Simulation design - peer-to-peer training as preparation for full-scale scenarios.

OBJECTIVES: Design of simulation training can have important implications for learning outcomes. This paper describes a pilot simulation training program for baccalaureate nursing students that includes intensive preparations, peer-to-peer skills training (P2P), prior to full-scale scenario training. METHODS: A quality improvement analysis of a large scale experimental, mixed methods study. The project describes the design, analysis, and potential effects of a simulation education program containing P2P for third year nursing students (163 in treatment; 148 in control, n=311). RESULTS: The intervention group was found to be significantly more confident in both technical and non-technical nursing skills. Results suggest that the addition of P2P training may have a direct positive impact and increase the impact on full-scale simulations and debriefing. CONCLUSIONS: Enhanced focus on preparation activities prior to full-scale scenarios, including the use of P2P training methods are advocated.

Testing the cultural-invariance hypothesis: A global analysis of the relationship between scientific knowledge and attitudes to science.

A substantial body of research has demonstrated that science knowledge is correlated with attitudes towards science, with most studies finding a positive relationship between the two constructs; people who are more knowledgeable about science tend to be more positive about it. However, this evidence base has been almost exclusively confined to high and middle-income democracies, with poorer and less developed nations excluded from consideration. In this study, we conduct the first global investigation of the science knowledge-attitude relationship, using the 2018 Wellcome Global Monitor survey. Our results show a positive knowledge-attitude correlation in all but one of the 144 countries investigated. This robust cross-national relationship is consistent across both science literacy and self-assessed measures of science knowledge.

What if some people just do not like science? How personality traits relate to attitudes toward science and technology.

As societal discussion on the public opinion of science and technology ignites over and over again, understanding where such opinions are rooted is increasingly relevant. A handful of prior studies have suggested personality traits as a root of science and technology attitudes. However, these report mixed findings, and employ small student or convenience samples. This leaves considerable uncertainty regarding personality traits' relation to attitudes toward science and technology. If in fact stable psychological predispositions play a role, this has considerable implications for science policy and science communication. This article investigates the relationship between the big five personality traits and science attitudes in Germany and the Netherlands. Findings indicate that personality traits are related to science attitudes but only very weakly so, among them openness to experience and negative emotionality are most notably related to science attitudes, whereas extraversion, in contrast to prior studies, shows no relation to science and technology attitudes.

Researchers on research integrity: a survey of European and American researchers.

BACKGROUND: Reports of questionable or detrimental research practices (QRPs) call into question the reliability of scientific evidence and the trustworthiness of research. A critical component of the research ecosystem is the organization within which research takes place. We conducted a survey to explore the attitudes and beliefs of European and American researchers about the organisations in which they work, their own research practices and their attitudes towards research integrity and research integrity policies. METHODS: We administered an online survey (International Research Integrity Survey (IRIS)) to 2,300 active researchers based in the US and 45,000 in Europe (including UK, Norway, Iceland and Switzerland).  We employed a stratified probability sample of the authors of research articles published between 2016 and 2020 included in Clarivate's Web of Science citation database. Coverage includes researchers in the humanities, social sciences, natural sciences and medical sciences, who hold at least a master's level degree. RESULTS: In comparison to researchers in the US, European researchers admit to more QRPs and are less confident in maintaining high research integrity (RI) standards. In the US and Europe, many researchers judge their organization to fall short of best RI practice. All researchers recognize the benefits of RI, reliable knowledge and the trust of colleagues and the public, and there is support for RI training particularly among Europeans. CONCLUSION: To create and maintain a culture of integrity in scientific research, a collective commitment from researchers, their institutions and funders is needed. Researchers rely on many channels of communication about research integrity and thus the involvement of many different participants in the research system is required to make improvements. Policies must be developed to reinforce best practice rather than being seen as an irrelevance to the real business of research.

Simulation training and professional self-confidence: A large-scale study of third year nursing students.

