Fate of nonobstructive aneurysmatic coronary artery disease: angiographic and clinical follow-up report

Predictors of outcomes in medically treated patients with acute coronary syndromes after angiographic triage: an Acute Catheterization And Urgent Intervention Triage Strategy (ACUITY) substudy

BACKGROUND

Outcomes of patients presenting with acute coronary syndromes are improved with an early invasive approach; however, approximately one third of these patients are treated medically after angiographic screening. We sought to assess the predictors of adverse cardiac events in patients with acute coronary syndrome assigned to medical management.

METHODS AND RESULTS

This substudy of the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial included 4491 acute coronary syndrome patients treated medically after angiographic triage. Rates of bleeding and composite ischemia (death, myocardial infarction, revascularization) were compared among the 3 antithrombotic treatment arms. Composite ischemia occurred in 399 patients (9.5%) at 1 year. Treatment with bivalirudin glycoprotein IIb/IIIa inhibitors significantly reduced major bleeding at 30 days (2.5% bivalirudin monotherapy; P=0.005, 2.0% bivalirudin plus glycoprotein IIb/IIIa inhibitors; P=0.0002 versus 4.4% heparin with glycoprotein IIb/IIIa inhibitors). Composite ischemic events at 1 year were not significantly different in the 3 groups (bivalirudin monotherapy, 9.6%; bivalirudin plus glycoprotein IIb/IIIa inhibitors, 9.7%; heparin plus glycoprotein IIb/IIIa inhibitors, 9.1%). Independent predictors of composite ischemia were mostly angiographic factors at 30 days, including jeopardy score and coronary ectasia, and at 1 year, including previous percutaneous coronary intervention, jeopardy score, coronary ectasia, and increasing number of diseased vessels.

CONCLUSIONS

Among the ACUITY acute coronary syndrome patients treated medically after angiographic triage, bivalirudin therapy significantly reduced bleeding complications compared with heparin without any negative impact on ischemic outcomes at 1 year. The most powerful predictors of ischemic outcomes were angiographic rather than traditional clinical parameters, supporting the early use of angiographic screening in the moderate- and high-risk but medically treated acute coronary syndrome population. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.

Mean platelet volume in patients with coronary artery ectasia

Coronary artery ectasia (CAE) is a variant of coronary atherosclerosis. Mean platelet volume (MPV), an indicator of platelet activation, has been shown to be elevated in patients with acute coronary syndromes and myocardial infarction in the setting of obstructive coronary artery disease. The aim of this study was to assess the MPV in patients with CAE. We retrospectively studied 366 consecutive patients with CAE (195 men/171 women; mean age 55.4 +/- 10.9 years) and 160 control patients (81 men/79 women; mean age 53.5 +/- 10.2 years). MPV values were recorded in all study and control patients. The MPV values of patients with CAE were found to be significantly higher than those of the controls (9.2 +/- 1.1 versus 8.8 +/- 1.2 fl, respectively; P < 0.001). The platelet count was detected to be significantly lower in patients with CAE group than in patients with control group (233.7 +/- 70.7 versus 264.7 +/- 102.8 (x10(9)/l), respectively; P < 0.0001). We have shown that MPV was significantly elevated in patients with CAE compared with controls.

Left main coronary artery aneurysm in young patient with acute myocardial infarction

Aneurysms of the left main coronary artery (LMCAA) are extremely uncommon, with an incidence of 0.1%. The main etiologic factor is atherosclerosis. Other causes include connective tissue disorders, trauma, vasculitis, congenital, mycotic, and idiopathic. These dilated sections of coronary artery are not benign pathology because they are subject to spasm, thrombosis, and subsequent distal embolism, spontaneous dissection and rupture. Treatment options include anticoagulation, custom-made covered stents, reconstruction, resection and exclusion with bypass. Our report on a young case illustrates the potential complication of LMCAA and presents its management.

Progressive coronary artery aneurysm presenting as acute myocardial infarction

Coronary artery aneurysms (CAA) are commonly of atherosclerotic origin and asymptomatic. The natural history is uncertain given its uncommon occurrence and lack of longitudinal data. We report a case of CAA, presenting with myocardial infarction. Follow-up coronary angiography revealed enlargement of the CAA, suggesting a progressive nature.

Pathogenetic mechanisms of coronary ectasia

Coronary ectasia is defined as local or generalized aneurysmal dilatation of the coronary arteries. The present review summarizes the molecular, cellular and vascular mechanisms which are involved in the pathobiology of coronary ectasia. Coronary ectasia likely represents an exaggerated form of expansive vascular remodeling (i.e. excessive expansive remodeling) in response to atherosclerotic plaque growth. Enzymatic degradation of the extracellular matrix of the media is the major pathophysiologic process that leads to ectasia. Atherosclerotic lesions within ectatic regions of the coronary arteries appear to be highly inflamed high-risk plaques with proclivity to rupture. Better understanding of the pathogenetic processes involved in coronary ectasia is anticipated that will provide a further insight into the clinical significance and natural history of this entity, and may also have direct clinical implications in the management and follow-up strategy of this condition.

