"Killer coronary artery" and aortic valve stenosis: A tricky case.

Anomalous origin of the left main coronary artery from the right coronary sinus is rarely diagnosed in elderly patients. We report such an anomaly in a 75-year-old lady presenting with chest pain and syncope. Preoperative screening revealed that her aortic valve was moderately stenotic. The patient underwent a successful unroofing procedure combined with aortic valve replacement. The outcome was uncomplicated and the patient remained asymptomatic at one year postoperatively.

Coronary artery disease and 10-year outcome after hospital admission for heart failure with preserved and with reduced ejection fraction.

AIMS: The prognostic impact of coronary artery disease (CAD) in heart failure is debated. Whereas causes of death have been well described in patients with cardiomyopathy, little is known about how CAD influences causes of death in heart failure with preserved ejection fraction (HFPEF). We undertook a 10-year study and analysed causes of death in relation with CAD in HFPEF and in heart failure with reduced ejection fraction (HFREF). METHODS AND RESULTS: Our prospective analysis included 591 consecutive patients (320 HFPEF and 271 HFREF) hospitalized for the first time for heart failure during 2000 and followed for 10 years. History of CAD was documented in 25% of HFPEF and 39% of HFREF patients (P < 0.001). Overall, CAD was independently predictive of all-cause and cardiovascular death. CAD had powerful prognostic impact in HFREF [adjusted hazard ratio (HR) 1.60 (1.19-2.15) for all-cause death, and adjusted HR 2.01 (1.38-2.92) for cardiovascular death]. In HFPEF, the association between CAD and cardiovascular death was no longer observed after adjustment [adjusted HR 1.01 (0.69-1.50)]. In HFREF, CAD was associated with increased risk of heart failure-related (adjusted HR 2.03 (1.21-3.43)] and myocardial infarction-related fatal events [adjusted HR 3.84 (1.16-12.7)], while HFPEF patients with CAD appeared at greater risk of sudden death [adjusted HR 2.22 (1.05-4.95)]. CONCLUSION: The prognostic impact of CAD is different in HFPEF compared with HFREF. Patients with HFPEF and CAD are at high risk of cardiovascular death, especially sudden death.

Renal function and long-term survival after hospital discharge in heart failure with preserved ejection fraction.

BACKGROUND: Baseline renal function and worsening of renal function (WRF) during hospitalization for heart failure (HF) have a major prognostic impact in patients with left ventricular systolic dysfunction. METHODS: We sought to prospectively investigate the impact of reduced baseline renal function and WRF during hospitalization on the 7-year outcome in 358 patients surviving a first admission to hospital for heart failure with preserved (≥ 50%) ejection fraction (HFPEF). RESULTS: Mean baseline estimated glomerular filtration rate (eGFR) was 59.4 ± 23.6 ml/min/1.73 m². Low admission eGFR (<60 ml/min/1.73 m²) was frequently observed (190 patients--53% of the study population). Low baseline eGFR was associated with an increased risk of 7-year overall mortality (unadjusted hazard ratio [HR] 1.43[1.10-1.86]; p = 0.007) and cardiovascular mortality (unadjusted HR 1.57[1.13-2.19]; p = 0.007). After adjustment for covariates, the relationships remained significant. During hospitalization, WRF occurred in 43 patients (12%). History of renal failure, baseline systolic blood pressure >160 mm Hg, and baseline atrial fibrillation were independent predictors of the development of WRF during hospitalization. WRF was independently predictive of 7-year overall mortality (adjusted HR 2.10[1.24-3.58]; p = 0.006) and cardiovascular mortality (adjusted HR 2.54[1.35-4.78]; p = 0.004) in patients with low baseline eGFR but not in those with baseline eGFR ≥ 60 ml/min/1.73 m². CONCLUSIONS: In patients admitted for the first time for HFPEF, low baseline eGFR is a potent predictor of long-term mortality. Patients with impaired renal function at baseline who develop WRF during hospitalization have particularly poor prognosis.

Communicating bilateral coronary artery to pulmonary artery fistula with aneurysm in asymptomatic patient: successful conservative management with selective coil embolization of the aneurysm.

Congenital coronary artery fistula (CAF) is a rare disease. We report a case of a 58-year-old man having a complex coronary to pulmonary artery fistula associated with a large saccular aneurysm originated from the terminal portion of the right coronary artery. An endovascular approach was adopted in order to prevent aneurysmal rupture without need of complete closure of the fistula. We suggest transcatheter embolization as an alternative technique for aneurysmal formation closure in asymptomatic patients with complex CAF complicated with aneurysmal formation if it is not necessary to obtain a complete CAF closure.