DCM patients, impairment of CFR in LAD and PD is related to a worse outcome; CFR impairment is more relevant when it occurs in LAD. PD evaluation may be redundant and time-consuming, because the additive value is small and the feasibility suboptimal.

During the last century, many investigators reported on myocardial bridges in the adult human heart. In the present study, 39 human fetal hearts (the mean gestastional age was 30 weeks) were studied for myocardial bridging, and the results were correlated with adult data. Among the 39 (27 male and 12 female) fetal hearts studied, 26 bridges were observed on 18 fetal hearts (46.2%). Ten of the bridges had one myocardial bridge, whereas double myocardial bridges were observed in eight fetal hearts. The most frequent myocardial bridges were observed on the left anterior descending artery (LAD), which had 13 bridges (50%). Eight (30.7%) myocardial bridges were on the diagonal artery, and on the posterior descending artery there were five (19.3%). Myocardial bridges were not observed on the circumflex artery. The data presented in this study may provide potentially useful information for the preoperative evaluation of the newborn and may have a clinical implication for sudden fetal death.

This report describes the case of a 58-year-old male patient with a previous history of aortitis, who had undergone coronary artery bypass graft surgery 4 months before, evolving with unstable angina and presenting severe lesion at the bifurcation of a "Y" saphenous sequential graft. Patient successfully underwent coronary angioplasty with a paclitaxel eluting stent implanted at the ostium of one of the limbs of the "Y" graft, anastomosed to the posterior descending artery and marginal branch of the left circumflex artery.

A 76-year-old woman underwent coronary angiography for chest pain. On the coronary angiogram, no significant coronary artery atherosclerotic stenosis was observed. Multiple coronary artery microfistulas, draining from the left anterior descending artery to the left ventricle and from the posterior descending artery of the right coronary artery to the left ventricle, were observed. Apical wall thickening and fistula flow from the left anterior descending artery were demonstrated by using transthoracic echocardiography. We describe a rare case of multiple coronary artery microfistulas from the left and right coronary artery to the left ventricle combined with apical hypertrophic cardiomyopathy.

Objective: The purpose of this study was to determine the correlation between cardiac index (CI) measurements made using intermittent thermodilution (ITD) technique by pulmonary artery catheter (PAC) and arterial pulse-contour analysis by FloTrac. Design: Prospective observational study. Setting: Cardiac surgery unit in a 350 bedded tertiary care hospital in India. Participants: 31 adult patients undergoing elective off-pump coronary artery bypass grafting (OPCABG) Interventions: CI measurements performed by the two different methods at six time points during the surgery (before skin incision, during grafting of left anterior descending artery, obtuse marginal artery and right coronary/ posterior descending artery, after protamine administration and after shifting the patient to recovery room). Measurements and results: The techniques a weak correlation at all six time points during the OPCABG. The mean bias of 0.85 L/min/m2 and precision of 0.55 was found in the study population. The percentage error calculated using Critchley s criteria was found to be 46%. Conclusion: CI measurements obtained using FloTrac showed a limited correlation with those acquired by ITD technique at different stages of OPCABG. Further studies are required in other patient populations and clinical situations.

Objectives. The purpose of this study is to define the long-term patency of the radial artery (RA) graft and review the current literature. Methods. Two hundred and eighty-six RA symptom-directed graft angiograms were studied in 209 patients. The preoperative patient characteristics and intraoperative variables were collected prospectively from patients who had primary coronary artery bypass grafting between 1995 and 2002. A total of 166 (79%) patients were male with a mean age of 65 years. The mean period from operation to re-angiogram was 35 months. Actuarial techniques are not valid in graft patency studies as the time when the graft occluded is not known. Therefore, RA patency was analyzed at four categorical time intervals. The RA was grafted to the left anterior descending artery (LAD) in six patients (2%), diagonal (DIAG) in 29 (10%), obtuse marginal (OM) in 166 (58%), right coronary artery (RCA) in 9 (3%) and posterior descending artery (PDA) in 76 (27%) cases. The graft failure was defined as ≥80% stenosis. Results. A total of 259 (91%) grafts were patent and 26 (9%) had failed. Most grafts were widely patent or occluded. The LAD/DIAG patency was 30/35 (86%), OM patency 154/166 (93%) and RCA/PDA patency 79/84 (94%). The interval from surgery to angiogram did not affect the RA graft patency (86% at 5 years). Conclusions. Even in a patient cohort with adverse symptoms, excellent RA patency was achieved that remained almost constant through all time intervals studied. Better selection, harvesting and preservation may further improve early patency.

