Coronary artery anomalies (CAAs) are congenital vascular defects which can remain hidden and asymptomatic over the complete life course of an individual. They are defined as deviations from the ...normal coronary anatomy regarding the arterial origin, course, or both. Their incidence varies from 1.3% to 5.64% in coronary angiography cohorts, and they can be detected as incidental findings. In certain cases, CAAs can be hemodynamically significant and unfortunately can be proven lethal. Their link with sudden cardiac death, especially in otherwise healthy competitive athletes, is well established, but their prognostic significance, range of symptoms, and pathophysiology remain to be further elucidated. Here, along with a brief review of related literature, we present a series of three cases: one case of an anomalous origin of the right coronary artery (RCA) from the left coronary sinus, one case of a split RCA originating from the left coronary sinus, and one case of a dual left anterior descending (LAD) artery system.
The-double chambered right ventricle (DCRV) is a rare distinctive anatomic entity with both congenital and acquired components, wherein abnormally located or hypertrophied muscular bands divide the ...right ventricle into a proximal high-pressure and a distal lower pressure chambers - even to the point of mid-ventricular obstruction. As the DCRV is very often associated with other congenital cardiac defects, such as a perimembranous ventricular septal defect (PM-VSD), it is usually diagnosed in infancy and childhood. However, it may remained unrecognised until adulthood, when the patient presents with atypical symptoms mimicking common acquired cardiac diseases. In the current case report, we present an adult patient with DCRV that underwent a complex cardiac surgery, not only for the primary defect, but also for the coexisting cardiac pathologies.
A 63yr old female patient, with a known medical history of an uncorrected VSD, presented to our hospital with intense chest discomfort and dyspnea on minimal exertion (NYHA III). The laboratory exams showed mild troponin increase, whilst the TTE verified the presence of a VSD, but also revealed the existence of a DCRV with normal function and dimensions, a severely stenosed aortic valve, a severely regurgitant mitral valve and a left ventricle with preserved EF. After performing a coronary angiography that showed right coronary artery disease and common origin of the left and right coronary arteries from a single ostium, the patient was scheduled for surgery. Intraoperatively, the TOE examination showed a normally functioning hypertrophied RV, with abnormal muscular bands (AMB) that cross its cavity and cause nearly total RVOT obstruction and turbulent flow. The usage of a Swan-Ganz catheter verified the existence of two separate chambers with a pressure gradient of almost 100mmHg inside the RV and set the diagnosis of a DCRV. Furthermore, the known VSD was more specifically a PM-VSD with left to right flow between the LVOT and the proximal supra-systematic chamber of the RV, because of the simultaneous severe aortic valve stenosis.
The patient underwent excision of the AMB through a small right ventriculotomy, mitral valve repair with an Alfieri stitch transaortically and aortic valve replacement with root enlargement. No graft was placed to the RCA because of the poor distal target. Despite the successful excision of the AMB and the release of the intracavitary obstruction, the separation from the CPB was very difficult due to biventricular, but mostly RV dysfunction. The patient was placed on V-A ECMO and transferred to the CICU.
In this case report, we showed that a rare congenital cardiac disease (DCRV) can remain masked until adulthood, when the patient becomes finally symptomatic but with atypical symptoms. Definitive treatment is surgery and generally has an excellent prognosis. However, we should be very careful before attempting to derange the balances that the RV has set to itself until then.
We evaluated right ventricular (RV) systolic and diastolic function in 30 patients with acute RV myocardial infarction on echocardiography. Systolic and diastolic function were impaired early in the ...setting of RV myocardial infarction, but improved significantly at 3 months.
Diabetic cardiomyopathy is a distinct entity in diabetic patients with congestive heart failure, who have no angiographic evidence of significant coronary artery stenosis. The aim of this study was ...to evaluate left ventricular (LV) function in 24 elderly patients (mean age 67 ±2 years) with type 2 diabetes, who were asymptomatic and had no history of hypertension, or coronary or valvular heart disease. LV systolic indices (ejection fraction EF and fractional shortening FS), diastolic indices (E wave, A wave, E/A ratio, isovolumic relaxation time IVRT and deceleration time DT) and the myocardial performance index (MPI) were evaluated with echocardiography. Compared to controls (24 age- and gender-matched normal subjects), the E wave was reduced (0.60 ±0.10 m/sec vs 0.72 ±0.08 m/sec, p<0.05), the A wave was increased (0.77 ±0.07 m/sec vs 0.68 ±0.06 m/sec, p<0.05), the E/A ratio was decreased (0.78 ±0.20 vs 1.06 ±0.18, p<0.001) and both IVRT and DT were prolonged (0.115 ±0.01 sec vs 0.09 ±0.01 sec, p<0.001 and 0.240 ±0.04 sec vs 0.180 ±0.03 sec, p<0.001, respectively). The MPI was significantly increased (0.640 ±0.170 vs 0.368 ±0.098, p<0.001). LV diastolic function and the MPI are markedly impaired in asymptomatic elderly patients with type 2 diabetes.
