Volume 124 Number
design. Catheter exchanges and imaging add approximately 15 minutes to the atherectomy procedure. Furthermore, recollection and reconstruction of the three-dimensional spatial orientation is dependent on the operator’s memory, and realignment of the directional atherectomy device is still performed under flouroscopic guidance and relies on operator skill. These problems are being addressed by the development of a combined imagingatherectomy catheterlo and the emergence of three-dimensional on-line reconstruction of ultrasound images,lz The two cases presented here demonstrate how imaging yields important information about plaque distribution that can help guide directional atherectomy. The casesillustrate the technique for orienting the atherectomy cuts based on correlating the location of neighboring branches on the ultrasound images and the angiogram. REFERENCES 1. Waller
2.
3.
4.
5.
6
7
8,
9.
10.
11.
12.
Brief Communications
5
BF. Anatomy, histology, and pathology of the major epicardial coronary arteries relevant to echocardiographic imaging techniques. J Am Sot Echo 1989;2:232-52. Safian RD, Gelbfish JS, Erny RE, Schnitt SJ, Schmidt DA, Bairn DS. Coronary atherectomy: clinical, angiographic, and histological findings and observations regarding potential mechanisms. Circulation 1990;82:69-79. Garratt KN, Edwards WD, Kaufman UP, Vlietstra RE, Holmes DR. Differential histopathology of primary atherosclerotic and restenotic lesions in coronary arteries and saphenous vein bypass grafts: analysis of tissue obtained from 73 patients by directional atherectomy. J Am Co11 Cardiol 1991;17:442-8. Nobuyoshi M, Kimura T, Ohishi H, Horiuchi H, Nosaka H, Hamasaki N, Yokoi H, Kim K. Restenosis after percutaneous transluminal coronary angioplasty: pathologic observations in 20 patients. J Am Co11 Cardiol 1991;17:433-9. Garratt KN, Holmes DR Jr, Bell MR, Breshnahan JF, Kaufmann UP, Vlietstra RE, Edwards WD. Restenosis after directional coronary atherectomy: differences between primary atheromatous and restenosis lesions and influence of subintimal tissue resection. J Am Co11 Cardiol 1990;16:166571. Yock PG, Fitzgerald PJ, Linker DT, Angelsen BAJ. Intravascular ultrasound guidance for catheter-based coronary interventions. J Am Co11 Cardiol 1991;17:39B-45B. Yock PG, Fitzgerald PJ, White N, Linker DT, Angelsen BAJ. Intravascular ultrasound as a guiding modality for mechanical atherectomy and laser ablation. Echocardiography 1990;7:425-31. Ellis SG, DeCesare NB, Pinkerton CA, Whitlow P, King SB III, Ghazzal ZMB, Kereiakes DJ, Popma JJ, Menke KK, Top01 EcJ, Holmes DR. Relation of stenosis moruholoev and clinical presentation to the procedural results of directional coronary atherectomy. Circulation 1991;84:644-53. Popma ,JJ, DeCesare NB. Ellis SG, Holmes DR, Pinkerton CA, Whitlow P. King SB III, Ghassal ZMB, Top01 EJ, Garratt KN, Kereiakes DJ. Clinical, angiographic and procedural correlates of quantitative coronary dimensions after directional coronary atherectomy. J Am Co11 Cardiol 1991;1&1183-9. Yock PG, Fitzgerald PG, ,Jang YT, et al. Initial trials of a combined ultrasound/atherectomy catheter [Abstract]. J Am Co11 Cardiol 1990;7&17A. Fishman R, Kuntz R, Carrozza J, Pomerantz R, Diver D, Safian R, Bairn D. Results of coronarv atherectomv-bizeer is -” better [Abstract]. Circulation 1991;&:11-520. Rosenfeld K, Losordo DW, Ramaswamy K, Pastore .JO, Langevin RE, Razvi S, Kosowsky BD, Isner JM. Three-dimensional reconstruction of human and peripheral arteries from images recorded during two-dimensional intravascular ultrasound examination. Circulation 1991:84:1938-56.
