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.
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.
In April 2012, a 25-year-old lady was seen in our clinic with the chief complaint of chest pain on exertion. The pain was central, crushing like, radiating to her neck, and was typically occurring on exertion. The patient noted that she experienced the pain especially in the mornings when she was rushing to catch her bus to work; the pain was worse when the weather was cold and if she had her breakfast. She was consistently experiencing the pain on exertion for the last 2 years. She did not have any risk factors for atherosclerotic coronary artery disease. Echocardiography findings were within normal limits. A treadmill exercise stress test was performed where she reached the target heart rate and complained of chest pain at peak exercise, but only nondiagnostic subtle upsloping ST depressions were observed. Because of low pretest probability of an obstructive coronary artery stenosis a conventional coronary angiography was not performed at that stage. With the possibility of a coronary artery anomaly the patient was referred for a computed tomography (CT) coronary angiography. The CT scan demonstrated anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva and the proximal course of the RCA between the aorta and pulmonary artery (►Fig. 1).When requestioned in depth, the patient did not report any history of syncope-presyncope or palpitations.While the patients symptoms were typical of angina, to aid in therapeutic decision making an objective criteria for ischemia was searched. A nuclear perfusion scan was performed that revealed a mild stress induced perfusion defect in the inferior segment of the left ventricle (►Fig. 2) (the interpreting physician was aware of patient's typical anginal symptoms and the presence of coronary anomaly, but not of the exact anatomy to avoid any bias). The decision was to refer patient for surgery. Robotic surgery through a minithoracotomy was performed and the right internal mammary artery was anastomosed to the distal RCA, the proximal RCA was tied off to prevent steal phenomenon. After an uneventful surgery, the patient recovered and her chest pain on exertion subsided completely. Two months after the operation, an exercise stress test was performed which confirmed complete relief of symptoms. A further nuclear perfusion study was not performed at that stage not to expose the patient to further radiation.Anomalous coronary arteries are rare congenital abnormalities; however, they may be life threatening.
Keywords► coronary anomaly ► ischemia ► computed tomography ► coronary artery disease ► angina
AbstractClinical 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 ar...
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