Pericardial Calcification: An Uncommon Case with Intraventricular Extension.

An 80-year-old man presented to the cardiology outpatient clinic due to shortness of breath. His past medical history included alcohol intake, hypertension, inferior wall myocardial infarction (five years ago), an ischemic stroke, and permanent atrial fibrillation (diagnosed three years before the current examination). A physical exam revealed a decreased intensity of S1 and S2, irregular rate and rhythm, and no murmurs nor friction rub. X-rays, Computed Tomography, and echocardiography exhibited pericardial calcification, involving mostly the inferior wall and protruding into the left ventricle. A diagnosis of constrictive pericarditis due to pericardial calcification was established and considered idiopathic. Even when it may be related to ischemic heart disease, post-infarction pericarditis could explain how the calcification extended to adjacent territory perfused by the circumflex coronary artery. Combined imaging studies were crucial not only for identifying calcium deposits in the pericardium but also in assessing a patient inherently prone to co-existing and exacerbating conditions. Even though pericardiectomy allows for removal of the clinical manifestations of congestive pericarditis in the most symptomatic patients with pericardial calcification, among patients like ours, with tolerable symptoms, cardiologists should discuss the therapeutic options considering the patient's choices, potentially including a rehabilitation plan as part of non-pharmacological management.

Deep Sternal Wound Infection After Beating Heart Coronary Artery Bypass Surgery with Routine Use of Skeletonized Bilateral Internal Thoracic Artery.

INTRODUCTION: Despite its survival benefits, bilateral internal thoracic artery (BITA) grafting is not commonly utilized due to concerns over deep sternal wound infection (DSWI). We observed the role of routine use of BITA and off-pump coronary artery bypass grafting (OPCABG) in the incidence of DSWI and associated risk factors. METHODS: Between January 2010 and December 2020, 1,207 patients were treated with isolated coronary artery bypass grafting. In all cases, OPCABG was attempted, and BITA was used whenever there was a need for a second arterial graft for the left coronary artery. DSWI was defined as a wound infection requiring surgical intervention and/or the administration of antibiotics. Multiple linear regression analysis was employed to model the risk of DSWI. RESULTS: The incidence of DSWI was 0.58%. Mortality rate was higher in DSWI group than in no-DSWI group (28.57% vs. 1.25%; P<0.001). No significant difference in DSWI incidence was observed when BITA (70.6%) or single internal thoracic artery (29.4%) were used (P=0.680). The prevalence of diabetes (100% vs. 40.7%; P=0.001), hyperlipidemia (100% vs. 85.9%; P=0.045), and obesity (71.4% vs. 26.8%; P-0.017) was significantly elevated in DSWI group, when compared with no-DSWI group. Diabetes (P=0.0001), unstable angina (P=0.0064), previous myocardial infarction > 30 days (P=0.0009), left ventricular ejection fraction < 50% (P=0.0074), and emergency surgery (P=0.0002) were independent risk factors. CONCLUSION: The results of routine use of skeletonized BITA after OPCABG were satisfactory regarding DSWI incidence and operative mortality in a single-center experience.

Achados tomográficos incidentais de calcificações coronarianas: um estudo de prevalência na região sul do Brasil / Incidental tomographic findings of coronary artery calcifications: a prevalence study in southern Brazil