1369
Reversal of silent myocardial ischemia by surgery for isolated anomalous origin of the left anterior descending coronary artery from the pulmonary artery Morgan Fu, MD,* JuiSung Hung, MD,a San-Jou Yeh, MD,a and Chau-Hsiung Chang, MDb Taipei,
Taiwan,
Republic
of China
Isolated anomalous origin of the left anterior descending artery (LAD) from the pulmonary artery is very rare. In the English literature, only 14 such cases that were proven either by aortography or selective coronary angiography have been rep0rted.l.s In this article we report the case of a 19year-old girl who was free of symptoms in whom, for the first time in this anomaly, the presence of silent myocardial ischemia and its reversal after surgery were documented by the results of serial treadmill exercise tests and thallium201 myocardial scans. The surgery consisted of use of left internal mammary artery graft to the LAD along with conventional ligation of the proximal LAD. A 19-year-old girl presented with a grade 4/6 pansystolic murmur that was accompanied by a thrill in the third intercostal space at the left sternal border. Results of cardiac examination were otherwise negative. Results of chest x-ray studies, ECG, and transthoracic two-dimensional echocardiography were normal. Because we suspected that a small ventricular septal defect was present, the patient underwent cardiac catheterization. Cardiac hemodynamics were normal. There was a 5 7; oxygen saturation increase in the pulmonary artery from the right ventricle, and the pulmonary-to-systemic flow ratio was 1.3. Left ventriculograms showed no evidence of ventricular septal defect. Aortograms revealed markedly dilated and tortuous right coronary and left circumflex arteries. The LAD was not visualized until the late frames were seen. Selective coronary angiograms showed that the left main coronary artery gave rise only to the circumflex artery (Fig. 1, A). Delayed visualization of the LAD occurred because the vessel was fed by collaterals from the circumflex and right coronary arteries, respectively (Fig. 1, B and C). The LAD drained into the main pulmonary artery. Its drainage site in the pulmonary artery was confirmed by contrast injection after selective cannulation of the LAD with an Amplatz right coronary catheter (Cordis Corp., Miami, Fla.) (Fig. 1, D). Treadmill exercise test with the Bruce protocol revealed horizontal ST-T depression (>2 mm) in precordial leads Vz to V’s,which started at 3 minutes of exercise. The changes resolved 5 minutes after the exercise was terminated at 9
From %he Section of Cardiology and hthe Section of Cardiovascular Surgery, Chang Gung Medical College and Chang Gung Memorial Hospital, Taipei. Taiwan, Republic of China, Reprint requests: Jui-Sung Hung, MD, Chang Gung Memorial Hospital, Tung Hwa North Rd., Taipei 105, Taiwan, Republic of China. 41414Q565
199
1370
Brief Communications
American
November 1992 Heart Journal
Fig. I. Selective coronary angiograms in right anterior oblique view. A, After contrast injection in the left main coronary artery, only the left circumflex artery (LCX) is visualized. White arrow indicates assumed normal location of the left anterior descending artery (LAD). B, The LAD being fed by abundant collaterals (c) from the LCX drains into the pulmonary artery (PA). Ao, Aorta; OM, obtuse marginal artery. C, The LAD being fed by abundant collaterals (c) from the right coronary artery (RCA) drains into the PA. D, Selective contrast injection in the PA allows visualization of the LAD.
minutes because of dyspnea. Thallium-201 myocardial scans immediately and 4 hours after exercise showed reversible perfusion defects in the anterior, apical, and lateral segments of the left ventricle and an irreversible defect in the septal area (Fig. 2, left punel). The patient underwent surgery, which consisted of a left internal mammary artery graft to the LAD and ligation of the LAD near its origin from the pulmonary trunk. Treadmill exercise testing 4 months after the surgery no longer showed ST-T abnormalities. Results of the resting ECG were normal. Repeat thallium-201 myocardial scan showed no perfusion
defects in the anterior, apical, and lateral segments but revealed early washout in the septal area (Fig. 2, right pcznel). Selective coronary angiography demonstrated a patent internal mammary graft to the LAD. The collaterals from the right and the left circumflex coronary arteries to the LAD were much less prominent. The patient had remained well, and results of the treadmill test (exercise time = 18 minutes) were normal at the most recent follow-up examination (3 years after the surgery). Patients with isolated anomalous origin of the LAD from the pulmonary artery may survive into adulthood because
Volume 124 Number 5
Brief Communications
After
Before Fig. 2. Thallium-201 myocardial Anterior view; EXER, immediately
1371
perfusion scans before and after surgery (see text for discussions). AN?“, after exercise; LAO, left anterior oblique view; LLAT, left lateral view.
