Annotations

Single coronary artery with myocardial infarction and mitral regurgitation

Single coronary artery, without other congenital cardiac defects, has been thought an interesting, but unimportant finding because its peripheral distribution is usually adequate for myocardial needs. We studied a patient with single coronary artery, myocardial infarction, and mitral regurgitation. A 45-year-old man entered the hospital for congestive heart failure with mitral regurgitation. The electrocardiogram and vectorcardiogram showed an old anterior myocardial infarction and atria1 fibrillation. Cardiac catheterization revealed severe mitral regurgitation with mild pulmonary hypertension. Selective coronary angiography showed the right coronary artery to be a large dominant vessel (Figs. 1 and 2). Almost immediately after its origin, a large branch arose which represented the left coronary artery. It coursed posterior to the aorta and divided into a marginal circumflex artery, a very small left anterior descending, and several diagonal branches which followed the usual distribution (R-2-A in Ogden’s classification”). No atherosclerosis was seen. At surgery, the left anterior descending artery was hypoplastic. A ruptured chorda tendinea of the anterior mitral leaflet was found. The diffusely thickened mitral valve was replaced by a porcine xenograft. Microscopic examination revealed focal vascularization consistent with rheumatic valvulitis. Anomalies of the coronary arteries occur in 2.85 per 1,000 autopsies.’ A large series of coronary angiograms yielded an incidence of 1.9 per 1,000 studies.‘!’ Single coronary artery comprises 4.5 per cent of congenital coronary anomalies.’ The number of reported cases has greatly increased with the widespread use of coronary angiograms. Myocardial infarction has occurred in 22 cases.‘. :‘, *. h-‘.5. Ii. ‘!’ Of these, 15 were male and five were female with an average age of 53 years. Fifteen of 22 (73 per cent) patients with infarction had a single vessel originating from the right sinus which is unusual since single coronary arteries generally originate equally from the right and left sinuses of Valsalva. Angina pectoris with ischemic ST segment depression may occur with a single coronary artery in the absence of atheromatous obstruction.‘n Furthermore, atria1 pacing and measurement of coronary arteriovenous lactate differences have shown ischemic ST segment depression”’ and lactate production”’ ?” in this situation. Moreover, focal myocardial necrosis and fibrosis may be associated with clinical and electrocardiographic evidence of severe myocardial infarction without atheromatous occlusion of coronary arteries when a portion of the myocardium is supplied by a small or hypoplastic vessel.’ The absence in our patient of atheromatous obstruction in the coronary artery with evidence of myocardial infarction by electrocardiogram, vectorcardiogram, and left ventriculography led us to conclude that myocardial fibrosis occurred

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Fig. 1. Selective injection of the right coronary artery in the 30 degree left anterior oblique projection. RCA = right coronary artery; LCA = left coronary artery; LAD = left anterior descending; D = diagonal; CXM = circumflex marginal; PD = posterior descending; PL = posterolateral branches.

Fig. 2. Aortic supravalvular injection in the 30 degree left anterior oblique projection. Ao = aorta; RCA = right coronary artery; LCA = left coronary artery.

January,

1978, Vol. 95, No. 1

Annotations from

chronic

ischemia

due

to

the

underdeveloped

blood

7.

SUPPlY. Rheumatic valvulitis has occurred in seven cases of single the rheumatic etiology coronary artery.‘. ‘. ” Iti In our patient, is supported by diffuse thickening of both mitral cusps at the time of surgery and by the presence of microscopic fibrosis. The association of rheumatic valvulitis with myocardial infarction in our patient was apparently fortuitous. Nevertheless, the combination of chronic mitral regurgitation, perhaps made worse by a ruptured chorda, and left ventricular dysfunction from the myocardial infarction, led to congestive heart failure in this patient. In summary, myocardial infarction in single coronary artery is quite unusual and may be due to underdeveloped blood supply with secondary fibrosis. Maury C. Newton, Jr., M.D. Lawrence R. Burwell, M.D. Cardiology Division University of Virginia School of Medicine Charlottesville, Va. 22901

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12. 13. 14.

15. REFERENCES 1.

2. 3. 4. 5.

6.

Alexander, R. W., and Griffith, G. C.: Anomalies of the coronary arteries and their clinical significance, Circulation 24:800, 1956. Ogden, J. A.: Congenital anomalies of the coronary arteries, Am. J. Cardiol. 25474, 1970. Hillestad, L., and Eie, H.: Single coronary artery, Acta Med. Stand. 189:409, 1971. Roberts, J. T., and Loobe, S. D.: Congenital single coronary artery in man, AM. HEART J. 34:187, 1947. Ogden, J. A., and Goodyer, A. V. N.: Patterns of distribution of the single coronary artery, Yale J. Biol. Med. 25:11, 1970. Spring, D. A., and Thomson, J. H.: Severe atherosclerosis in the “single coronary artery,” Am. J. Cardiol. 31:662, 1973.