Fundamento: As calcificações de artérias coronárias (CAC) mostram-se como fator preditivo de doenças cardiovasculares (DCV). A tomografia computadorizada (TC) de tórax com protocolo de aquisição de baixa dose apresenta acurácia na identificação de CAC e propicia achados incidentais dessas calcificações, que são comumente negligenciados. Este estudo analisará a prevalência de achados incidentais de calcificação em artérias coronárias em indivíduos não cardiopatas submetidos à TC de tórax. Métodos: Estudo transversal consecutivo de caráter analítico e descritivo. Foram incluídos indivíduos de ambos os sexos que realizaram TC de tórax por encaminhamento, acima de 18 anos e não cardiopatas. A coleta de dados foi realizada por meio de prontuários e ficha de anamnese auto aplicada. As variáveis referentes às CAC e à extensão do comprometimento foram obtidas a partir da reavaliação das imagens de TC de tórax disponíveis no sistema da instituição. Os exames foram anonimizados e avaliados por dois médicos radiologistas experientes. Considerou-se como estatisticamente significativo p≤0,05. Resultados: Foram analisados 397 exames. Encontrou-se prevalência de calcificações em 176 (44%) dos casos. A existência dessas calcificações coronárias está relacionada à idade (p<0,001). As calcificações possuem relação com o sexo (p = 0,03) com maior razão de chance de desenvolvimento em homens (odds ratio [OR] = 1,55). O tabagismo (p<0,001), o sedentarismo (p<0,001), a hipertensão arterial sistêmica (p<0,001), o diabetes mellitus (p = 0,04) e as dislipidemias (p<0,001) mostraram associação positiva. Conclusão: A prevalência de achados incidentais de CAC foi de 44%; variam em maior número entre leve e grave; maior razão de chance no sexo masculino e aumento da prevalência com a idade. Portanto, a TC de tórax mostra-se um efetivo método para avaliar as CAC, e juntamente com a história clínica do paciente pode ser utilizada para medir os fatores de risco para doenças cardiovasculares e intervir no desfecho do quadro.(AU)

Introduction: Coronary artery calcifications (CAC) are shown to be a predictive factor of cardiovascular diseases. Computed tomography (CT) of the chest with a low-dose acquisition protocol is accurate in identifying CAC and provides incidental findings of these calcifications, which are commonly overlooked. This study will analyze the prevalence of incidental findings of calcification in coronary arteries in non-cardiac individuals undergoing chest CT. Methods: Consecutive cross-sectional study of an analytical and descriptive nature. Individuals of both genders who underwent chest CT by referral, over 18 years of age and without heart disease were included. Data collection was carried out using medical records and a self-applied anamnesis form. The variables referring to the CAC and the extension of the impairment were obtained from the reassessment of the chest CT images available in the institution's system. The exams were anonymized and evaluated by two experienced radiologists. P≤0.05 was considered statistically significant. Results: 397 exams were analyzed. A prevalence of calcifications was found in 176 (44%) of the cases. The existence of these coronary calcifications is related to age (p<0.001). Calcifications are related to gender (p = 0.03) with a higher odds ratio of development in men (odds ratio [OR] = 1.55). Smoking (p<0.001), sedentary lifestyle (p<0.001), systemic arterial hypertension (p<0.001), Diabetes Mellitus (p = 0.04), and dyslipidemia (p<0.001) showed a positive association. Conclusion: The prevalence of incidental CAC findings was 44%; vary in greater numbers between mild and severe; higher odds ratio in males and increased prevalence with age. Therefore, chest CT proves to be an effective method to assess CAC, and together with the patient's clinical history, it can be used to measure risk factors for CVD and intervene in the outcome of the condition.(AU)

Anomalous aortic origin of the left coronary artery / Origen aórtico anómalo de la arteria coronaria izquierda

Abstract We present an unusual case of an anomalous left coronary artery arising from the contralateral sinus of Valsalva: a 63-year-old male patient who consulted to our emergency department with 1-week history of progressive dyspnea on exertion with clinical signs of heart failure, associated with lung congestion on the chest X ray and elevated NT-proBNP levels (2000 pg/ml; normal value <150). Doppler echocardiography showed severe dilation of both left atrium and left ventricle, with severe deterioration of LV systolic function (Ejection fraction of 26%), global hypokinesia and a moderate mitral regurgitation with central jet. A cardiac cath eterization was performed, which evidenced an anomalous origin of the left main coronary artery from the right coronary sinus with a proximal lesion of nearly 50%. A coronary computed tomographic angiography confirmed the diagnosis of an anomalous origin with an intramyocardial path at the level of the interventricular septum, as sociated with moderate extrinsic compression. To determine the degree of functional ischemia presented by the left main coronary artery lesion we performed a fractional flow reserve evaluation, resulting in 0.75, which was ranked as significant. An angioplasty with implantation of a drug-eluting stent (with Everolimus) was performed successfully to the target lesion. The patient evolved favorably during hospitalization and was discharged from the medical center to continue outpatient follow-up. Patient remained asymptomatic at 1-month and 6 months, during clinical evaluation, without evidence of ischemia on noninvasive functional assessment.