of the presence of abundant collaterals from the left circumflex and right coronary arteries1 However, the collaterals may be insufficient to maintain adequate perfusion to the LAD territory. Among the 14 reported patients, 10 presented with angina, myocardial infarction, and/or congestive heart failure.le5 The other four patients who were free of symptoms presented with a heart murmur (systolic in one, continuous in two, and not specified in its characteristic in one patient) as in our patient. Results of resting EGGS were normal, and objective evidence of myocardial ischemia was sought only in the case of Wheatley et al.’ In that patient, results of treadmill exercise ECGs and the thallium-201 myocardial scan were normal. Our patient is unique in that although she had abundant collaterals from the circumflex and right coronary arteries, she had silent myocardial ischemia. Three types of revascularization surgery have been performed in 10 of 14 reported cases of isolated anomalous origin of the LAD from the pulmonary artery: (1) simple ligation of the proximal LAD in three cases,l* 3 (2) reimplantation of the LAD to the aorta in four cases,‘~‘~’ and (3) combination of ligation of LAD and coronary artery bypass with vein graft in three cases.‘.’ After the surgery, angina lessened in most patients, whereas improvements in myo-
cardial ischemia have not been objectively documented. In our patient, ligation of the proximal LAD and a novel surgical approach with left internal mammary artery graft to the LAD resulted in reversal of silent myocardial ischemia, as documented by serial treadmill exercise tests and thallium-201 myocardial scans.
REFERENCES
1. Roberts WC, Robinowitz M. Anomalous origin of the left anterior descending coronary artery from the puimonary trunk with origin of the right and left circumflex coronary arteries from the aorta. Am J Cardiol 1984;54:1381-3. 2. Evans JJ, Phillips JF. Origin of the left anterior descending coronary artery from the pulmonary artery: 3 year angiographic follow-up after saphenous vein bypass graft and proximal ligation. J Am Co11 Cardiol 1984:3:219-24. 3. Tamer-DF, Mallon SM, Garcia OL, Wclff GS Anomalous origin of the left anterior descending coronary artery from the pulmonary artery. AM HEART J 1984;10&341-5. 4. Wbeatley CE, Chalam NV, Demetropoulous KC. Anomalous origin of the left coronary arterial tree through three stemsone from the pulmonary trunk. Int J Cardiol 1985;9:238-42. 5. El Habbal MM, de Leval M, Somerville J. Anomalous origin of the left anterior descending coronary artery from the pulmonary trunk recognition in life and successful surgical t,reatment. Br Heart J 198860:90-2.
design. Catheter exchanges and imaging add approximately 15 minutes to the atherectomy procedure. Furthermore, recollection and reconstruction of the three-dimensional spatial orientation is dependent on the operator’s memory, and realignment of the directional atherectomy device is still performed under flouroscopic guidance and relies on operator skill. These problems are being addressed by the development of a combined imagingatherectomy catheterlo and the emergence of three-dimensional on-line reconstruction of ultrasound images,lz The two cases presented here demonstrate how imaging yields important information about plaque distribution that can help guide directional atherectomy. The casesillustrate the technique for orienting the atherectomy cuts based on correlating the location of neighboring branches on the ultrasound images and the angiogram. REFERENCES 1. Waller
2.
3.
4.
5.
6
7
8,
9.
10.
11.
12.
Brief Communications
5
BF. Anatomy, histology, and pathology of the major epicardial coronary arteries relevant to echocardiographic imaging techniques. J Am Sot Echo 1989;2:232-52. Safian RD, Gelbfish JS, Erny RE, Schnitt SJ, Schmidt DA, Bairn DS. Coronary atherectomy: clinical, angiographic, and histological findings and observations regarding potential mechanisms. Circulation 1990;82:69-79. Garratt KN, Edwards WD, Kaufman UP, Vlietstra RE, Holmes DR. Differential histopathology of primary atherosclerotic and restenotic lesions in coronary arteries and saphenous vein bypass grafts: analysis of tissue obtained from 73 patients by directional atherectomy. J Am Co11 Cardiol 1991;17:442-8. Nobuyoshi M, Kimura T, Ohishi H, Horiuchi H, Nosaka H, Hamasaki N, Yokoi H, Kim K. Restenosis after percutaneous transluminal coronary angioplasty: pathologic observations in 20 patients. J Am Co11 Cardiol 1991;17:433-9. Garratt KN, Holmes DR Jr, Bell MR, Breshnahan JF, Kaufmann UP, Vlietstra RE, Edwards WD. Restenosis after directional coronary atherectomy: differences between primary atheromatous and restenosis lesions and influence of subintimal tissue resection. J Am Co11 Cardiol 1990;16:166571. Yock PG, Fitzgerald PJ, Linker DT, Angelsen BAJ. Intravascular ultrasound guidance for catheter-based coronary