Of plastic

materials

in clinical

17. 18.

19.

20.

medicine

The trend toward greater use of plastic materials in clinical practice has advantages and disadvantages. The convenience and advantage of discarding plastic devices after use and the assurance of individual use are definite. The lack of need to clean and sterilize these materials is a definite cost advantage. However, there are at least two plastic devices that are important and frequently used in hospitals which are certainly traumatizing and injurious to patients, namely, the plastic needle and the plastic nasogastric tube. Both are traumatiiing, especially thd plastic nasogastric tube. This tube is so rigid and inflexible that it produces pressure necrosis at every turn it makes on its course from the nares to the stomach. Even worse, its leading edge is often so sharp and so rigid that it scrapes and tears the surfaces of the nasopharynx as it is passed into the stomach, especially in the unconscious patient. The resultant hemorrhage can be large, and the blood is aspirated into the respiratory tract, which leads to complications associated with choking and the development of aspiration pneumonia. In a recent instance at a local hospital,

American Heart Journal

16.

Halperih, I. C., Penny, J. L., and Kennedy, R. J.: Single coronary artery, Am. J. Cardiol. 19:424, 1967. Tomary, A., and Reid, J. D.: Single coronary artery with myocardial infarction and AV block, Arch. Pathol. 99:143, 1975. Sharbaugh, M. D., and White, R. S.: Single coronary artery, analysis of the anatomic variation, clinical importance, and report of five cases, J.A.M.A. 230:243, 1974. Fort+ N. J., and Roberts, W. C.: Congenital atresia of the main left coronary artery, Am. J. Med. 50:385, 1971. Krumbhaar, E. B., and Ehrlich, W. E.: Varieties of single coronary artery in man, occurring as isolated cardiac anomalies, Am. J. Med. Sci. 196:407, 1938. Dent, E. D., and Fisher, R. S.: Single coronary artery: report of two cases, Ann. Intern. Med. 44:1024, 1956. Swan, P., and Fitzpatrick, M.: Single coronary artery, Br. Heart J. 18:457, 1954. Tremouroux, J, Brasaeur, L., Meersseman, F., and Vavenne, F.: Infarctus myocardique auriculaire et ventriculaire dans us Cas de Coronaire Unique, Acta Cardiol. 14:425, 1959. Allen, G. L., and Snider, T. H.: Myocardial infarction with a single coronary artery, Arch. Intern. Med. 117:261, 1966. Smith, J. C.: Review of single coronary artery with report of two cases, Circulation 1:1168, 1950. Davis, L. P., and Compton, V.: Congenital absence of the left coronary artery, Med. Times 90:293, 1962. Chapman, D. W., and Peterson, P. K.: Unusual forms of coronary disease as demonstrated by percutaneous coronary angiography, Med. Rec. Annals (Houston) 57:320, 1964. Chaitman, B. R., Lesperance, J., Saltiel, J., and Bourassa, M. G.: Clinical, angiographic and hemodynamic findings in patient with anomalous origin of the coronary arteries, Circulation 53:122, 1976. Pachinger, 0. M., Vanden Hoven, P., and Judkins, M. P.: Single coronary artery-A cause of angina pectoris, Eur. J. Cardiol. 2/2:161, 1974.

an area of pressure necrosis in a patient bled so profusely that the patient became exsanguinated as he quietly lay in his bed asleep during the night. He was found dead in bed early the next morning. There is available the much tested and superior soft Levine rubber nasogastric tube. Why not use it? It is a simple and extremely useful and important clinical device; but, unfortunately, some physicians do not know how to use any nasogastric tube. There is a need to learn more about the advantages and disadvantages of plastic clinical devices. The devices are all extremely useful and necessary in the practice of medicine, but who buys plastic devices and why? We are overly committed to plastics for insufficient reasons. Some plastic things are good but many are bad. At least, let’s not use those that hurt our patients. G. E. Burch, M.D. Tulane University School of Medicine and Charity Hospital of Louisiana New Orleans, La.

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Single coronary artery with myocardial infarction and mitral regurgitation.

Annotations Single coronary artery with myocardial infarction and mitral regurgitation Single coronary artery, without other congenital cardiac defe...
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