Giant left anterior descending coronary artery aneurysm

Small atherosclerotic coronary artery aneurysms are a relatively frequent incidental finding at angiography. We report an unusual case in that the aneurysm found was extremely large and therefore potentially at risk of rupture.

Successful trapping of an organized thrombus in a coronary artery aneurysm in myocardial infarction: case report and literature review

A 44-year-old female presented with acute inferior myocardial infarction. Emergency coronary angiography showed an aneurysm of the proximal right coronary artery and an occlusion of the vessel downstream due to a huge organized thrombus. Mechanical fragmentation, glycoprotein IIb/IIIa antagonist, and intracoronary thrombolysis were all tested without success. Finally, the aneurysm was covered with a standard bare metal stent in order to trap the thrombus between the stent and the vessel wall and at least partially in the aneurysm. The strategy was successful, and after 1 week, the blood flow in the right coronary artery was normal; however, the aneurysm remained. After 6 months, there was significant in-stent restenosis of the proximal and mid segments of the right coronary artery but no evidence of the aneurysm. The restenosis was treated with two drug-eluting stents, leading to an excellent result after a further 6 months. The patient was free of symptoms and the left ventricular ejection fraction was within the normal range.

Increased platelet activity in patients with isolated coronary artery ectasia

BACKGROUND

The common coexistence with coronary artery disease has led to the suggestion that coronary artery ectasia (CAE) is a variant of coronary artery disease. The mechanisms, however, responsible for CAE formation during the atherosclerotic process and the exact clinical significance are not well known. In this study, we aimed to investigate platelet activity in patients with isolated CAE by using specific markers of platelet activation as P-selectin, beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4).

METHODS

Thirty-two patients with isolated CAE without significant stenosis and 30 control participants with angiographically normal coronary arteries were included in this study. According to the angiographic definition used in the Coronary Artery Surgery Study, a vessel is considered to be ectasic when its diameter is > or = 1.5 times that of the adjacent normal segment in segmental ectasia. Plasma P-selectin, beta-TG and PF4 levels were measured in all patients and control participants using enzyme-linked immunosorbent assay method.

RESULTS

Patients with isolated CAE were detected to have significantly higher levels of plasma P-selectin, beta-TG and PF4 in comparison with control participants with angiographically normal coronary arteries (P-selectin: 248+/-46 vs. 154+/-32 ng/ml, respectively, P<0.001; beta-TG: 51+/-19 vs. 21+/-9 ng/ml, respectively, P<0.001; PF4: 58+/-23 vs. 33+/-11 ng/ml, respectively, P<0.001).

CONCLUSION

In conclusion, we have shown for the first time that patients with isolated CAE have raised levels of plasma P-selectin, beta-TG and PF4 compared with control participants with angiographically normal coronary arteries, suggesting increased platelet activation in patients with CAE.

A case of recurrent myocardial infarction caused by a giant right coronary artery aneurysm

We report a rare case of a giant coronary artery aneurysm with recurrent myocardial infarction (MI) in a 52-year-old man. He was admitted with severe chest pain and was diagnosed with acute MI. Ten days after thrombolysis, a transthoracic echocardiogram demonstrated a spherical mass apposed to the outer wall of the right atrium. Computed tomography with angiography showed this mass to be a huge aneurysm of the right coronary artery with a maximal diameter of 4 cm and filled with mural thrombus. Surgical resection of the aneurysm and coronary arterial bypass grafting were recommended. On day 60, while the patient awaited surgical treatment, recurrent MI caused by thrombotic occlusion occurred in the aneurysm site despite anticoagulant therapy. Two days after thrombolytic therapy, he underwent coronary artery bypass grafting and aneurysmal resection.

Aortic elastic properties in patients with coronary artery ectasia

BACKGROUND

The purpose of the present study was to investigate the elastic characteristics of the aorta in patients with coronary ectasia (CE) and the relationship between these characteristics and echocardiographic left ventricular (LV) diastolic functions.

METHODS AND RESULTS

In the first group there were 35 patients with CE, the second group consisted of 35 patients with coronary artery disease (CAD) and the third group consisted of 35 patients with normal coronary arteries. Echocardiographic investigation was carried out for the assessment of the LV diastolic functions. Aortic strain, beta index and aortic distensibility were used as aortic elasticity parameters. LV diastolic functions were impaired in both the ectasia group and the CAD group as compared with patients with normal coronary arteries. Beta index and aortic distensibility measurements were similar between the CAD and CE groups. The values obtained for aortic strain, beta index and aortic distensibility were lower in the CAD and ectasia groups when compared with the values of the normal group. On performing the stepwise linear multivariable analyses, aortic elastic parameters have been determined to possess the strongest diagnostic power for LV diastolic functions.

CONCLUSIONS

The results of the current study show that stiffness parameters of aorta are impaired in the patients with CE as in the patients with CAD. The increase in aortic stiffness might be responsible for LV diastolic dysfunction.

Novel insights into an old controversy: is coronary artery ectasia a variant of coronary atherosclerosis?

