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.