BACKGROUND: While hands-on training is a prerequisite for successful education of nursing students, constraints on clinical training availability and quality have increased focus on effects of in-school simulation training. However, existing research has produced inconsistent conclusions and the literature lacks high-powered evidence from controlled trials. OBJECTIVES: To test effects of a simulation scheme on student professional self-confidence in technical and non-technical skills, as well as to investigate effects on knowledge acquisition and interaction with clinical training. DESIGN: Field experiment, treatment is a three + two day simulation training scheme while control is a standard three hour simulation session. Self-confidence in a list of technical and non-technical skills is measured in three survey-rounds. Enriched with data on type of clinical training site and grade attainment. SETTING: University College Copenhagen Department of Nursing, all third year students in 2019. PARTICIPANTS: 352 in cohort, out of which 316 participated and 311 answered first survey round (163 in treatment, 148 in control). METHODS: Field experiment analyzed utilizing multivariate OLS regression analysis. RESULTS: Students who receive increased simulation training report markedly higher levels of professional self-confidence immediately after training. This effect is double the size for confidence in technical skills, compared to non-technical skills. The effects on self-confidence in technical skills persist at the end of the following semester for those that receive low intensity clinical training. Students who receive the treatment see a small (and statistically uncertain) relative increase in grade attainment in the semester of treatment, but this difference dissipates over time. CONCLUSIONS: Simulation training has substantial positive short-term effects for the professional self-confidence of nursing students and appears to have small positive effects on knowledge acquisition. Most of these effects are crowded out by other factors (notably intensive clinical training) over time but might have long-term positive effects for those that do not receive other intensive hands-on experiences. This is interpreted as an indication that simulation training can be used to compensate for uncertainties in providing sufficient training experiences outside of academic training.

Microbiology of parapharyngeal abscesses in adults: in search of the significant pathogens.

We aimed to describe the microbiology of parapharyngeal abscess (PPA) and point out the likely pathogens using the following principles to suggest pathogenic significance: (1) frequent recovery, (2) abundant growth, (3) growth in relative abundance to other microorganisms, (4) percentage of the isolates recovered in both absolute and relative abundance, (5) more frequent recovery in PPA pus compared with tonsillar surface and tissue. Comprehensive bacterial cultures were performed on specimens obtained from adult patients (n = 60) with surgically verified PPA, who were prospectively enrolled at five Danish ear-nose-throat departments. The prevalent isolates (in PPA pus) were unspecified anaerobes (73%), non-hemolytic streptococci (67%), Streptococcus anginosus group (SAG) (40%), Corynebacterium spp. (25%), Neisseria spp. (23%), Fusobacterium spp. (22%), Fusobacterium necrophorum (17%), Prevotella spp. (12%), and Streptococcus pyogenes (10%). The bacteria most frequently isolated in heavy (maximum) growth were unspecified anaerobes (60%), SAG (40%), F. necrophorum (23%), and Prevotella spp. (17%). The predominant microorganisms (those found in highest relative abundance) were unspecified anaerobes (53%), SAG (28%), non-hemolytic streptococci (25%), F. necrophorum (15%), S. pyogenes (10%), and Prevotella spp. (10%). Four potential pathogens were found in both heavy growth and highest relative abundance in at least 50% of cases: F. necrophorum, Prevotella spp., SAG, and S. pyogenes. SAG, Prevotella spp., F. necrophorum, S. pyogenes, and Bacteroides spp. were recovered with the same or higher frequency from PPA pus compared with tonsillar tissue and surface. Our findings suggest that SAG, F. necrophorum, Prevotella, and S. pyogenes are significant pathogens in PPA development.

Stroke in acute type A aortic dissection: the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD).