Coronary artery ectasia (CAE) is defined as a localized or diffuse non-obstructive lesion of the epicardial coronary arteries with a luminal dilation exceeding 1.5-fold the diameter of the normal adjacent arterial segment. The incidence of CAE has been reported to range between 2% and 4%, which might be an overestimation of the true frequency. The coincidence of CAE with other systemic vascular dilatations has suggested that the mechanism underlying CAE is not only localized to coronary arteries, but also to other vascular compartments such as aorta or peripheral veins. Although the pathophysiology of CAE remains largely unknown, it was supposed to represent a variant of coronary atherosclerosis. This review focuses on this controversy of whether CAE and coronary artery disease (CAD) are two manifestations of the same underlying process. There are clear differences between CAD and CAE with respect to cardiovascular risk factors such as diabetes mellitus, and pathogenic steps in disease progress such as inflammation or extracellular matrix remodeling. As this review will underscore, the current knowledge of the field is insufficient to finally clarify the causative interrelation between CAE and CAD. The clinical course and treatment of CAE mainly depends on its coexistence with CAD. When coexisting with CAD, the prognosis and treatment of CAE are the same as for CAD alone. In isolated CAE, prognosis is better and anti-platelet drugs are the mainstay of treatment. Surgical treatment can be considered in selected patients. For clarifying the mechanism underlying CAE, additional clinical, histopathological and pathophysiological investigations are required. In fact, every patient with CAE should be evaluated systematically for pathological changes in other vascular territories, both in the arterial system as well as in the venous system, which might occur in the disease process.

Noninvasive assessment of coronary artery ectasia using multidetector computed tomography

OBJECTIVES

The aim of this study is to determine the prevalence of coronary artery ectasia and its relationship to atheromatous changes in participants undergoing coronary computed tomography angiography.

BACKGROUND

Coronary artery ectasia occasionally encountered on conventional coronary angiography is considered a manifestation of atherosclerosis.

METHODS

Four hundred consecutive participants, 300 men (mean age 56 years) who underwent coronary computed tomography angiography were evaluated. Coronary artery ectasia was defined as an arterial segment with a diameter of at least 1.5 times the diameter of the adjacent normal coronary artery. The prevalence and location of coronary artery ectasia as well as concomitant atherosclerotic changes were evaluated. The association of coronary artery ectasia with coronary risk factors was also studied.

RESULTS

Coronary artery ectasia was encountered in 31 participants (8%), 29 men. The right coronary artery was most commonly affected with ectasia (50%) and most participants had single-vessel involvement (74%). Twenty-six of 31 participants (84%) had coexisting atheromatous wall changes or insignificant coronary artery disease; four participants out of 31 (13%) had significant coronary artery disease. Coronary artery ectasia thrombosis was found only in one patient (3%). No apparent correlation was present between coronary artery ectasia and diabetes mellitus, hypertension, hyperlipidemia, smoking and family history of coronary artery disease.

CONCLUSION

The prevalence of coronary artery ectasia in consecutive participants who underwent coronary computed tomography angiography is 8%. The right coronary artery was most commonly affected and most participants had single-vessel involvement. Coronary artery ectasia usually is associated with atheromatous changes, but not with significant coronary artery disease. Coronary artery ectasia thrombosis was a rare complication. No specific predisposing factors have been identified.

Effects of isolated coronary artery ectasia on electrocardiographic parameters reflecting ventricular heterogeneity

Isolated coronary ectatic but otherwise normal epicardial coronary arteries are an infrequent angiographic finding. We sought to determine whether coronary artery ectasia (CAE) may alter QT-interval duration and dispersion. The study population consisted of 24 patients with isolated CAE and otherwise normal epicardial coronary arteries (group 1) and sex- and age-matched subjects with atypical chest pain and otherwise normal coronary flow (group 2). Both groups underwent a routine standard 12-lead surface electrocardiogram recorded at 50 mm/s during rest. QT dispersion (QTd), corrected QT (QTc), and corrected QT dispersion (QTcd) were calculated. Distribution of sex, age, body mass index, and cardiac risk factors were similar in the 2 groups. Mean heart rate was similar in the 2 groups (74 +/- 10 vs 70 +/- 7, P > .05). In group 1, QTd, QTcd, and QTc were significantly higher than those of group 2 (QTd, 40 +/- 17 vs 29 +/- 10 milliseconds [P < .05]; QTcd, 43 +/- 19 vs 30 +/- 10 milliseconds [P < .05]; QTc, 410 +/- 21 vs 397 +/- 19 milliseconds [P < .05]). In conclusion, CAE was found to be associated with prolonged QT interval and increased QTd. Microvascular dysfunction and/or ischemia may be responsible mechanisms.

Mean platelet volume in patients with isolated coronary artery ectasia

Coronary artery ectasia (CAE) is frequently considered to be an incidental angiographic finding; however, several reports have shown an association with myocardial ischemia and infarction. In this study, we aimed to evaluate the mean platelet volume (MPV), which is a marker of platelet reactivity, in patients with isolated CAE. In this study we investigated the platelet functions by MPV measurement in patients with isolated CAE. The study population consisted of 23 patients (17 males, 6 females) with isolated CAE (Group-I). Sex-age matched 30 patients (22 males, 8 females) with angiographically proven normal coronary arteries served as the control group (Group-II). Serum total cholesterol, HDL-C, LDL-C, triglyceride level, hemoglobin, white blood cell count, CRP, platelet count and MPV were compared in both groups. There was no significant difference between two groups in terms of age, gender, body mass index, blood pressure and heart rate. Serum total cholesterol, HDL-C, LDL-C, triglyceride level, hemoglobin, white blood cell count, platelet count were also similar in both groups. However, the MPV values of patients with isolated CAE were significantly higher than those of controls (P < 0.0001). In addition to that, CRP levels were found to be significantly higher in patients with isolated CAE (P < 0.002). Increased MPV may indicate the altered platelet reactivity and aggregation and thereby may be associated with ischemic events, observed in patients with isolated CAE.