interventions. J Am Co11 Cardiol 1991;17:39B-45B. Yock PG, Fitzgerald PJ, White N, Linker DT, Angelsen BAJ. Intravascular ultrasound as a guiding modality for mechanical atherectomy and laser ablation. Echocardiography 1990;7:425-31. Ellis SG, DeCesare NB, Pinkerton CA, Whitlow P, King SB III, Ghazzal ZMB, Kereiakes DJ, Popma JJ, Menke KK, Top01 EcJ, Holmes DR. Relation of stenosis moruholoev and clinical presentation to the procedural results of directional coronary atherectomy. Circulation 1991;84:644-53. Popma ,JJ, DeCesare NB. Ellis SG, Holmes DR, Pinkerton CA, Whitlow P. King SB III, Ghassal ZMB, Top01 EJ, Garratt KN, Kereiakes DJ. Clinical, angiographic and procedural correlates of quantitative coronary dimensions after directional coronary atherectomy. J Am Co11 Cardiol 1991;1&1183-9. Yock PG, Fitzgerald PG, ,Jang YT, et al. Initial trials of a combined ultrasound/atherectomy catheter [Abstract]. J Am Co11 Cardiol 1990;7&17A. Fishman R, Kuntz R, Carrozza J, Pomerantz R, Diver D, Safian R, Bairn D. Results of coronarv atherectomv-bizeer is -” better [Abstract]. Circulation 1991;&:11-520. Rosenfeld K, Losordo DW, Ramaswamy K, Pastore .JO, Langevin RE, Razvi S, Kosowsky BD, Isner JM. Three-dimensional reconstruction of human and peripheral arteries from images recorded during two-dimensional intravascular ultrasound examination. Circulation 1991:84:1938-56.
1369
Reversal of silent myocardial ischemia by surgery for isolated anomalous origin of the left anterior descending coronary artery from the pulmonary artery Morgan Fu, MD,* JuiSung Hung, MD,a San-Jou Yeh, MD,a and Chau-Hsiung Chang, MDb Taipei,
Taiwan,
Republic
of China
Isolated anomalous origin of the left anterior descending artery (LAD) from the pulmonary artery is very rare. In the English literature, only 14 such cases that were proven either by aortography or selective coronary angiography have been rep0rted.l.s In this article we report the case of a 19year-old girl who was free of symptoms in whom, for the first time in this anomaly, the presence of silent myocardial ischemia and its reversal after surgery were documented by the results of serial treadmill exercise tests and thallium201 myocardial scans. The surgery consisted of use of left internal mammary artery graft to the LAD along with conventional ligation of the proximal LAD. A 19-year-old girl presented with a grade 4/6 pansystolic murmur that was accompanied by a thrill in the third intercostal space at the left sternal border. Results of cardiac examination were otherwise negative. Results of chest x-ray studies, ECG, and transthoracic two-dimensional echocardiography were normal. Because we suspected that a small ventricular septal defect was present, the patient underwent cardiac catheterization. Cardiac hemodynamics were normal. There was a 5 7; oxygen saturation increase in the pulmonary artery from the right ventricle, and the pulmonary-to-systemic flow ratio was 1.3. Left ventriculograms showed no evidence of ventricular septal defect. Aortograms revealed markedly dilated and tortuous right coronary and left circumflex arteries. The LAD was not visualized until the late frames were seen. Selective coronary angiograms showed that the left main coronary artery gave rise only to the circumflex artery (Fig. 1, A). Delayed visualization of the LAD occurred because the vessel was fed by collaterals from the circumflex and right coronary arteries, respectively (Fig. 1, B and C). The LAD drained into the main pulmonary artery. Its drainage site in the pulmonary artery was confirmed by contrast injection after selective cannulation of the LAD with an Amplatz right coronary catheter (Cordis Corp., Miami, Fla.) (Fig. 1, D). Treadmill exercise test with the Bruce protocol revealed horizontal ST-T depression (>2 mm) in precordial leads Vz to V’s,which started at 3 minutes of exercise. The changes resolved 5 minutes after the exercise was terminated at 9
From %he Section of Cardiology and hthe Section of Cardiovascular Surgery, Chang Gung Medical College and Chang Gung Memorial Hospital, Taipei. Taiwan, Republic of China, Reprint requests: Jui-Sung Hung, MD, Chang Gung Memorial Hospital, Tung Hwa North Rd., Taipei 105, Taiwan, Republic of China. 41414Q565
199
1370
Brief Communications
American
November 1992 Heart Journal
Fig. I. Selective coronary angiograms in right anterior oblique view. A, After contrast injection in the left main coronary artery, only the left circumflex artery (LCX) is visualized. White arrow indicates assumed normal location of the left anterior descending artery (LAD). B, The LAD being fed by abundant collaterals (c) from the LCX drains into the pulmonary artery (PA). Ao, Aorta; OM, obtuse marginal artery. C, The LAD being fed by abundant collaterals (c) from the right coronary artery (RCA) drains into the PA. D, Selective contrast injection in the PA allows visualization of the LAD.