OBJECTIVES: Stroke is a serious complication in patients with acute type A aortic dissection (ATAAD). Previous studies investigating stroke in ATAAD patients have been limited by small cohorts and have shown diverging results. We sought to identify risk factors for stroke and to evaluate the effect of stroke on outcomes in surgical ATAAD patients. METHODS: The Nordic Consortium for Acute Type A Aortic Dissection database included patients operated for ATAAD at 8 Scandinavian Hospitals between 2005 and 2014. RESULTS: Stroke occurred in 177 (15.7%) out of 1128 patients. Patients with stroke presented more frequently with cerebral malperfusion (20.6% vs 6.3%, P < 0.001), syncope (30.6% vs 17.6%, P < 0.001), cardiogenic shock (33.1% vs 20.7%, P < 0.001) and pericardial tamponade (25.9% vs 14.7%, P < 0.001) and more often underwent total aortic arch replacement (10.7% vs 4.7%, P = 0.016), compared to patients without stroke. In the 86 patients presenting with cerebral malperfusion, 38.4% developed stroke. Thirty-day and 5-year mortality in patients with and without stroke were 27.1% vs 13.6% and 42.9% vs 25.6%, respectively. Stroke was an independent predictor of early- [odds ratio 2.02, 95% confidence interval (CI) 1.34-3.05; P < 0.001] and midterm mortality (hazard ratio 1.68, 95% CI 1.27-2.23; P < 0.001). CONCLUSIONS: Stroke in ATAAD patients is associated with increased early- and midterm mortality. Preoperative cerebral malperfusion and impaired haemodynamics, as well as total aortic arch replacement, were more frequent among patients who developed stroke. Importantly, a large proportion of patients presenting with cerebral malperfusion did not develop a permanent stroke, indicating that signs of cerebral malperfusion should not be considered a contraindication for surgery.

Outcome after type A aortic dissection repair in patients with preoperative cardiac arrest.

AIM OF THE STUDY: Patients presenting with acute type A aortic dissection (ATAAD) and cardiac arrest before surgery are considered to have very poor prognosis, but limited data is available. We used a large database to evaluate the outcome of ATAAD patients with a cardiac arrest before surgery. METHODS: We evaluated 1154 surgically treated ATAAD patients from the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database between 2005 and 2014. Patients with (n = 44, 3.8%) and without preoperative cardiac arrest were compared and variables univariably associated with mortality in the cardiac arrest group were identified. Median follow-up time was 2.7 years (interquartile range 0.5-5.5). RESULTS: Thirty-day mortality in the arrest and non-arrest group was 43.2% and 16.6%, respectively (odds ratio [OR] 3.83, CI 2.06-7.09; P < 0.001). In the nine patients with ongoing cardiopulmonary resuscitation when cardiopulmonary bypass was initiated, five died intraoperatively and one died after 65 days. In patients surviving the operation, stroke was significantly more common in the arrest group (48.4% vs 18.2%; OR 4.21, CI 2.05-8.67; P < 0.001). In total, 50.0% (22/44) of the arrest patients survived to the end of follow-up. Non-survivors in the arrest group more often had DeBakey type I dissection, cardiac tamponade, cardiac malperfusion and higher preoperative serum lactate (all P < 0.05). CONCLUSIONS: Early mortality and complications after ATAAD surgery in patients with a preoperative cardiac arrest are high, but mid-term outcome after surviving the initial period is acceptable. Preoperative cardiac arrest should not be considered an absolute contraindication for a surgical ATAAD repair.

Malperfusion in acute type A aortic dissection: An update from the Nordic Consortium for Acute Type A Aortic Dissection.

OBJECTIVES: To evaluate the effect of preoperative malperfusion on 30-day and late mortality and postoperative complications using data from the Nordic Consortium for Acute Type A Aortic Dissection (ATAAD) registry. METHODS: We studied 1159 patients who underwent ATAAD surgery between January 2005 and December 2014 at 8 Nordic centers. Multivariable logistic and Cox regression analyses were performed to identify independent predictors of 30-day and late mortality. RESULTS: Preoperative malperfusion was identified in 381 of 1159 patients (33%) who underwent ATAAD surgery. Thirty-day mortality was 28.9% in patients with preoperative malperfusion and 12.1% in those without. Independent predictors of 30-day mortality included any malperfusion (odds ratio, 2.76; 95% confidence interval [CI], 1.94-3.93), cardiac malperfusion (odds ratio, 2.37; 95% CI, 1.34-4.17), renal malperfusion (odds ratio, 2.38; 95% CI, 1.23-4.61) and peripheral malperfusion (odds ratio, 1.95; 95% CI, 1.26-3.01). Any malperfusion (hazard ratio, 1.72; 95% CI, 1.21-2.43), cardiac malperfusion (hazard ratio, 1.89; 95% CI, 1.24-2.87) and gastrointestinal malperfusion (hazard ratio, 2.25; 95% CI, 1.18-4.26) were predictors of late mortality. Malperfusion was associated with significantly poorer survival at 1, 3, and 5 years (95.0% ± 0.9% vs 88.7% ± 1.9%, 90.1% ± 1.3% vs 84.0% ± 2.4%, and 85.4% ± 1.7% vs 80.8% ± 2.7%; log rank P = .009). CONCLUSIONS: Malperfusion has a significant influence on early and late outcomes in ATAAD surgery. Management of preoperative malperfusion remains a major challenge in reducing mortality associated with surgical treatment of ATAAD.