Resumen Presentamos un raro caso de nacimiento anómalo de arteria coronaria izquierda en el seno de Valsalva contralateral. Se trata de un hombre de 63 años que consultó al servicio de emergencias de nuestro centro por disnea progresiva de una semana de evolución, con signos clínicos de insuficiencia cardíaca, aso ciado a signos de congestión en la radiografía de tórax, y valores de NT-proBNP elevados (2000 pg/ml; valor normal <150). El ecocardiograma Doppler evidenció dilatación grave de la aurícula y del ventrículo izquierdo, con deterioro grave de la función sistólica (fracción de eyección de 26%), hipoquinesia global e insuficiencia mitral moderada con jet central. Se realizó una cinecoronariografía que evidenció el nacimiento anómalo del tronco de arteria coronaria izquierda desde el seno coronario derecho, con una lesión cercana al 50%. Una angiotomografía coronaria confirmó el origen anómalo del vaso coronario, con trayecto intramiocárdico a nivel del septum interventricular asociado a compresión extrínseca moderada. Para determinar el grado de isquemia funcional que presentaba la lesión del tronco coronario izquierdo se evaluó la reserva de flujo fraccional, que arrojó un resultado de 0.75 el cual se consideró significativo, prosiguiendo a angioplastia con implante de stent liberador de droga (con Everolimus) a dicha lesión. El paciente evolucionó favorablemente durante la internación en el hospital, egresando de la institución para continuar seguimiento ambulatorio. Persistió asintomático en los controles realizados al mes y a los 6 meses, sin evidencia de isquemia en la evaluación funcional no invasiva.

Anomalous aortic origin of the left coronary artery.

We present an unusual case of an anomalous left coronary artery arising from the contralateral sinus of Valsalva: a 63-year-old male patient who consulted to our emergency department with 1-week history of progressive dyspnea on exertion with clinical signs of heart failure, associated with lung congestion on the chest X ray and elevated NT-proBNP levels (2000 pg/ml; normal value <150). Doppler echocardiography showed severe dilation of both left atrium and left ventricle, with severe deterioration of LV systolic function (Ejection fraction of 26%), global hypokinesia and a moderate mitral regurgitation with central jet. A cardiac catheterization was performed, which evidenced an anomalous origin of the left main coronary artery from the right coronary sinus with a proximal lesion of nearly 50%. A coronary computed tomographic angiography confirmed the diagnosis of an anomalous origin with an intramyocardial path at the level of the interventricular septum, associated with moderate extrinsic compression. To determine the degree of functional ischemia presented by the left main coronary artery lesion we performed a fractional flow reserve evaluation, resulting in 0.75, which was ranked as significant. An angioplasty with implantation of a drug-eluting stent (with Everolimus) was performed successfully to the target lesion. The patient evolved favorably during hospitalization and was discharged from the medical center to continue outpatient follow-up. Patient remained asymptomatic at 1-month and 6 months, during clinical evaluation, without evidence of ischemia on noninvasive functional assessment.

