Infarto agudo al miocardio secundario a disección coronaria espontánea biarterial: reporte de un caso y revisión de literatura / Acute myocardial infarction due to spontaneous two vessel coronary artery dissection

Resumen: La disección coronaria espontánea ha surgido como una causa interesante y poco reconocida de síndrome coronario agudo no aterosclerótico. Ocurre más frecuentemente en mujeres jóvenes, donde de forma importante puede asociarse a anomalías arteriales no coronarias. La clave para un tratamiento oportuno es el diagnóstico precoz que impida su evolución a cuadros más severos. Se presenta el caso de una mujer de 36 años con un síndrome coronario agudo secundario a una disección coronaria espontánea bi-arterial que evolucionó de forma grave a una insuficiencia cardíaca aguda. El objetivo es informar un cuadro poco usual y proporcionar evidencia que respalde el cómo debe enfrentarse.

Abstract: Spontaneous coronary dissection is an important cause of acute non-atherosclerotic coronary syndrome. It occurs more frequently in young women, often without significantly associated coronary arterial anomalies. Early diagnosis is a key to prompt treatment, in order to prevent severe complications. We report the case of a 36-year-old woman with an acute coronary syndrome secondary to spontaneous bi-arterial coronary dissection progressing to severe acute heart failure. A discussion of the management of this condition is included.

Challenges in diagnosis and management of spontaneous coronary artery dissection in a young patient

Abstract Spontaneous coronary artery dissection (SCAD) is characterized by tear of the inner layer in the coronary artery, creating a false lumen between the inner and central layer. Its infrequent incidence often leads to delay in diagnosis posing challenges in management. There are currently no guidelines for the treatment of this condition. We describe an adult patient who presented with multiple episodes of ventricular fibrillation, in whom cardiac catheterization showed SCAD, treated by off-pump coronary artery bypass.

Arteria coronaria única y cardiopatía coronaria: origen anómalo de la arteria coronaria derecha desde la descendente anterior: casos clínicos / Anomalous origin of the right coronary artery in the middle third of the anterior descending artery: report of two cases

The anomalous origin of the coronary arteries is uncommon and the origin of the right coronary artery from the middle third of the anterior descending artery is a finding of extreme rarity. We report two patients with coronary atherosclerotic disease and with an acute coronary syndrome, in whom a single left coronary artery was found. The clinical and angiographic characteristics and the treatment of these patients are described.

Spontaneous left anterior descending coronary artery dissection requiring coronary artery bypass surgery

Abstract Introduction: Spontaneous coronary artery dissection is a sudden separation between the layers of a coronary artery wall, non-iatrogenic or trauma related, that has been recognized as an important cause of myocardial infarction. Objective: To report an emblematic case, in terms of angiographic images, clinical presentation and predisposing factors, whose clinical management failure led to surgical intervention. Methods: A previously healthy 48-year-old male farmer was admitted to the emergency room complaining of anterior chest pain described as "tearing", which started after physical exertion. Anterior wall ST-segment depression was observed in the electrocardiogram and troponin levels were increased. The patient then underwent coronary catheterization. Angiography showed a tortuous left anterior descending coronary artery with a dissection line involving proximal and middle segments, resulting in mild to moderate luminal stenosis. At first, a conservative approach was chosen. Control cardiac catheterization, 3 months later, showed dissection progression to the distal segment. Results: The patient was referred to surgical treatment. Internal thoracic artery and a great saphenous vein graft were used to revascularize the target vessels. He had an uneventful postoperative course. Conclusion: In this report, we describe a typical clinical manifestation of an uncommon cause of acute myocardial infarction. The dissection was started by an extreme physical effort, which is a known triggering factor. Management of these cases is always challenging because there are no evidence-based therapies or guideline-based recomendations.