Coronary artery ectasias: imaging, functional assessment and clinical implications

Coronary artery ectasia is a relatively common entity characterized by inappropriate dilatation of the coronary vasculature. The exact mechanism of its development is unknown, but evidence suggests a combination of genetic predisposition, common risk factors for coronary artery disease and abnormal vessel wall metabolism. It frequently coexists with aneurysms elsewhere, mostly involving the aorta. In this review, the flow disturbances that are associated with this condition and the imaging modalities, which can be used for diagnosis and prospective follow-up are described. The prognosis of coronary ectasias is controversial and prospective studies focusing on conservative or invasive strategies to prevent cardiac complications are needed.

Aneurysm involving bifurcation of left main coronary artery presenting with transient ischemic attack, paroxysmal atrial fibrillation and ventricular tachycardia

Coronary artery aneurysm, especially left main coronary artery (LMCA) aneurysm is a rare phenomenon. The disease may be congenital or acquired. The most common cause of coronary artery aneurysm is atherosclerosis. We presented a man with a large LMCA aneurysm presenting with unstable angina, transient ischemic attack, ventricular tachycardia and paroxysmal atrial fibrillation.

Diffuse Nonatherosclerotic Coronary Aneurysms

Coronary artery aneurysms are uncommon, usually associated with atherosclerosis and rarely involve all 3 main coronary arteries. Sudden death from documented thrombosis within large coronary aneurysms has been rarely reported. The authors report a case of a previously healthy 36-year-old male who presented with myocardial infarction complicated by sudden cardiac death. The patient was successfully resuscitated, and coronary angiography revealed diffuse, severe aneurysmal disease without evidence of atherosclerosis. A thrombus was visualized in a large aneurysm of the proximal left anterior descending artery, and there was total occlusion of a second diagonal branch, presumably due to thrombus embolization. The patient had no history of Kawasaki disease, and evaluation revealed no inflammatory or autoimmune condition. Optimal treatment and prognosis for patients with nonatherosclerotic coronary aneurysms remains unclear. Our patient was treated medically with chronic warfarin and low-dose aspirin therapy and recovered without complication.

Increased prevalence of coronary artery aneurysms among cocaine users

BACKGROUND

Cocaine abuse has been implicated in multiple cardiovascular complications. Coronary artery aneurysms (CAAs) and ectasia occur in 0.2% to 5.3% of patients referred for angiography and are associated with atherosclerosis, Kawasaki's disease, and several rare disorders. After observing CAAs in multiple young cocaine users, we investigated the prevalence of CAAs among cocaine users undergoing coronary angiography.

METHODS AND RESULTS

Clinical and angiographic characteristics of 112 consecutive patients with a history of cocaine use and coronary angiography were compared with a control group of similar age and risk factors from an existing angiographic database over the same time period. Coronary angiograms were independently read by 3 reviewers blinded to cocaine use. Cocaine users were young (mean age, 44 years), predominantly male (80%), and cigarette smokers (95%). Control patients had higher rates of diabetes (33%) and more severe coronary artery disease (P=0.01). Previous myocardial infarction was common in both groups (45% of cocaine users, 38% of control patients). Despite the frequent history of myocardial infarction among cocaine users, 48% had nonobstructive coronary artery disease. Among cocaine users, 34 of 112 (30.4%) had CAAs compared with 6 of 79 (7.6%) in the control group (P<0.001). Cocaine use was a strong predictor of CAA by univariate and multivariate analyses.

CONCLUSIONS

This is the first description of an association between cocaine use and CAA. The prevalence of CAA among cocaine users was higher than expected (30.4%), given such a young cohort. Cocaine use may predispose to the formation of CAA, which may in turn be a contributing factor to myocardial infarction.

Association of coronary artery ectasia with plasma insulin levels in Japanese men of heterozygous familial hypercholesterolemia with the low-density lipoprotein receptor gene mutation K790X

BACKGROUND

Hyperinsulinemia is widely believed to be an important coronary risk factor. We investigated the effect of plasma insulin levels on the development of coronary ectasia in Japanese men with heterozygous familial hypercholesterolemia (FH).

METHODS

A cross-sectional study was conducted in 20 FH men with the LDL receptor mutation (K790X) [age 42.3+/-2.8 years old, body mass index (BMI) 24.6+/-0.7 kg/m2, total cholesterol (TC) 8.68+/-0.36 mmol/l, triglycerides (TG) 1.76+/-0.23 mmol/l, high-density lipoprotein cholesterol (HDL-C) 0.977+/-0.065 mmol/l]. Subjects with diabetes mellitus were excluded. Plasma insulin levels, either fasting or during oral glucose tolerance test, were compared between subjects with and without coronary artery ectasia.