minutes because of dyspnea. Thallium-201 myocardial scans immediately and 4 hours after exercise showed reversible perfusion defects in the anterior, apical, and lateral segments of the left ventricle and an irreversible defect in the septal area (Fig. 2, left punel). The patient underwent surgery, which consisted of a left internal mammary artery graft to the LAD and ligation of the LAD near its origin from the pulmonary trunk. Treadmill exercise testing 4 months after the surgery no longer showed ST-T abnormalities. Results of the resting ECG were normal. Repeat thallium-201 myocardial scan showed no perfusion
defects in the anterior, apical, and lateral segments but revealed early washout in the septal area (Fig. 2, right pcznel). Selective coronary angiography demonstrated a patent internal mammary graft to the LAD. The collaterals from the right and the left circumflex coronary arteries to the LAD were much less prominent. The patient had remained well, and results of the treadmill test (exercise time = 18 minutes) were normal at the most recent follow-up examination (3 years after the surgery). Patients with isolated anomalous origin of the LAD from the pulmonary artery may survive into adulthood because
Volume 124 Number 5
Brief Communications
After
Before Fig. 2. Thallium-201 myocardial Anterior view; EXER, immediately
1371
perfusion scans before and after surgery (see text for discussions). AN?“, after exercise; LAO, left anterior oblique view; LLAT, left lateral view.
of the presence of abundant collaterals from the left circumflex and right coronary arteries1 However, the collaterals may be insufficient to maintain adequate perfusion to the LAD territory. Among the 14 reported patients, 10 presented with angina, myocardial infarction, and/or congestive heart failure.le5 The other four patients who were free of symptoms presented with a heart murmur (systolic in one, continuous in two, and not specified in its characteristic in one patient) as in our patient. Results of resting EGGS were normal, and objective evidence of myocardial ischemia was sought only in the case of Wheatley et al.’ In that patient, results of treadmill exercise ECGs and the thallium-201 myocardial scan were normal. Our patient is unique in that although she had abundant collaterals from the circumflex and right coronary arteries, she had silent myocardial ischemia. Three types of revascularization surgery have been performed in 10 of 14 reported cases of isolated anomalous origin of the LAD from the pulmonary artery: (1) simple ligation of the proximal LAD in three cases,l* 3 (2) reimplantation of the LAD to the aorta in four cases,‘~‘~’ and (3) combination of ligation of LAD and coronary artery bypass with vein graft in three cases.‘.’ After the surgery, angina lessened in most patients, whereas improvements in myo-
cardial ischemia have not been objectively documented. In our patient, ligation of the proximal LAD and a novel surgical approach with left internal mammary artery graft to the LAD resulted in reversal of silent myocardial ischemia, as documented by serial treadmill exercise tests and thallium-201 myocardial scans.
REFERENCES
1. Roberts WC, Robinowitz M. Anomalous origin of the left anterior descending coronary artery from the puimonary trunk with origin of the right and left circumflex coronary arteries from the aorta. Am J Cardiol 1984;54:1381-3. 2. Evans JJ, Phillips JF. Origin of the left anterior descending coronary artery from the pulmonary artery: 3 year angiographic follow-up after saphenous vein bypass graft and proximal ligation. J Am Co11 Cardiol 1984:3:219-24. 3. Tamer-DF, Mallon SM, Garcia OL, Wclff GS Anomalous origin of the left anterior descending coronary artery from the pulmonary artery. AM HEART J 1984;10&341-5. 4. Wbeatley CE, Chalam NV, Demetropoulous KC. Anomalous origin of the left coronary arterial tree through three stemsone from the pulmonary trunk. Int J Cardiol 1985;9:238-42. 5. El Habbal MM, de Leval M, Somerville J. Anomalous origin of the left anterior descending coronary artery from the pulmonary trunk recognition in life and successful surgical t,reatment. Br Heart J 198860:90-2.