Coronary arteriovenous fistulas in adult patients: surgical management and outcomes

Abstract Objective: The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods: Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results: A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion: The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

Fístula coronaria gigante. Presentación clínica, caracterización angiográfica, tratamiento y seguimiento a largo plazo: caso clínico / Giant coronary artery fistula: report of one case

Coronary artery fistulae are abnormal connections between a coronary artery and any cardiac chamber or other vessels. Most of them have a congenital origin. We report a 60 years old woman referring a history of progressive dyspnea and orthopnea during the last year. A continuous heart murmur was audible in the third and fourth intercostal spaces at the left sternal border. Electrocardiogram was normal and echocardiography showed mild dilation of right cavities and an image suggesting a dilated right coronary artery with flow to right atrium. Coronary angiography was performed, showing a normal left coronary artery and a very large, tortuous right coronary artery with an extensive communication to coronary venous sinus. Surgical treatment was decided and was performed without incidents. The patient is well after five years of follow up.

Disección coronaria espontánea: comunicación de 2 casos tratados quirúrgicamente / Spontaneous coronary artery dissection: report of two cases

Spontaneous coronary artery dissection is a rare condition that usually causes a coronary syndrome, but may also cause sudden death. It is more common in women and is associated with factors such as the peripartum period and oral contraceptive use. We report two cases. A 45-year-old woman with hepatitis C, presenting in the emergency room with angina. An intravascular ultrasound showed a dissecting hematoma involving the left, anterior descending and circumflex coronary arteries. She was initially managed with nitroglycerin, anticoagulation and anti-platelet drugs but due to persistence of symptoms, she required surgical revascularization. A 32-year-old woman presenting in the emergency room with angina. A coronary angiogram revealed a dissection of the anterior descending coronary artery. Eight days later an intravenous ultrasound showed a retrograde progression of the dissection and she was subjected to a surgical revascularization.

Transposition of Great Arteries with Intramural Coronary Artery: Experience with a Modified Surgical Technique

Abstract Objective: Transposition of the great arteries is a common congenital heart disease. Arterial switch is the gold standard operation for this complex heart disease. Arterial switch operation in the presence of intramural coronary artery is surgically the most demanding even for the most experienced hands. We are presenting our experience with a modified technique for intramural coronary arteries in arterial switch operation. Methods: This prospective study involves 450 patients undergoing arterial switch operation at our institute from April 2006 to December 2013 (7.6 years). Eighteen patients underwent arterial switch operation with intramural coronary artery. The coronary patterns and technique used are detailed in the text. Results: The overall mortality found in the subgroup of 18 patients having intramural coronary artery was 16% (n=3). Our first patient had an accidental injury to the left coronary artery and died in the operating room. A seven-day old newborn died from intractable ventricular arrhythmia fifteen hours after surgery. Another patient who had multiple ventricular septal defects with type B arch interruption died from residual apical ventricular septal defect and sepsis on the eleventh postoperative day. The remainder of the patients are doing well, showing a median follow-up duration of 1235.34±815.26 days (range 369 - 2730). Conclusion: Transposition of the great arteries with intramural coronary artery is demanding in a subset of patients undergoing arterial switch operation. We believe our technique of coronary button dissection in the presence of intramural coronary arteries using coronary shunt is simple and can be a good addition to the surgeons' armamentarium.

Disección coronaria espontánea post parto: reporte de un caso clínico y revisión de la literatura / Spontaneous coronary artery dissection in the post partum: report of one case

Coronary artery dissection is a rare cause of acute coronary syndrome. Most cases occur in women during the peripartum period, most likely influenced by hormonal changes, hemodynamic stress and modifications in the immune system during pregnancy. The pathogenesis of coronary artery dissection is unknown, hence numerous theories have been postulated such as pregnancy-related conditions, the presence of connective tissue disorders, trauma, etc. The clinical presentation ranges from asymptomatic patients to the whole spectrum of acute coronary syndrome manifestations. The management of these patients requires a multidisciplinary approach, with two options: medical therapy or an invasive approach, with percutaneous coronary intervention or coronary artery bypass graft surgery. The choice of treatment options depends on the hemodynamic status of the patient, the extension of the dissection and the myocardial territory at risk. In this case report we present a 38-year-old female who had a coronary artery dissection seven days postpartum. Coronary catheterization showed dissection of the left main coronary artery that extended until the circumflex artery. An intra-aortic balloon pump was installed and the patient then underwent coronary artery bypass graft surgery, with satisfactory results.