RESULTS

FH subjects with coronary ectasia had significantly higher fasting plasma insulin levels than those without (12.6+/-1.4 vs. 7.7+/-0.5 mU/l; p<0.05). Also, plasma insulin levels during oral glucose tolerance test tended to be higher in the former than in the latter.

CONCLUSIONS

Plasma insulin level could be an important determinant of the development of coronary artery ectasia in Japanese heterozygous FH men.

Surgical treatment for coronary artery aneurysm

Two successful cases of the surgical treatment for coronary artery aneurysm (non-Kawasaki disease) were reported. The first case had a saccular aneurysm on the left circumflex coronary artery (LCx) #14. Resection of the LCx aneurysm was performed subsequent to single vessel coronary artery bypass grafting (CABG) to the distal portion of LCx#14 under the cardioplegic cardiac arrest. The second case had aneurysms on both the left anterior descending artery (LAD) #7 (fusiform) and the LCx#11 (saccular). After double vessel CABG to LAD#7 and LCx#11, ligation or resection of two aneurysms was performed successfully. Postoperative courses have been uneventful with good angiographic results achieved. Since these surgical procedures demonstrated safety, the patients are expected to achieve a good long-term prognosis.

Mural Thrombus in an Ectatic Right Coronary Artery Caused Acute Myocardial Infarction at Downstream Coronary Artery

A 72-year-old woman was admitted to our institution because of sudden chest pain. Emergency coronary angiography revealed thrombotic occlusion of the distal right coronary artery. A large cylindrical thrombus was retrieved from her distal right coronary artery using a thrombus aspiration catheter. IVUS showed minimal atherosclerosis and moderate ectatic change at the proximal right coronary artery. A reconstructed IVUS image also showed that a mural thrombus with abrupt ending was still retained at the ectatic segment. Based on this evidence, coronary ectasia was thought to be the primary cause for the thrombus formation and acute myocardial infarction in this case.

Giant right coronary artery aneurysm presenting as a mediastinal mass

Coronary artery aneurysms are commonly of atherosclerotic origin and are frequently asymptomatic. However, they may have varied presentations including angina, myocardial infarction, and sudden death. A case of a giant right coronary artery aneurysm presenting with acute myocardial infarction is presented, where the aneurysm appeared to be a mediastinal mass on transthoracic and transoesophageal echocardiography. Although computed tomography and magnetic resonance imaging of the heart suggested the correct diagnosis, definitive proof came from coronary angiography. Coronary artery aneurysms should be considered in the differential diagnosis of mediastinal masses.

Predictors of exercise induced myocardial ischemia in patients with isolated coronary artery ectasia

The aim of this study was to investigate the angiographic predictors of exercise induced ischemia in patients with isolated coronary ectasia. We have prospectively analysed coronary angiograms of 1521 consecutive patients undergoing cardiac catheterisation. The overall incidence of coronary ectasia was 6.7% (102 patients). Forty-six patients (3%) with non-obstructive, diffuse or segmental coronary ectasia (i.e. isolated coronary ectasia) constituted the main study group. Coronary angiograms were reviewed for stigmata of an impaired coronary blood flow such as 'slow flow', 'segmental backflow phenomenon' and stasis. 'Slow flow' was quantified with frame counting. An ectasia-jeopardy score was also described in order to assess the effect of the extent of coronary ectasia on exercise induced ischemia. Exercise induced ischemia was observed in 24 patients (52%). Exercise test was abnormal in 70% of the patients with diffuse ectasia and 26% of patients with segmental ectasia (p = 0.003). The frame count of the arteries of the study group was higher than the control group but the correlation between the frame count of the ectatic vessels and exercise induced ischemia was not significant. Stasis of the dye also did not correlate with ischemia. There was a significant correlation between exercise induced ischemia and backflow phenomenon in left anterior descending artery (LAD) (r = 0.56, p = 0.0001). Exercise induced ischemia was best correlated with the ectasia-jeopardy score (r = 0.77, p = 0.0001) and a score of > or =4 identified the patients at risk with 90% sensitivity and 80% specificity. In conclusion, the extent of the ectasia within the coronary tree, diffuse ectasia and backflow-phenomenon in LAD were identified as the most important predictors of exercise induced ischemia.

Congenital right coronary artery aneurysm causing myocardial infarction, pseudoaneurysm formation, and right atrial compression

We present a case of a young woman with symptoms of acute myocardial infarction and found to have a nonatherosclerotic coronary aneurysm of the right coronary artery, which ruptured and formed a pseudoaneurysm. The pseudoaneurysm was sufficiently large that it mimicked an atrial mass on diagnostic imaging modalities. With the attendant risk of further rupture and compression of the heart chambers, the patient underwent successful resection of the aneurysm and pseudoaneurysm with single vessel bypass surgery.