Retropharyngeal vascular malformation removed using transoral robotic surgery-A case report.

INTRODUCTION: Although vascular lesions are relatively common in head and neck, they are rarely seen in the retropharyngeal space. Frequent symptoms include mass sensation, dysphagia, dyspnea, snoring, and oral bleeding. PRESENTATION OF CASE: A 31-year-old male was referred from his general practitioner with mass sensation in the throat, increasing snoring, and changing resonance of his voice. Flexible laryngoscopy revealed a large mass extending from the nasopharynx to the hypopharynx, primarily involving retropharyngeal and right parapharyngeal areas, resulting in a significant narrowing. The malformation was resected with good result using a transoral robot-assisted surgical approach. At 1-year follow-up, the patient was symptom free; however, some residual rhinopharyngeal lesion was seen. DISCUSSION: Management strategies include surgical removal, corticosteroid injection, chemotherapy, and cryotherapy. Different surgical approaches have been used over the years. CONCLUSION: Transoral robotic surgery was successful, providing minimally invasive access with good visualization.

Low rate of reoperations after acute type A aortic dissection repair from The Nordic Consortium Registry.

OBJECTIVES: To describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection. METHODS: A retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation. RESULTS: The median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease. CONCLUSIONS: Type A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival.

Hospital volumes and later year of operation correlates with better outcomes in acute Type A aortic dissection.

OBJECTIVES: Acute Type A aortic dissection remains a life-threatening disease, but there are indications that its surgical mortality is decreasing. The aim of this report was to study how surgical mortality has changed and what influences those changes. METHODS: Nordic Consortium for Acute Type A Aortic Dissection is a retrospective database comprising 1159 patients (mean age 61.6 ± 12.2 years, 68% male) treated for acute Type A aortic dissection at 8 centres in Denmark, Finland, Iceland and Sweden from 2005 to 2014. Data gathered included demographics, symptoms, type of procedure, complications and 30-day mortality. RESULTS: The annual number of operations increased significantly from 85 in 2005 to 150 in 2014 (P < 0.001). Chest pain was present in 85% of patients, 24% were hypotensive on presentation and 28% had malperfusion syndrome. Open distal anastomosis technique under hypothermic circulatory arrest was used in 85% of cases and its use increased significantly throughout the study. The 30-day mortality decreased from 24% in 2005 to 13% in 2014 (P = 0.003). Independent predictors for 30-day mortality were preoperative cardiac arrest, malperfusion syndrome, Penn Class C, Penn Class B and C and cardiopulmonary bypass time, whereas later calendar year and higher hospital operative volumes predicted improved survival. CONCLUSIONS: Surgical mortality for acute Type A aortic dissection remains high but has decreased significantly over the last decade. This correlated with later year of operation and increased the number of operations performed per year, indicating that cumulative surgical experience contributes significantly to improved surgical outcomes.

Recombinant factor VIIa use in acute type A aortic dissection repair: A multicenter propensity-score-matched report from the Nordic Consortium for Acute Type A Aortic Dissection.

