Patient: Female, 58Final Diagnosis: Anomalous origin of RCA from PA with reversible myocardial ischemia of the inferior wallSymptoms: Chest pain • shortness of breathMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Congenital defects/diseasesBackground:Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare congenital anomaly with an incidence of 0.002%.Case Report:A 58-year-old African American female with a history of diabetes mellitus, hyperlipidemia, and hypertension was evaluated for shortness of breath and chest heaviness. On physical examination, she was found to be morbidly obese. Her blood pressure was 160/90 mmHg. There were no carotid bruits or jugular venous distension. Cardiac auscultation showed distant heart sounds with no audible murmurs. Lower extremity examination showed +1 edema with weak pedal pulses. ECG showed non-specific ST segment and T-wave changes. Echocardiogram demonstrated dysfunction grade I with preserved ejection fraction. An adenosine nuclear study showed an area of reversible ischemia of the inferior wall. Selective left coronary angiography showed the left coronary artery (LCA) originating from the left sinus of Valsalva. From the LCA, the left anterior descending and the left circumflex coronary arteries arose in a typical course. The right coronary artery (RCA) was visualized in a retrograde fashion via collaterals originating from the left coronary system and it drained into the pulmonary artery. On aortic root angiography, the origin of the RCA could not be determined. The patient’s surgical risk was deemed unacceptably high and she was not considered a surgical candidate. Her symptoms were controlled conservatively.Conclusions:By reporting this case, we shed some light on a rare congenital anomaly involving the coronary arteries. Variable presentations have been described for ARCAPA, however, many patients remain asymptomatic. Diagnosis can be confirmed by coronary angiography. Surgical correction is the definitive treatment.
Key Clinical MessageEndovascular treatment of coronary subclavian steal syndrome is usually successful and safe. However, it might be lethally complicated, such as our case of STEMI and ventricular fibrillation during stent deployment. Early diagnosis of subclavian stenosis, intermittent dilations of balloons during stent deployment, and choosing the accurate stent size are suggested to avoid such complications.
The Takotsubo syndrome is a clinical entity consisting of transient, regional left ventricular (LV) contraction abnormalities in the absence of signifi cant epicardial coronary artery disease. Patients usually present with acute hemodynamic deterioration following an emotional or physical stress. The Takotsubo syndrome is uncommon among patients with end-stage renal disease (ESRD) and patients with congenital coronary abnormalities, such as right coronary artery (RCA) originating from left sinus of Valsalva. Here we describe a patient presenting with acute respiratory distress and anterolateral ST-T segment changes, with negative troponin-I and elevated levels of brain natriuretic peptide. Coronary angiography showed a right coronary artery arising from the left sinus of Valsalva without obstructive coronary artery disease, while ventriculography and echocardiogram showed fi ndings compatible with apical ballooning. Magnetic resonance imaging confi rmed the diagnosis of a biventricular Takotsubo cardiomyopathy. SOUHRNTako-tsubo (stresová) kardiomyopatie je klinickou jednotkou, při níž dochází k přechodným, regionálním abnormalitám stahů levé komory (LK) v nepřítomnosti významného postižení epikardiálních koronárních tepen. K lékaři se pacienti obvykle dostavují s akutním hemodynamickým zhoršením po emocionální nebo fyzické zátěži. U nemocných s terminálním selháním ledvin a u osob s vrozenými anomáliemi koronárních tepen, např. s pravou věnčitou tepnou odstupující z levého Valsalvova sinu, se tako-tsubo kardiomyopatie běžně nevyskytuje. V našem příspěvku popisujeme pacienta s akutní dechovou tísní a změnami anterolaterálního segmentu ST-T, negativním troponinem I a zvýšenými hodnotami natriuretického peptidu typu B. Koronarografi e zjistila anomální odstup pravé věnčité tepny z levého Valsalvova sinu bez přítomnosti obstrukční ischemické choroby srdeční, zatímco nálezy ventrikulografi ckého a echokardiografi ckého vyšetření ukazovaly na stresovou kardiomyopatii. Vyšetření magnetickou rezonancí potvrdilo diagnózu biventrikulární tako-tsubo kardiomyopatie.
Right ventricular (RV) myxomas are extremely rare, but may have dreadful clinical sequelae including pulmonary embolism (PE). We present a case of a patient who had an RV myxoma that was attached to the tricuspid valve, and therefore could not be resected completely during surgery, and remnants of the tumor were seen on transthoracic echocardiogram during post-operative follow-up. Five months after surgery, the patient had PE, which could be due to tumor emboli or thromboemboli. Since repeat surgical resection was not feasible, the patient was started on warfarin. The patient is doing well and has had no PE recurrence over the past 20 months of follow-up. We have complemented the current case report with a comprehensive literature search and review on RV myxomas associated with PE in order to shed light on this uncommon but potentially lethal disorder. We concluded that right-sided cardiac myxomas, including RV myxomas, should be considered while dealing with PE, particularly in young patients with no risk factors, and that follow-up with echocardiography after surgery is important due to the possibility of recurrence, especially if complete resection was difficult to perform.Plain Language SummaryPlain language summary available for this article.
A 61-year-old African American male with hypertension, endstage renal disease, on haemodialysis since four years. He was referred to cardiology for evaluation of his cardiac status prior to possible renal transplantation. During the time he was on dialysis, he initially had a left subclavian catheter for access. This was removed after an AV fistula was placed in the right arm. Due to thrombosis of the fistula, a right internal jugular tunnelled catheter was inserted and was in place for about three years. His most recent dialysis access was an AV fistula in the left forearm.Upon examination, patient's face was puffy and plethoric. His superficial neck, chest and abdominal wall veins were markedly Correspondence to: Medhat Farwati,
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