Origem anômala da artéria coronária esquerda do tronco pulmonar em criança de sete meses: papel do strain miocárdico após oito anos de acompanhamento / Anomalous origin of the left coronary artery from the pulmonary trunk in a seven-months baby: role of myocardial strain after eight years follow-up / Origen Anómalo de la Arteria Coronaria Izquierda del Tronco Pulmonar en Niño de Siete Meses: Papel del Strain Miocárdico tras Ocho Años de Acompañamiento

Dentre algumas doenças descritas na literatura, a origem anômala da artéria coronariana esquerda é uma das causas de insuficiência cardíaca e isquemia miocárdica nos primeiros meses de vida. Neste relato, apresentamos caso de uma criança que aos sete meses, quando em franca insuficiência cardíaca, foi submetida a um ecocardiograma que evidenciou tronco da artéria coronariana esquerda com origem na artéria pulmonar e fluxo reverso nessa artéria ao mapeamento de fluxo em cores. Submetida a cirurgia corretiva com sucesso, foi seguida por oito anos, evoluindo com fibrose do músculo papilar e consequente insuficiência mitral moderada.

Among some pathologies described in the literature, the anomalous origin of the left coronary artery is a cause of heart failure and myocardial ischemia in the early months of life. Here we report a case of a child who at seven months, when in open heart failure underwent echocardiography showed that the left main coronary artery originating from the pulmonary artery and reverse flow in this artery flow mapping in color. Underwent corrective surgery has successfully been followed for eight years, evolving with papillary muscle fibrosis and moderate mitral regurgitation.

De entre algunas enfermedades descritas en la literatura, el origen anómalo de la arteria coronaria izquierda es una de las causas de insuficiencia cardíaca e isquemia miocárdica en los primeros meses de vida. En el presente informe, presentamos el caso de un niño que a los siete meses, cuando en franca insuficiencia cardíaca, se sometió a un ecocardiograma que evidenció tronco de la arteria coronaria izquierda con origen en la arteria pulmonar y flujo inverso en esta arteria al mapeo de flujo en colores. Sometido a la cirugía correctiva con éxito, fue acompañada por ocho años, evolucionando con fibrosis del músculo papilar y consecuente insuficiencia mitral moderada.

Angioplastía de circunfleja en paciente con doble arteria descendente anterior tipo IV: Propuesta para actualizar la clasificación de Spindola-Franco / Circumflex angioplasty in a patient with type IV dual left anterior descending coronary artery: Proposal for updating the classification of Spindola-Franco

La anatomía normal de las arterias coronarias incluye una serie de variantes respecto a su origen, distribución y recorrido, que hacen que no existan 2 pacientes con coronarias exactamente iguales. La arteria descendente anterior puede tener variantes anatómicas que no afectan el aporte normal de sangre al territorio miocárdico correspondiente. En nuestros 25 años de trabajo y más de 11,000 coronariografías realizadas, sólo habíamos encontrado un paciente con un doble sistema, tipo IV, de la arteria descendente anterior. En este artículo mostramos el caso de una paciente con la anomalía coronaria descrita que presentaba, además, una estenosis severa de la arteria circunfleja que fue tratada exitosamente por vía percutánea. También, se propone una actualización de la clasificación de Spindola-Franco, donde se mantienen los 4 tipos originales y se añaden 7 variantes anatómicas o subtipos.

The normal anatomy of coronary arteries includes a kind of variants with regard to its origin, distribution and route, which makes that 2 patients do not have coronary arteries exactly alike. Left anterior descending artery could have anatomical variations that do not affect the normal supply of blood to the corresponding myocardial territory. In our 25 years of experience, and more than 11,000 coronary angiographies, we have found only one patient with a type IV Classification; dual left anterior descending coronary artery. In this article we show the case of a patient with the described coronary anomaly, presenting a severe stenosis of the circumflex artery which was successfully treated percutaneously. Besides, a proposal for updating the classification of Spindola-Franco is made, where the 4 types previously described were kept invariable, and 7 anatomical variants or subtypes were added.