Presentamos un raro caso de nacimiento anómalo de arteria coronaria izquierda en el seno de Valsalva contralateral. Se trata de un hombre de 63 años que consultó al servicio de emergencias de nuestro centro por disnea progresiva de una semana de evolución, con signos clínicos de insuficiencia cardíaca, asociado a signos de congestión en la radiografía de tórax, y valores de NT-proBNP elevados (2000 pg/ml; valor normal <150). El ecocardiograma Doppler evidenció dilatación grave de la aurícula y del ventrículo izquierdo, con deterioro grave de la función sistólica (fracción de eyección de 26%), hipoquinesia global e insuficiencia mitral moderada con jet central. Se realizó una cinecoronariografía que evidenció el nacimiento anómalo del tronco de arteria coronaria izquierda desde el seno coronario derecho, con una lesión cercana al 50%. Una angiotomografía coronaria confirmó el origen anómalo del vaso coronario, con trayecto intramiocárdico a nivel del septum interventricular asociado a compresión extrínseca moderada. Para determinar el grado de isquemia funcional que presentaba la lesión del tronco coronario izquierdo se evaluó la reserva de flujo fraccional, que arrojó un resultado de 0.75 el cual se consideró significativo, prosiguiendo a angioplastia con implante de stent liberador de droga (con Everolimus) a dicha lesión. El paciente evolucionó favorablemente durante la internación en el hospital, egresando de la institución para continuar seguimiento ambulatorio. Persistió asintomático en los controles realizados al mes y a los 6 meses, sin evidencia de isquemia en la evaluación funcional no invasiva.

Ischemic Postconditioning Attenuates Myocardial Ischemia-Reperfusion-Induced Acute Lung Injury by Regulating Endoplasmic Reticulum Stress-Mediated Apoptosis

ABSTRACT Objective: To explore the effect of ischemic postconditioning on myocardial ischemia-reperfusion-induced acute lung injury (ALI). Methods: Forty adult male C57BL/6 mice were randomly divided into sham operation group (SO group), myocardial ischemia-reperfusion group (IR group), ischemic preconditioning group (IPRE group) and ischemic postconditioning group (IPOST group) (10 mice in each group). Anterior descending coronary artery was blocked for 60 min and then reperfused for 15 min to induce myocardial IR. For the IPRE group, 3 consecutive cycles of 5 min of occlusion and 5 minutes of reperfusion of the coronary arteries were performed before ischemia. For the IPOST group, 3 consecutive cycles of 5 min reperfusion and 5 minutes of occlusion of the coronary arteries were performed before reperfusion. Pathological changes of lung tissue, lung wet-to-dry (W/D) weight ratio, inflammatory factors, oxidative stress indicators, apoptosis of lung cells and endoplasmic reticulum stress (ERS) protein were used to evaluate lung injury. Results: After myocardial IR, lung injury worsened significantly, manifested by alveolar congestion, hemorrhage, structural destruction of alveolar septal thickening, and interstitial neutrophil infiltration. In addition, lung W/D ratio was increased, plasma inflammatory factors, including interleukin (IL)-6, tumor necrosis factor (TNF)-α, and IL-17A, were increased, malondialdehyde (MDA) activity of lung tissue was increased, and superoxide dismutase (SOD) activity was decreased after myocardial IR. It was accompanied by the increased protein expression levels of ERS-related protein glucose regulatory protein 78 (GRP78), CCAAT/enhancer-binding protein (C/EBP) homologous protein (CHOP), and caspase-12, and the increased apoptotic indices of lung tissues. Conclusion: IPOST can effectively improve myocardial IR-induced ALI by inhibiting ERS-induced apoptosis of alveolar epithelial cells.

Novel Technique for Box-Lesion Ablation of Atrial Fibrillation Combined with Off-Pump Coronary Surgery.

INTRODUCTION: We propose a new technique for box-lesion ablation combined with off-pump coronary artery bypass grafting for the treatment of patients with coronary artery disease and paroxysmal or persistent atrial fibrillation. METHODS: Eight male patients with paroxysmal (n=2) or persistent atrial fibrillation (n=6) and coronary artery disease underwent box-lesion ablation combined with off-pump coronary artery bypass grafting. Box-lesion ablation was performed using a bipolar flexible clamping device with irrigated electrodes which was originally designed for thoracoscopic epicardial ablation. RESULTS: Complete revascularization was performed in all patients. There were no deaths or major complications. At a median follow-up of 14 months, seven patients (87.5%) were in sinus rhythm. CONCLUSION: Box-lesion ablation can be easily and effectively combined with coronary artery surgery in an off-pump setting.