BACKGROUND: Surgery for acute type A aortic dissection (ATAAD) is often complicated by excessive bleeding. Recombinant factor VIIa (rFVIIa) effectively treats refractory bleeding associated with ATAAD surgery; however, adverse effects of rFVIIa in these patients have not been fully assessed. Here we evaluated rFVIIa treatment in ATAAD surgery using the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database. METHODS: This was a multicenter, propensity score-matched, retrospective study. Information about rFVIIa use was available for 761 patients, of whom 171 were treated with rFVIIa. We successfully matched 120 patients treated with rFVIIa with 120 controls. Primary endpoints were in-hospital mortality, postoperative stroke, and renal replacement therapy (RRT). Survival data were presented using Kaplan-Meier estimates. RESULTS: Compared with controls, patients treated with rFVIIa received more transfusions of packed red blood cells (median, 9.0 U [4.0-17.0 U] vs 5.0 U [2.0-11.0 U]; P = .008), platelets (4.0 U [2.0-8.0 U] vs 2.0 U [1.0-4.4 U]; P <.001), and fresh frozen plasma (8.0 U [4.0-18.0 U] vs 5.5 U [2.0-10.3 U]; P = .01) underwent reexploration for bleeding more often (31.0% vs 16.8%; P = .014); and had greater 24-hour chest tube output (1500 L [835-2500 mL] vs 990 mL [520-1720 mL]). Treatment with rFVIIa was not associated with significantly increased rates of in-hospital mortality (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.34-1.55; P = .487), postoperative stroke (OR, 1.75; 95% CI, 0.82-3.91; P = .163), or RRT (OR, 1.18; 95% CI, 0.48-2.92; P = .839). CONCLUSIONS: In this propensity-matched cohort study of patients undergoing ATAAD surgery, treatment with rFVIIa for major bleeding was not associated with a significantly increased risk of stroke, RRT, or mortality.

Medium-term survival after surgery for acute Type A aortic dissection is improving.

OBJECTIVES: To report long-term survival and predictors of mortality in patients included in a large, contemporary, multicentre, multinational database: Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD), which consists of 8 centres in 4 Nordic countries. METHODS: Currently, NORCAAD includes 1159 patients operated between 2005 and 2014. In 30-day survivors (n = 955, 82%), the Kaplan-Meier and Cox proportional hazard methods were used to analyse medium-term (up to 8 years) survival and relative survival versus a matched normal population. Pre- and intraoperative predictors were expressed as hazard ratio (HR) with 95% confidence interval (95% CI). RESULTS: Cumulative follow-up was 3514 patient-years with a median of 3.2 years (range 0-10.2 years). Survival was 95% (95% CI 93-96) at 1 year, 86% (95% CI 83-88) at 5 years and 76% (95% CI 72-81) at 8 years. Relative survival versus a matched normal population was 95% (95% CI 94-97) at 1 year, 90% (95% CI 87-93) at 5 years and 85% (95% CI 80-90) at 8 years. In multivariable analysis, increased age (HR 1.05 per year, 95% CI 1.04-1.07), previous abdominal or thoracic aortic repair (HR 3.2, 95% CI 1.6-6.4) and chronic renal disease (HR 2.7, 95% CI 1.2-6.2) were associated with increased medium-term mortality. Open distal anastomosis (HR 0.55, 95% CI 0.35-0.87) and operation in the 2010-2014 period (HR 0.90, 95% CI 0.83-0.97) were associated with decreased medium-term mortality. CONCLUSIONS: Medium-term survival after acute Type A aortic dissection in the NORCAAD registry is satisfactory, close to a matched normal population and improved in the later part of the study period. The use of open distal anastomosis was associated with decreased medium-term mortality.

Exercise-based cardiac rehabilitation in surgically treated type-A aortic dissection patients.