Polytetrafluoroethylene-covered stent and coronary artery aneurysms

Angiographically detected coronary aneurysms (i.e., coronary segment greater then 1.5 times the normal artery) have an incidence of 0.3%-4.9% among patients undergoing coronary angiography and have been reported after an intervention procedure with a frequency of 2%-10%. The indication for treatment and the best modality still need to be defined. Some authors reported the successful treatment of coronary aneurysms with the polytetrafluoroethylene (PTFE)-covered stent implantation, supporting the role of this strategy. In our institution, from September 1997 to December 1999 eight PTFE-covered stents were implanted to treat seven coronary aneurysms in seven patients. All aneurysms were successfully treated by the PTFE-covered stent. In one case, there was the necessity of an additional PTFE stent to cover the aneurysm completely. In no case did the loss of stent occur. No in-hospital MACE occurred. At 35 +/- 8 (21-44) months, six patients were symptom-free. Angiographic follow-up was performed in all patients at 10 +/- 6 months. Restenosis occurred in one patient (14%) who had repeat percutaneous coronary interventions. This preliminary experience suggests that PTFE-covered stent may be useful in the treatment of coronary artery aneurysms.

[Giant left main coronary aneurysm without associated coronary lesions]

Left main coronary artery aneurysms are very infrequent (0.1%) and the majority are related to atherosclerotic obstructive lesions. Only a few isolated cases without associated coronary lesions have been reported until now. The management of these patients is not well established, thus both conservative and surgical treatments have been postulated. We present a case of giant left main coronary artery aneurysm with a diameter of 27.7 x 18.6 mm (the biggest reported until now) without coronary tree associated stenosis. It was treated conservatively with oral anticoagulation only and the 5 years evolution has been favourable.

Pulse-spray thrombolysis in acute myocardial infarction caused by thrombotic occlusion of an ectatic coronary artery

Pulse-spray thrombolysis was performed in 2 patients with acute myocardial infarction (AMI) caused by thrombotic occlusion of coronary artery ectasia. Case 1, a 66-year-old woman with an inferior AMI underwent emergency coronary arteriography, which revealed occlusion of an ectatic right coronary artery. Primary balloon angioplasty failed to reestablish distal flow. Urokinase was administered through the pulse-spray infusion catheter (UltraFuse) and intravenous recombinant tissue plasminogen activator was also administered. Angiographic disappearance of the thrombus was observed within 30 min of starting the infusion, and there was only mild irregularity in the ectatic coronary artery. Case 2, a 45-year-old man with an inferior AMI underwent emergency coronary arteriography, which revealed occlusion of an ectatic right coronary artery. TIMI-3 flow was soon obtained after administration of 480,000 units of urokinase through the pulse-spray infusion catheter. There was diffuse right coronary ectasia without angiographic evidence of coronary stenosis. Coronary ectasia sometimes develops into AMI without the coexistence of coronary stenosis. Because a massive thrombus plays a major role, pulse-spray thrombolysis is a possible treatment in coronary artery ectasia with thrombotic occlusion.

Probable Kawasaki disease in a 52-year-old man presenting with acute myocardial infarction treated with percutaneous revascularization

This is a case report of a 52-year-old man who presented with an acute myocardial infarction. In the process of performing an angiogram to delineate the anatomy for possible percutaneous transluminal coronary angioplasty, large, diffuse coronary aneurysms were observed. When the vessel was opened, several aneurysms were seen to contain thrombus. The size, location, and diffuseness of the aneurysms are suggestive of Kawasaki disease.

Large atherosclerotic left main coronary aneurysm--a case report and review of the literature

Coronary artery aneurysm (CAA) is a rare disorder, characterized by an abnormal dilatation of a localized portion of the coronary artery. It is usually diagnosed incidentally by coronary angiography. Over 50% of coronary artery aneurysms are of atherosclerotic origin. The natural history of coronary aneurysms is not well understood. Their presence is not always considered to be an operative indication; rather, the severity of the associated coronary artery disease (CAD) is what dictates a surgical approach. In the absence of obstructive CAD, the definitive treatment for this condition is unclear. The authors present the case of an isolated saccular left main coronary aneurysm with no associated flow-limiting CAD. The patient was treated medically with antiplatelet and anticoagulant medication with no adverse events at 3, 6, 9, and 12 months of follow-up.

Exercise-induced myocardial ischemia in patients with coronary artery ectasia without obstructive coronary artery disease

BACKGROUND

Aetiology, clinical significance and treatment options for coronary artery ectasia/aneurysm is not clear.

OBJECTIVE

We sought to determine whether exercise can induce coronary ischemia in patients with coronary artery ectasia/aneurysm without significant coronary stenosis.

METHODS

Coronary artery ectasia was defined as 1.5-2-fold, aneurysm as >2-fold luminal dilatation of the adjacent normal segment. The study patients could have irregularities with ectatic coronaries but they did not have stenotic lesions >50% with visual assessment of two blinded observers. Patients having coronary artery ectasia or aneurysm with prior myocardial infarction, dilated cardiomyopathy, valvular heart disease, bundle branch block, significant ST-T changes were excluded. The control group was formed from a well matched population of 32 patients with normal coronary arteries who have not performed a treadmill test before coronary angiography. The study group underwent a symptom limited treadmill test if they did not have one before coronary angiogram, all control patients underwent treadmill test.

RESULTS

Thirty-three patients with coronary artery ectasia/aneurysm (ranging from one to three vessels) but without significant stenosis were derived from 4470 cardiac catheterization procedures between January 1998 and July 2000. In the study group, 17 of the patients had positive treadmill tests with respect to five patients in the control group (P = 0.004). In subgroup analysis, diffuse ectasia/aneurysm (involving 2-3 vessels) was found to be strongly related with ischemia (P = 0.005) with respect to local disease.