Impact of Coronary Artery Disease on The Outcomes of Catheter Ablation in Patients with Atrial Fibrillation.

INTRODUCTION: The objective of this study is to investigate the possible impact of coronary artery disease (CAD) on clinical outcomes of catheter ablation in patients with atrial fibrillation (AF). METHODS: Patients with AF who underwent coronary computed tomography and catheter ablation were enrolled. The presence of stenotic severity and plaque, characteristics of coronary arteries, clinical data, and adverse outcomes of catheter ablation were analysed. RESULTS: A total of 243 patients were enrolled, 100 (41%) patients with CAD. The CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, and sex category) score of AF patients with CAD was significantly (P<0.001) higher than of those without CAD. Presence of stenotic artery and plaques increased significantly with increase of CHA2DS2-VASc score (P<0.05). There was no significant (P=0.342) difference in AF recurrence between patients with and without CAD (30% versus 24%). Age, AF type, duration of AF, heart failure, CHA2DS2-VASc score, left ventricular ejection fraction, and left atrial diameter were significantly (P<0.05) correlated with AF recurrence in univariant analysis. Multivariable analysis revealed that duration of AF (hazard ratio [HR] 1.769), heart failure (HR 1.821), and left atrial diameter (HR 1.487, P=0.022) remained significant independent predictors of AF recurrence. Patients with AF and concomitant CAD were significantly (P=0.030) associated with a worse outcome. CONCLUSION: CAD concomitant with AF may be associated with a worse clinical outcome even though CAD does not significantly affect the risk of AF recurrence after ablation therapy.

Ischemic Postconditioning Attenuates Myocardial Ischemia-Reperfusion-Induced Acute Lung Injury by Regulating Endoplasmic Reticulum Stress-Mediated Apoptosis.

OBJECTIVE: To explore the effect of ischemic postconditioning on myocardial ischemia-reperfusion-induced acute lung injury (ALI). METHODS: Forty adult male C57BL/6 mice were randomly divided into sham operation group (SO group), myocardial ischemia-reperfusion group (IR group), ischemic preconditioning group (IPRE group) and ischemic postconditioning group (IPOST group) (10 mice in each group). Anterior descending coronary artery was blocked for 60 min and then reperfused for 15 min to induce myocardial IR. For the IPRE group, 3 consecutive cycles of 5 min of occlusion and 5 minutes of reperfusion of the coronary arteries were performed before ischemia. For the IPOST group, 3 consecutive cycles of 5 min reperfusion and 5 minutes of occlusion of the coronary arteries were performed before reperfusion. Pathological changes of lung tissue, lung wet-to-dry (W/D) weight ratio, inflammatory factors, oxidative stress indicators, apoptosis of lung cells and endoplasmic reticulum stress (ERS) protein were used to evaluate lung injury. RESULTS: After myocardial IR, lung injury worsened significantly, manifested by alveolar congestion, hemorrhage, structural destruction of alveolar septal thickening, and interstitial neutrophil infiltration. In addition, lung W/D ratio was increased, plasma inflammatory factors, including interleukin (IL)-6, tumor necrosis factor (TNF)-α, and IL-17A, were increased, malondialdehyde (MDA) activity of lung tissue was increased, and superoxide dismutase (SOD) activity was decreased after myocardial IR. It was accompanied by the increased protein expression levels of ERS-related protein glucose regulatory protein 78 (GRP78), CCAAT/enhancer-binding protein (C/EBP) homologous protein (CHOP), and caspase-12, and the increased apoptotic indices of lung tissues. CONCLUSION: IPOST can effectively improve myocardial IR-induced ALI by inhibiting ERS-induced apoptosis of alveolar epithelial cells.