Right ventricular (RV) infarction (RVI) is usually associated with severe RV global dysfunction representing predominantly stunned myocardium that may respond favorably to reperfusion. We assessed ...the efficacy of low-dose dobutamine stress echocardiography (DSE), performed early in the course of a reperfused RVI, to predict the recovery of RV systolic and diastolic function in 3 months, documenting the recovery of stunned myocardium. In all, 27 patients with acute, successfully thrombolyzed RVI comprised the study population. All patients underwent standard echocardiography at baseline and 3 months later for evaluation of RV systolic and diastolic function. At day 5 DSE was performed for evaluation of RV contractile reserve. Of the total number of segments analyzed, 69% were detected as stunned. At baseline, RV systolic and diastolic indices were seriously impaired showing significant improvement at follow-up. RV wall-motion score index during DSE was positively correlated with the same index at follow-up. DSE is a safe and precise modality to predict recovery of stunned myocardium in the setting of RVI.
The perception that women represent a low-risk population for cardiovascular (CV) disease (CVD) needs to be reconsidered. Starting from risk factors, women are more likely to be susceptible to ...unhealthy behaviors and risk factors that have different impact on CV morbidity and mortality as compared to men. Despite the large body of evidence as regards the effect of lifestyle factors on the CVD onset, the gender-specific effect of traditional and non-traditional risk factors on the prognosis of patients with already established CVD has not been well investigated and understood. Furthermore, CVD in women is often misdiagnosed, underestimated, and undertreated. Women also experience hormonal changes from adolescence till elder life that affect CV physiology. Unfortunately, in most of the clinical trials women are underrepresented, leading to the limited knowledge of CV and systemic impact effects of several treatment modalities on women's health.
Thus, in this consensus, a group of female cardiologists from the Hellenic Society of Cardiology presents the special features of CVD in women: the different needs in primary and secondary prevention, as well as therapeutic strategies that may be implemented in daily clinical practice to eliminate underestimation and undertreatment of CVD in the female population.
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Assessment of left ventricular (LV) function is crucial in the immediate postinfarction period. The authors evaluated the clinical applicability of the Doppler-derived myocardial performance index ...(MPI, defined as the sum of isovolumic contraction and relaxation times divided by LV ejection time) in patients with acute myocardial infarction (AMI) as to whether this index reflects the severity of LV dysfunction in this subgroup of patients. Post-AMI patients (n = 33) were compared with age- and sex-matched healthy subjects (n = 35). Within 24 hours of the AMI and 1 month thereafter, patients underwent 2D and Doppler echocardiography. Patients were divided into group A (Killip Class I, n = 22) and group B (Killip Class II-III, n = 11). The authors measured the LV ejection fraction (EF), diastolic indices (transmitral E and A waves, E/A ratio, deceleration time DT, isovolumic contraction time IVCT, isovolumic relaxation time IVRT, MPI, LV end-systolic and end-diastolic volume indices ESVi and EDVi and wall motion score index WMSi). One-year mortality was also assessed. There was no significant difference concerning E and A waves, E/A ratio, and IVRT between the 2 groups. There were highly statistical differences at day 1 for EF (59.3 ± 6.7% vs 36.8 ± 4.5%, p<0.0001), DT (0.160 ± 0.030 sec vs 0.127 ± 0.022, p < 0.005), MPI (0.344 ± 0.084 vs 0.686 ± 0.120, p < 0.0001), ESVi (28.4 ± 3.9 mL/m2 vs 46.2 ± 8.4, p < 0.001), and WMSi (1.58 ± 0.06 vs 1.88 ± 0.35, p = 0.05), which persisted after 1 month. One-year mortality was significantly (0 vs 27.3%, p<0.01) lower in group A patients. This study shows that the MPI, reliably indicated LV dysfunction post-AMI, significantly correlated with clinically determined functional class, and possibly has some prog nostic implication.
We sought to investigate the accuracy of dobutamine stress echocardiography to predict the degree and timing of recovery in resting function and contractile reserve (CR) after revascularization of ...the hibernating myocardium.
In all, 24 patients with ischemic cardiomyopathy (ejection fraction < 40%) underwent dobutamine stress echocardiography 1 week before and 6 weeks, 3 months, and 6 months after coronary artery bypass grafting.
Recovery rates at 6 weeks, 3 months, and 6 months postoperation were 21%, 33%, and 45% (P < .01) for resting function and 55%, 65%, and 74% (P < .01) for CR. Positive and negative predictive values for recovery of resting function and CR at 6 months postrevascularization were 66% vs 97% (P < .001) and 78% vs 48% (P < .001), respectively. Positive and negative predictive values were both high for recovery of CR at 6 weeks postrevascularization (89% and 78%).
Dobutamine stress echocardiography can predict early recovery in CR postrevascularization with an excellent accuracy but may underestimate the degree of late recovery in CR.
We evaluated right ventricular (RV) systolic and diastolic function in 30 patients with acute RV myocardial infarction on echocardiography. Systolic and diastolic function were impaired early in the ...setting of RV myocardial infarction, but improved significantly at 3 months. PUBLICATION ABSTRACT
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