CONCLUSION

Coronary artery ectasia/aneurysm may lead to exercise induced ischemia, especially in the diffuse form.

Exercise-induced myocardial ischemia in isolated coronary artery ectasias and aneurysms ("dilated coronopathy")

OBJECTIVES

The purpose of our study was to evaluate the clinical significance of isolated coronary artery ectasias or aneurysms (CEA).

BACKGROUND

It has been postulated that altered coronary blood flow in CEA predisposes patients to the development of myocardial ischemia (CI) and infarction.

METHODS

Sixty-seven patients with bilateral nonobstructive CEA without associated cardiac defects ("dilated coronaropathy") were derived from 16,341 cardiac catheterizations between 1986 and 1997. Ectasias were defined as luminal dilation of 1.5- to 2.0-fold, aneurysms of >2.0-fold of normal limits. Eleven of 25 patients presented with myocardial infarction due to an occlusion of the infarct vessel. In 42 patients without infarction (study group), exercise-induced CI was investigated.

RESULTS

A corresponding CI was documented in 32 of 42 patients in a coronary sinus lactate study (reduced lactate extraction 5.6 +/- 4.1%) and in 29 of 40 patients in an ergometry (0.25 +/- 0.06 mV ST depressions). The results differed significantly from a control group of 29 patients without heart disease (p < 0.001). Nitroglycerin (0.8 mg) provoked a further significant deterioration of CI in the 32 of 42 developing a frank cardiac lactate production (-2.6 +/- 6.8%, p < 0.001). The metabolic extent of CI was significantly correlated to the coronary diameters of the proximal and middle segments of left anterior descending artery and the middle segment of left circumflex artery (r = 0.87, p < 0.001). Stigmata of an impaired coronary blood flow such as delayed antegrade filling, segmental backflow phenomenon and local deposition of dye were found significantly more often with increasing coronary diameters (p < 0.04).

CONCLUSIONS

"Dilated coronaropathy" is an entity of nonobstructive, ischemic coronary artery disease. Nitroglycerin is of no therapeutic benefit but leads to an aggravation of exercise-induced CI.

Coronary artery aneurysms: A 25-patient study

Coronary artery aneurysm is a rare disorder, characterized by abnormal dilatation of a localized portion or diffuse segments of the coronary artery. We studied clinical demographics, catheterization findings, and clinical outcomes in an Asian patient cohort with documented coronary artery aneurysms. Compared to a Caucasian adult population, our patient cohort had a lower incidence of coronary artery aneurysm (0.25% vs. 2.6%), and more patients with nonobstructive coronary artery aneurysms (70%); age, gender, and coronary distribution were comparable. The initial presentation of myocardial infarction occurred in five patients (5/17, 30%) with nonobstructive coronary artery aneurysms; however, none who were receiving preventive medications consisting of anticoagulant and antiplatelet agents subsequently developed myocardial infarction. We conclude that the incidence of coronary artery aneurysms with or without associated significant coronary stenosis seems to be lower in the Asian population. In contrast, the incidence of nonobstructive coronary artery aneurysms is considerably high and should not be thought of as a relatively benign disease entity if not treated with preventive medications. Rheumatoid arthritis-related vasculitis might be a cause of coronary artery aneurysm. Surgical intervention is based on the severity of coronary artery stenosis. The result of medical treatment has been compatible with long-term survival. Cathet. Cardiovasc. Intervent. 48:31-38, 1999.

[Two cases of coronary artery aneurysm including one case of the left main coronary artery aneurysm]

We report two cases of coronary artery aneurysm including one case of the left main coronary artery aneurysm. The coronary angiogram of one patient, a 68-year-old male, having anterior chest pain on exertion, revealed left anterior descending coronary artery (segment 6) aneurysm of 7 mm in diameter with 90% stenosis distal to the aneurysm and 75% stenosis in the right coronary artery (segment 2). The coronary angiogram of another patient, a 69-year-old female, having chest pain unrelated to exertion, revealed left main coronary artery aneurysm of 25 mm in diameter and delayed filling of contrast medium into the left anterior descending coronary artery. We decided to operate by the reason of not only significant coronary artery stenosis but risks of myocardial infarction due to embolization into distal coronary arteries and rupture of the aneurysm. We performed coronary artery bypass graftings using the great saphenous veins and closure of the coronary arteries running into and out the aneurysm under cardiopulmonary bypass. It is recommended that ligation of the coronary arteries connecting to the aneurysm or resection of the aneurysm followed by coronary artery bypass grafting is performed before developing myocardial infarction or rupture of aneurysm.

Effect of adopting a new histological grading system of acute rejection after heart transplantation

BACKGROUND

Treatment policy of acute rejection after heart transplantation has been changed after adopting the ISHLT endomyocardial biopsy grading system in 1991.

OBJECTIVE

To determine the effect of this policy change on clinical outcome after transplantation.