Novel Technique for Box-Lesion Ablation of Atrial Fibrillation Combined with Off-Pump Coronary Surgery

ABSTRACT Introduction: We propose a new technique for box-lesion ablation combined with off-pump coronary artery bypass grafting for the treatment of patients with coronary artery disease and paroxysmal or persistent atrial fibrillation. Methods: Eight male patients with paroxysmal (n=2) or persistent atrial fibrillation (n=6) and coronary artery disease underwent box-lesion ablation combined with off-pump coronary artery bypass grafting. Box-lesion ablation was performed using a bipolar flexible clamping device with irrigated electrodes which was originally designed for thoracoscopic epicardial ablation. Results: Complete revascularization was performed in all patients. There were no deaths or major complications. At a median follow-up of 14 months, seven patients (87.5%) were in sinus rhythm. Conclusion: Box-lesion ablation can be easily and effectively combined with coronary artery surgery in an off-pump setting.

Impact of Coronary Artery Disease on The Outcomes of Catheter Ablation in Patients with Atrial Fibrillation

ABSTRACT Introduction: The objective of this study is to investigate the possible impact of coronary artery disease (CAD) on clinical outcomes of catheter ablation in patients with atrial fibrillation (AF). Methods: Patients with AF who underwent coronary computed tomography and catheter ablation were enrolled. The presence of stenotic severity and plaque, characteristics of coronary arteries, clinical data, and adverse outcomes of catheter ablation were analysed. Results: A total of 243 patients were enrolled, 100 (41%) patients with CAD. The CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, and sex category) score of AF patients with CAD was significantly (P<0.001) higher than of those without CAD. Presence of stenotic artery and plaques increased significantly with increase of CHA2DS2-VASc score (P<0.05). There was no significant (P=0.342) difference in AF recurrence between patients with and without CAD (30% versus 24%). Age, AF type, duration of AF, heart failure, CHA2DS2-VASc score, left ventricular ejection fraction, and left atrial diameter were significantly (P<0.05) correlated with AF recurrence in univariant analysis. Multivariable analysis revealed that duration of AF (hazard ratio [HR] 1.769), heart failure (HR 1.821), and left atrial diameter (HR 1.487, P=0.022) remained significant independent predictors of AF recurrence. Patients with AF and concomitant CAD were significantly (P=0.030) associated with a worse outcome. Conclusion: CAD concomitant with AF may be associated with a worse clinical outcome even though CAD does not significantly affect the risk of AF recurrence after ablation therapy.

Deep Sternal Wound Infection After Beating Heart Coronary Artery Bypass Surgery with Routine Use of Skeletonized Bilateral Internal Thoracic Artery

ABSTRACT Introduction: Despite its survival benefits, bilateral internal thoracic artery (BITA) grafting is not commonly utilized due to concerns over deep sternal wound infection (DSWI). We observed the role of routine use of BITA and off-pump coronary artery bypass grafting (OPCABG) in the incidence of DSWI and associated risk factors. Methods: Between January 2010 and December 2020, 1,207 patients were treated with isolated coronary artery bypass grafting. In all cases, OPCABG was attempted, and BITA was used whenever there was a need for a second arterial graft for the left coronary artery. DSWI was defined as a wound infection requiring surgical intervention and/or the administration of antibiotics. Multiple linear regression analysis was employed to model the risk of DSWI. Results: The incidence of DSWI was 0.58%. Mortality rate was higher in DSWI group than in no-DSWI group (28.57% vs. 1.25%; P<0.001). No significant difference in DSWI incidence was observed when BITA (70.6%) or single internal thoracic artery (29.4%) were used (P=0.680). The prevalence of diabetes (100% vs. 40.7%; P=0.001), hyperlipidemia (100% vs. 85.9%; P=0.045), and obesity (71.4% vs. 26.8%; P-0.017) was significantly elevated in DSWI group, when compared with no-DSWI group. Diabetes (P=0.0001), unstable angina (P=0.0064), previous myocardial infarction > 30 days (P=0.0009), left ventricular ejection fraction < 50% (P=0.0074), and emergency surgery (P=0.0002) were independent risk factors. Conclusion: The results of routine use of skeletonized BITA after OPCABG were satisfactory regarding DSWI incidence and operative mortality in a single-center experience.