OBJECTIVES: Surgically treated type-A aortic dissection patients are often restricted from physical exercise due to a lack of knowledge about the blood pressure increase. Our aims were to evaluate the hemodynamic responses during exercise, and to assess changes in peak oxygen uptake, maximal workload, and quality-of-life after completion of an exercise-based cardiac rehabilitation program. DESIGN: Three subgroups were retrospectively identified based on their different eligibility criteria. Group I (n = 10) had performed an exercise-based cardiac rehabilitation program including exercise tests. Group II (n = 9) had followed the program without the tests. Group III (n = 10) had neither been rehabilitated nor tested. For evaluation of hemodynamic parameters, we included a group of surgically treated patients with aortic valve stenosis, group IV (n = 32). Questionnaires were obtained to measure quality-of-life. RESULTS: At baseline the group I and IV mean systolic blood pressure changed from 143 ± 16 mmHg and 150 ± 16 mmHg to 200 ± 32 mmHg and 213 ± 27 mmHg, respectively. The group I mean peak oxygen uptake changed from 23.5 ± 7.9 ml/min/kg before rehabilitation to 28.6 ± 8.4 ml/min/kg, p = .001, after rehabilitation. The mean maximal workload changed from 143 ± 80 W before rehabilitation to 178 ± 97 W, p = .003, after rehabilitation. At follow-up, the groups I-III physical quality-of-life score was 45.1 ± 15.0, 40.0 ± 9.0, and 30.0 ± 11.3, p < .025, respectively, and the mental quality-of-life score was 51.1 ± 6, 41.7 ± 6.7, and 32.5 ± 13.3, p < .001, respectively. CONCLUSIONS: Our results suggest that type-A aortic dissection patients have hemodynamic responses to exercise that are comparable to other cardiovascular patients. Moreover, we found significant increases in peak oxygen uptake, maximal workload, and quality-of-life after ended ECR.

The Nordic Consortium for Acute type A Aortic Dissection (NORCAAD): objectives and design.

OBJECTIVES: The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) is a collaborative effort of Nordic cardiac surgery centers to study acute type A aortic dissection (ATAAD). Here, we outline the overall objectives and the design of NORCAAD. DESIGN: NORCAAD currently consists of eight centers in Denmark, Finland, Iceland and Sweden. Data was collected for patients undergoing surgery for ATAAD from 2005 to 2014. A total of 194 variables were retrospectively collected including demographics, past medical history, preoperative medications, symptoms at presentation, operative variables, complications, bleeding and blood transfusions, need for late reoperations, 30-day mortality and long-term survival. RESULTS: Information was gathered in the database for 1159 patients, of which 67.6% were male. The mean age was 61.5 ± 12.1 years. The mean follow-up was 3.1 ± 2.9 years with a total of 3535 patient years. CONCLUSIONS: NORCAAD provides a foundation for close collaboration between cardiac surgery centers in the Nordic countries. Substudies in progress include: short-term outcomes, long-term survival, time interval from diagnosis until operation, effects of surgical techniques, malperfusion syndrome, renal failure, bleeding and neurological complications on outcomes and the rate of late reoperations.

Severe Pulmonary Valve Regurgitation 40 Years After Blunt Chest Trauma.

Severe pulmonary valve regurgitation caused by a pulmonary valve tear is a rare complication to a blunt chest trauma. In this case report, we present a patient with pulmonary regurgitation originating from a chest trauma 40 years ago. Possible mechanisms are osseous pinch of the pulmonary valve between the anterior chest wall and the vertebral column, and retrograde blowout from severe compression of the lungs.

Anomalous origin of the right coronary artery with an interarterial course and intramural part.

INTRODUCTION: An anomalous origin and course of the right coronary artery (RCA)(1) is a very rare congenital anomaly that can be fatal if it remains undiscovered. PRESENTATION OF CASE: In this case report, we present a patient with a one-year history of exercise-induced angina and dyspnea caused by anomalous origin of the RCA from the left sinus, and anomalous course between the aorta and the pulmonary artery. DISCUSSION: Possible mechanisms of this disease's symptomatology are compression of the RCA between the aorta and the pulmonary artery in its anomalous inter-arterial course, and squeezing of the RCA in the proximal intramural part. CONCLUSION: In this report, we present some unique images of the RCAs course, which contribute to the understanding of this disease's symptomatology. The patient successfully underwent surgery with Right Internal Mammary Artery to RCA (RIMA-RCA)(2) bypass with complete remission of all symptoms.