Anestesia para correção cirúrgica de fístula de artéria coronária sem circulação extracorpórea: relato de caso / Anesthesia for surgical correction of coronary artery fistula without extracorporeal circulation: case report / Anestesia para la corrección quirúrgica de fístula de arteria coronaria sin circulación extracorpórea: relato de caso

JUSTIFICATIVA E OBJETIVOS: Descrita em 1865 por Krause ¹, a fístula de artéria coronária comunicando-se com cavidades cardíacas, artéria pulmonar ou seio coronário é muito rara. Representa 0,2 por cento a 0,4 por cento das cardiopatias congênitas e 0,1 por cento a 0,2 por cento da população adulta submetida a angiografias coronarianas ². O objetivo deste relato é apresentar anestesia para cirurgia de fechamento de fístula coronária em procedimento eletivo, considerando suas particularidades. RELATO DE CASO: Paciente do sexo masculino com 59 anos, cuja fístula coronária foi diagnosticada durante investigação clínica de dor torácica progressiva e dispneia de longa data. O paciente foi submetido a uma correção cirúrgica de fístula de artéria coronária sob anestesia geral sem a utilização de circulação extracorpórea (CEC).O paciente evoluiu sem intercorrências, tendo alta hospitalar com melhora clínica em sete dias de pós-operatório. CONCLUSÕES: A fístula coronária é afecção rara, mas o anestesiologista pode deparar com esse tipo de paciente em situações distintas. É importante compreender sua fisiopatologia para abordar adequadamente o paciente no perioperatório, favorecendo seu melhor prognóstico.

BACKGROUND AND OBJECTIVES: Described by Krause in 1865 ¹, coronary artery fistula communicating with cardiac cavities, pulmonary artery, or coronary sinus is very rare. It represents 0.2 percent to 0.4 percent of congenital cardiopathies and 0.1 percent and 0.2 percent of the adult population undergoing coronary angiography ². The objective of this report is to present the anesthetic management for surgical closure of a coronary fistula in an elective procedure, considering its particularities. CASE REPORT: This is a 59-year old male patient, whose coronary fistula was diagnosed during clinical investigation of progressive thoracic pain and long-standing dyspnea. The patient underwent surgical correction of coronary artery fistula under general anesthesia without extracorporeal circulation (ECC). The patient evolved without intercurrences, being discharged from the hospital with clinical improvement 7 days after surgery. CONCLUSIONS: Coronary artery fistula is rare, but the anesthesiologist may be faced with this type of patient in distinct situations. Understanding its pathophysiology is important for better perioperative management of the patient, therefore improving the prognosis.

JUSTIFICATIVA Y OBJETIVOS: Descrita en 1865 por Krause ¹, la fístula de arteria coronaria comunicándose con las cavidades cardíacas, arteria pulmonar o el seno coronario, es una patología muy rara. Representa entre el 0,2 por ciento al 0,4 por ciento de las cardiopatías congénitas y del 0,1 por ciento al 0,2 por ciento de la población adulta sometida a angiografías coronarias ². El objetivo de este relato es presentar la anestesia para la cirugía de cierre de la fístula coronaria en el procedimiento electivo, considerando sus particularidades. RELATO DE CASO: Paciente del sexo masculino con 59 años, cuya fístula coronaria fue diagnosticada durante la investigación clínica de dolor torácico progresivo y disnea desde hacía ya mucho tiempo. El paciente fue sometido a una corrección quirúrgica de fístula de arteria coronaria bajo la anestesia general sin la utilización de la circulación extracorpórea (CEC). Evolucionó sin intercurrencias, y obtuvo el alta con una mejoría clínica siete días después del postoperatorio. CONCLUSIONES: La fístula coronaria es una patología rara, pero el anestesiólogo puede toparse con ese tipo de paciente en situaciones distintas. Es importante que comprendamos su fisiopatología para abordar adecuadamente el paciente en el perioperatorio, favoreciendo su mejor pronóstico.