Tortuosidade das Artérias Coronárias como um Novo Fenótipo para Isquemia sem Doença Arterial Coronariana / Coronary Tortuosity as a New Phenotype for Ischemia without Coronary Artery Disease

Resumo Fundamento As artérias coronárias tendem a ser mais tortuosas que outras artérias e acompanham os movimentos repetidos de flexão e relaxamento que ocorrem durante o ciclo cardíaco. A Tortuosidade das artérias Coronárias (TCor) causa alterações no fluxo coronariano, com uma redução na pressão de perfusão distal, o que pode levar à isquemia miocárdica. Objetivo Avaliar a associação entre TCor e isquemia miocárdica. Métodos Entre janeiro de 2015 e dezembro de 2017, 57 pacientes com angina e doença arterial coronariana não obstrutiva pela angiografia coronária invasiva (ACI) foram incluídos retrospectivamente. Variáveis angiográficas foram analisadas para avaliar a presença e grau de tortuosidade e correlacionadas com seus respectivos territórios vasculares na cintilografia de perfusão miocárdica com estresse. A TCor foi definida como artérias coronárias com três ou mais curvaturas com ângulos ≤ 90o, medidos durante diástole. Um nível de 5% foi estabelecido como estatisticamente significativo. Um nível de 5% foi definido como estatisticamente significativo. Resultados Um total de 17 homens e 40 mulheres foram incluídos (idade média de 58,3 anos). A TCor foi observada em 16 pacientes (28%) e em 24 das 171 artérias. Observou-se uma associação significativa entre TCor e isquemia na análise por artéria (p<0,0001). O fator angiográfico mais associado com isquemia foi o número de curvaturas em uma artéria epicárdica medido na sístole (p=0,021). Conclusão Este estudo mostrou uma associação da TCor com isquemia miocárdica em pacientes com artérias coronárias não obstruídas e angina. Observou-se uma relação entre número aumentado de curvaturas na artéria coronária medido por angiografia durante sístole e isquemia.

Abstract Background Coronary arteries tend to be more tortuous than other arteries and follow the repeated flexion and relaxation movements that occur during the cardiac cycle. Coronary tortuosity (CorT) leads to changes in coronary flow with a reduction in distal perfusion pressure, which could cause myocardial ischemia. Objective To assess the association between CorT and myocardial ischemia. Methods Between January 2015 and December 2017, 57 patients with angina and nonobstructive coronary artery disease detected by invasive coronary angiography (ICA) were retrospectively enrolled. Angiographic variables were analyzed to assess the presence and degree of tortuosity and correlated with their respective vascular territories on stress myocardial perfusion imaging (MPI). CorT was defined as coronary arteries with three or more bend angles ≤90°, measured during diastole. Statistical significance was determined at the 5% level. Results A total of 17 men and 40 women were enrolled (mean age 58.3 years). CorT was observed in 16 patients (28%) and in 24 of 171 arteries. There was a significant association between CorT and ischemia when analyzed per artery (p<0.0001). The angiographic factor most associated with ischemia was the number of bend angles in an epicardial artery measured at systole (p=0.021). Conclusion This study showed an association of CorT and myocardial ischemia in patients with unobstructed coronary arteries and angina. An increased number of coronary bend angles measured by angiography during systole was related to ischemia.