Hyperdominant left anterior descending artery (LAD) is a rare coronary anomaly in which posterior descending artery arises from LAD instead of left circumflex or right coronary artery. Here we present a case of hyperdominant LAD presenting as acute myocardial infarction.

The posterior descending artery usually arises from either the right coronary artery or the left circumflex artery. Here we report an unusual case of super-dominant left anterior descending coronary artery continuing as the posterior descending artery beyond the crux which was totally occluded in a patient who presented with acute anterior wall myocardial infarction. Successful primary angioplasty and stenting of the super-dominant left anterior descending coronary artery was performed.JCMS Nepal. 2016;12(2):81-82

A 56-year-old man with diabetes and a history of triple coronary artery bypass graft surgery (left internal mammary artery [LIMA] to left anterior descending [LAD] artery, saphenous vein grafts to posterior descending artery and obtuse marginal artery) underwent coronary catheterization for

The coronary artery anatomy includes: (1) the left main coronary artery (LMCA), also known as the left coronary artery (LCA); (2) the left anterior descending artery (LAD) and its main branches; (3) the left circumflex artery (LCx) and its main branches; (4) the right coronary artery (RCA); and (5) the posterior descending artery (PDA) (Figs. 5.1a, b). The coronary vein is parallel to the artery (Figs. 5.2a–c). It merges into the coronary sinus, and all drain into the RA. The LCA originates from the left aortic sinus, whereas the RCA originates from the right aortic sinus above the AV (Figs. 5.3 and 5.4).

Surgical angioplasty for ostial stenosis of the major coronary arteries is a well-established treatment modality. Management of discrete stenoses of distal coronary arteries in the presence of mild proximal disease is a challenging task. Percutaneous intervention or grafting beyond the diseased segment may be limited by size of the target vessel, whereas endarterectomy followed by graft placement may result in graft occlusion due to competitive native flow. Patch angioplasty with or without endarterectomy is an effective option in this setting, which can be performed without cardiopulmonary bypass in the appropriate group of patients. A patient with triple vessel coronary artery disease and a discrete lesion in the posterior descending artery underwent off-pump endarterectomy with vein patch angioplasty in combination with bypass grafting to left anterior descending and obtuse marginal arteries. Operative technique and intraoperative strategies are discussed.

Intraoperative assessment of graft anastomoses is commonly performed after off-pump coronary artery bypass grafting (OPCAB). The SPY imaging system allows intraoperative graft assessment. We document correlation between intraoperative SPY images and wall motion abnormality by transesophageal echocardiogram (TEE) during OPCAB. A 79-year-old female underwent OPCAB. Intraoperative graft patency assessment was performed with the SPY and left ventricular wall motion was assessed by TEE. SPY imaging demonstrated poor flow trough the distal vein graft anastomosis to the posterior descending artery, which correlated with a new posterior wall motion hypokinesis. After graft revision, SPY imaging demonstrated good distal flow and the TEE demonstrated normalization of the left ventricular posterior wall motion. SPY technology allows the surgeon to accurately assess graft patency intraoperatively and allows immediate correction of a technical problem.

Coronary artery anomalies are rare entities. All angiographers and cardiac surgeons need to be familiar with these anatomic variants for proper surgical revasularisation in the presence of coronary artery disease. We report here an interesting case of superdominant right coronary artery with double posterior descending artery.