Case Presentations10/1/07

Case 1

69 y.o. female, presented with burning epigastric pain, radiating to her chest

PMHx

-CAD s/p stents 6 years ago at OSH, no records

-HTN

-HL

EKG: no acute changes

Labs: Trop 2.87, CK 260, Relative Index 67

Coronary Artery Fistula

Two types:

A. Coronary artery to Cardiac chambers, aka coronary-cameral fistulae

B. Coronary artery arteriovenous malfomation

Causes:

-Typically from abnormal embrynic development

-Also can be acquired:

-trauma (stab, gunshot)

-invasive cardiac procedures i.e. pacemaker implantation, cardiac biopsy

Coronary Artery Fistula

Coronary Artery Fistula

7 patients, all female w/ mean age 51, with demonstrated coronary-LV microfistulae from all three major arteries

-6 w/ h/o stable angina, 3 with history of MI

-no coronary disease by angiogram

Coronary sinus lactate was measured during atrial pacing by successive increases in heart rate.

-6 of the 7 patients had elevated coronary sinus lactate consistent with myocardial ischemia

Case 2

32 y.o. female, h/o congenital heart disease -1979, 4 y.o., surgical resection of subaortic

membrane -1985, 10 y.o., large muscle bundle resected from

subaortic region betwween right and left coronary cusp; supravalvular stenosis enlarged using a piece of Gortex.

-Lost to follow up after 1993, seen in Adult Cardiology Clinic in 2007 with complaints of DOE and CP.

Anomalous RCA

Anomalous RCAPresentation:

-Sudden death

-ischemia

-syncope

-asymptomatic

Etiology of Symptoms -cyclic compression of RCA between aorta and pulmonary artery -distorted, slit-like ostium of RCA -exercise-induced compression of the commissure between the right and left coronary cusps.

Treatment:

-For symptomatic patients, preferred treatment is surgical; options include:

-SVG or arterial bypass

-re-implantation

-coronary unroofing

45 y.o.h/o DM admitted with recurrent abdominal ascitis requiring large volume paracentesis every week

-negative liver bx

-scheduled for exploratory laporotomy

-pre-op TTE performed

Case 3

Case 4

45 y.o. female with h/o DM, HTN and positive outpatient stress test, referred for LHC.