METHODS

The outcome of 147 patients who had a transplant before (early group, median follow up 96 months) and 114 patients who had a transplant after (late group, median follow up 41 months) the introduction of the ISHLT biopsy grading system was studied retrospectively. Initially "moderate rejection" according to Billingham's conventional criteria was treated. From January 1991 grade 3A and higher was considered to require intensification of immunosuppression.

RESULTS

There were some differences between the two groups: recipients (50 v 44 years) as well as donors (28 v 24 years) were older in the "late group" and more patients of this group received early anti-T cell prophylaxis (92% v 56%). Despite more extensive use of early prophylaxis more rejection episodes were diagnosed (2.4 v 1.4) and considerably more courses of rejection treatment were instituted in the late compared with the early group (3.2 v 1.5). There were no deaths because of rejection in the late group, however, more infections occurred within the first year (mean 1.8 v 1.4) and more non-skin malignancies within the first 41 months were diagnosed (8 of 57 v 6 of 147, 95% CIs of difference includes 0). The incidence of graft vascular disease in the late group has been comparable to the early group until now.

CONCLUSION

The interpretation of the ISHLT grading system resulted in lowering of the threshold for the diagnosis of rejection thereby increasing the number of rejections and subsequently the immunosuppressive load and its complications.

Coronary aneurysm after bailout stent implantation: diagnosis of a false lumen with intravascular ultrasound

This case report describes the intravascular ultrasound (IVUS) evaluation of a coronary artery aneurysm, developed in a stented segment within 6 mo after bailout stenting. Analysis of the IVUS images provides in vivo insights in the vessel-remodeling process after mechanical injury. The proximal entrance of the false lumen could be clearly visualized as well as the relationship between the stent struts, neolumen, and vessel wall. The discussion is focused on the options for management of such patients.

Coronary artery aneurysm: a review

Coronary artery aneurysm is defined as coronary dilatation which exceeds the diameter of normal adjacent segments or the diameter of the patient's largest coronary vessel by 1.5 times. This is an uncommon disease which has been diagnosed with increasing frequency since the advent of coronary angiography. The incidence varies from 1.5% to 5% with male dominance and a predilection for the right coronary artery. Atherosclerosis accounts for 50% of coronary aneurysms in adults. Reported complications include thrombosis and distal embolization, rupture and vasospasm. The natural history and prognosis remains obscure. Controversies persist regarding the use of surgical or medical management. The authors recommend surgery based on the severity of associated coronary stenosis rather than the mere presence of aneurysm. Medical therapy is indicated for the majority of patients and consists of antiplatelet and anticoagulant medication.

Repair of an aneurysm of the left main coronary artery

Coronary artery aneurysms are rare, especially in the left main coronary artery. Coronary artery aneurysms may rupture or cause myocardial infarction. There are only a few reports of coronary artery aneurysms of the left main coronary artery treated surgically. We report a case in which an arterial graft from the internal iliac (hypogastric) artery was used for the reconstruction of a congenital coronary artery aneurysm of the left main coronary artery. After a follow-up of 5 years, the patient is well and in good condition.

Intravascular ultrasound approach to the diagnosis of coronary artery aneurysms

Coronary artery aneurysms are usually diagnosed by contrast coronary angiography, which portrays the silhouette of the lumen but cannot distinguish true and false aneurysms. To differentiate true and false aneurysms and to study the morphologic changes of the vessel wall, intravascular ultrasound (IVUS) was performed in patients with angiographic signs of coronary artery aneurysms. We used a 4.8F or 3.5F, 20 MHz IVUS catheter for ultrasound examination. Fourteen patients (12 men and two women ranging in age from 43 to 73 years) with angiographic signs of coronary aneurysm were enrolled. IVUS imaging was optimally obtained in all patients. The vessel area, lumen area, and plaque area of the aneurysm segment and of the proximal and distal segments were determined. IVUS showed that both the proximal and distal reference segments were severely affected by atherosclerotic lesions in all the patients and by calcium deposits in six patients. The percent stenoses were 63.0% +/- 13.7% and 60.9% +/- 17.8% in the proximal and distal reference segments, respectively. In nine patients the walls of the aneurysms showed signs of atherosclerosis. Three angiographically indicated aneurysms were found to be plaque ruptures. Although the lumen and the vessel areas of the aneurysm segments were larger than those of the proximal and distal segments (p < 0.01 and (p < 0.001), no significant differences in plaque area and plaque composition were found between the aneurysm segment and adjacent vessel segments (p > 0.05). In conclusion, IVUS allows detailed characterization of coronary aneurysms. Atherosclerosis seems to play an important role in the formation of acquired coronary aneurysms.

Aneurysm of the left main coronary artery without obstructive disease: report of a case presenting with severe unstable angina and treated with systemic thrombolysis

A fusiform aneurysm of the left main coronary artery without associated obstructive disease was detected in a 77-year-old patient with severe unstable angina treated with systemic thrombolysis. The authors emphasize the following features: (1) unusual location of the aneurysm, (2) absence of concomitant obstruction in this age group, and (3) clinical efficacy of thrombolysis and subsequent long-term oral anticoagulation.

Coronary aneurysms: a case report and review

This case report describes a large coronary aneurysm and poses questions regarding management. The discussion that follows addresses what is known about the natural history of and options for management of coronary aneurysms.