Multivessel coronary thrombosis and acute myocardial infarction associated to two genetic mutations for thrombophilia / Trombosis coronaria de múltiples vasos e infarto agudo de miocardio asociado a dos mutaciones genéticas para trombofilia

Abstract Several studies suggest that gene mutations from thrombophilia may constitute a significant risk factor for coronary artery disease, especially in young patients with normal coronaries and non-significant lesions. It is presented a case of a 42-year-old male patient who arrived at the emergency room due to an acute myocardial infarction. The electrocardiogram showed an ST elevation with upward convexity of 4 mm from V1 to V4 and of 1 mm at V5 and V6. Cardiac enzymes were positive (troponin I 8.4 ng/dl, normal range < 1 ng/dl). It was found septum and apical hypokinesia, with an ejection fraction of 44%. The culprit lesion of the infarction was treated with primary angioplasty, successfully dilating the left anterior descending coronary artery. However, spontaneous thrombi appeared at the middle third of the circumflex artery, an area without occlusive lesions previously. A full laboratory assessment for prothrombotic state diseases revealed positivity for gene mutations at A1298C from the methylene tetrahydropholate reductase (MTHFR) and plasminogen activator inhibitor-1 (PAI-1). Gene mutations at A1298C from the MTHFR and PAI-1 should be considered in young patients with acute coronary syndrome, mainly when thrombi are found in non-culprit arteries with no or non-significant coronary lesions.

Resumen Las mutaciones genéticas de la trombofilia pueden constituir un factor de riesgo significativo para la enfermedad de la arteria coronaria, especialmente en pacientes jóvenes con arterias coronarias normales y lesiones no significativas. Se presenta el caso de un paciente masculino de 42 años con infarto agudo de miocardio. El electrocardiograma demostró una elevación del ST con convexidad ascendente de 4 mm de V1 a V4 y de 1 mm en V5 y V6. Las enzimas cardíacas fueron positivas (troponina I 8.4 ng/dl, rango normal < 1 ng/dl). Se observó hipocinesia septal y apical con fracción de eyección de 44%. La lesión causante del infarto fue tratada con angioplastia primaria, dilatando con éxito la arteria coronaria descendente anterior. Sin embargo, aparecieron trombos espontáneos en el tercio medio de la arteria circunfleja, que previamente no presentaba lesiones ateroscleróticas oclusivas. Al evaluar enfermedades protrombóticas se reveló positividad para mutaciones del gen A1298C de la metileno tetrahidrofolato reductasa (MTHFR) y del inhibidor del activador del plasminógeno (PAI-1) del genotipo heterocigoto 675G. Las mutaciones en A1298C del gen MTHFR y del PAI-1 deben considerarse en jóvenes con síndrome coronario agudo, principalmente cuando se encuentran trombos en arterias no culpables sin lesiones coronarias significativas.

Nonatherosclerotic Giant Right Coronary Artery Aneurysm.

We present an unusual case of a 67-year-old woman with an incidental finding of a cardiac mass on a chest computed tomography. Coronary angiotomography confirmed the diagnosis of right coronary artery aneurysm, with 5.7×5.7 cm. The patient underwent aneurysm resection and coronary bypass surgery, with subsequent histologic study suggestive of arteritis sequelae. Giant coronary artery aneurysms have a high risk of complications and aneurysm exclusion must be beneficial. This is a rare condition that can also be part of a systemic inflammatory disease.

Giant Epicardial Cyst Eroding Left Ventricular Wall Mimicking as Simple Pericardial Cyst.

Epicardial cysts are rarer benign tumors than pericardial cysts. There have been few reports on surgical management of epicardial cysts. A 17-year-old normotensive boy presented with chest pain and palpitations, which on evaluation was found to be a mediastinal mass (pericardial cyst). Surgical resection of the cyst via thoracotomy was planned. The cyst was diagnosed as an epicardial cyst intraoperatively. However, due to the epicardial origin of cyst and posterior adhesions, resection was done via midline approach. The base was formed by visceral pericardium and eroding into myocardium of left ventricle, so the resection was concluded with on-pump surgery. In case of erroneous diagnosis or undesirable finding, a safer midline approach with on-pump surgery, as an alternative to minimally invasive approach for complicated epicardial cysts (erosion into ventricle/lying in close proximity to important structures or near to coronary arteries) should be considered.