Anomalous origin and interarterial course of right coronary artery associated with angina and proven ischemia.

Clinical significance of coronary arteries with anomalous origin and/or course is highly heterogeneous. Anomalies with the origin from the opposite sinus and interarterial course can be associated with angina, syncope, and sudden cardiac death. However, there are no clear guidelines for diagnosis and treatment of such cases. We present the case of a young lady who presented with typical angina, and later proved to have an anomalous right coronary artery (RCA) originating from the left sinus of Valsalva coursing between the aorta and pulmonary artery. This was associated with demonstrable stress ischemia with nuclear perfusion scan. The patient underwent surgery with a bypass graft to the anomalous RCA with complete relief of her angina.

Is Radial Access and Transradial Cardiac Catheterization Feasible without the Use of Any Vasodilator?

This is a "proof of concept" study to assess feasibility of transradial access without use of vasodilators. Radial artery spasm (RAS) is an important cause of patient discomfort and procedural failure with use of radial access. Vasodilators are routinely used to prevent RAS. However, the use of vasodilators may not be appropriate in substantial groups of patients. These include patients with myocardial infarction and low blood pressure who will benefit from radial access the most. No specific recommendations about use of vasodilators in these settings are stated on consensus documents on radial access. During a short period of shortage of verapamil in our country, 15 consecutive patients underwent cardiac catheterization by transradial route without the use of vasodilators. Procedural success, and pain perceived by the patients along with radial occlusion after the procedure were assessed. In 14 of the 15 patients, the procedure was completed successfully without the use of vasodilators. In one patient, RAS developed and the procedure could be completed after injection of verapamil. Mean pain score was 5.3 on a scale of 0 to 10. No radial occlusion was detected early after the procedure. In three of the patients, a reason that would otherwise preclude use of a vasodilator was identified. Radial access can safely and effectively be performed without the use of vasodilators. Consideration of this approach when use of vasodilators is not appropriate should be formally discussed by the interventional cardiology community.

Right coronary artery arising as a sidebranch from the left anterior descending artery: a single coronary ostium anomaly.

We present a patient with abnormal origin of the right coronary artery from the left anterior descending artery. The patient had chest pain probably related to myocardial ischemia. This anomaly is very rare and has only been reported in a few cases. The abnormal vessel had a rightward course following its take-off from the left anterior descending artery and remained anterior to the main pulmonary artery. There was no significant obstruction. The mechanism of myocardial ischemia remains unexplained.

Systolic anterior motion of the mitral valve in the absence left ventricular hypertrophy: role of mitral leaflet elongation and papillary muscle displacement.

We report a 15-year-old patient who presented with exercise dyspnea and limitation of physical activity. Echocardiography revealed significant left ventricular outflow tract obstruction caused by systolic anterior motion (SAM) of the mitral valve. The wall thickness of the left ventricle was within normal limits. Elongation of the mitral leaflets and anterior displacement of the posteromedial papillary muscle were apparent in the echocardiographic examination. These two factors have been previously demonstrated to play a central role in the occurrence of SAM in patients with hypertrophic cardiomyopathy. The present case validates that such intrinsic abnormalities of the mitral valve can cause significant SAM even in the absence of left ventricular hypertrophy.

Severe tricuspid regurgitation in a patient receiving low-dose cabergoline for the treatment of acromegaly.

Cabergoline, an ergot-derived dopamine receptor agonist, is used widely in the treatment of Parkinson's disease (PD) and hyperprolactinemia, but may cause heart valve fibrosis, retraction, and clinically significant regurgitation in PD patients. While cabergoline has been used at much lower doses in patients with hyperprolactinemia, controversy persists as to whether it may cause heart valve disease in this situation. Cabergoline is also used in acromegaly at doses similar to those used in hyperprolactinemia. The case is reported of a female patient with acromegaly who had been taking low-dose (0.5 mg/day) cabergoline for one year, and presented with signs and symptoms of right-sided heart failure. Echocardiography revealed a thickened and retracted tricuspid valve associated with severe tricuspid regurgitation and enlargement of the right-heart chambers. The morphology of the tricuspid valve was typical for cabergoline-related valvulopathy. Cabergoline may not be totally safe even at lower doses, and close echocardiographic monitoring is recommended in patients receiving cabergoline treatment, regardless of the dose level employed.

Effectiveness of enoxaparin for prevention of radial artery occlusion after transradial cardiac catheterization.

The aim of this study was to assess the efficacy of enoxaparin for prevention of radial artery (RA) occlusion after transradial access for diagnostic and interventional cardiac procedures. RA occlusion is a potential complication of transradial cardiac catheterization. Conventionally, unfractionated heparin is used for prevention of RA occlusion. Effectiveness of low molecular weight heparins for prevention of this complication has not been tested before. Fifty transradial catheterizations were performed for diagnostic and/or interventional cardiac procedures in 39 patients. All the patients received 60 mg enoxaparin through the radial sheath at the beginning of the procedure for prevention of RA occlusion. RA patency was evaluated by Doppler examination. Patients were assessed for postprocedural RA occlusion at discharge and 5.5 +/- 2.8 days follow-up. RA occlusion was detected after 2 of the 50 transradial accesses, yielding a RA occlusion rate of % 4. In this study we found a low rate of RA occlusion with use of enoxaparin during transradial access. Enoxaparin is safe and effective in transradial procedures with a RA occlusion rate comparable to use of unfractionated heparin.

Isolated cleft of the posterior mitral valve leaflet in a patient with Marfan syndrome.

Isolated cleft of the mitral valve is an uncommon congenital cause of mitral regurgitation. Most of the clefts involve the anterior leaflet and isolated clefts of the posterior leaflet have been anecdotally identified. We report a case of Marfan syndrome in whom an echocardiographic examination revealed a cleft in the posterior mitral leaflet. Marfan syndrome frequently involves the mitral valve causing mitral valve prolapse. Occurrence of a cleft may be an extension of its mitral valve involvement.

Demonstration of coronary-to-pulmonary fistula with MDCT and conventional angiography.

The coronary pulmonary fistulas are usually discovered incidentally during routine cardiac catheterization after the development of atherosclerotic coronary artery disease. Here we present a 59-year-old man with anginal symptoms who was found to have two fistulas originating from the left coronary system and right coronary sinus and draining into the pulmonary trunk. We delineated the courses of the fistulas in detail using both of the imaging techniques of MDCT and conventional angiograhy.