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The de Winter electrocardiogram (ECG) pattern indicates severe stenosis or occlusion of the left anterior descending artery (LAD). We present a 72-year-old female with 1.5-h chest pain. Angiography and optical coherence tomography (OCT) revealed 90 % LAD stenosis with plaque rupture, but no ST-segment elevation in the precordial leads. The de Winter pattern, characterized by upsloping ST-segment depression in V1-V6, appeared only in lead V2. Following successful percutaneous coronary intervention (PCI), the de Winter pattern disappeared. This case underscores the significance of the de Winter pattern in one precordial lead, necessitating prompt angiography and PCI for improved patient outcomes.

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OBJECTIVE: Myocardial bridging (MB) occurs when a coronary artery, commonly the left anterior descending (LAD), has an intramyocardial course. In symptomatic patients who fail medical therapy, surgical unroofing can provide symptomatic relief by improving coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing. METHODS: There were 34 patients with an LAD-MB who failed medical therapy and underwent robotic totally endoscopic, off-pump unroofing between January 2017 and October 2023. Patients were evaluated by a multidisciplinary team and underwent provocative coronary angiography to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients for midterm follow-up, including completion of a modified Seattle Angina Questionnaire (SAQ). RESULTS: The mean age was 48 ± 8 years, and 56% were female patients. One patient had prior septal myectomy via sternotomy. All patients had significant dobutamine Pd/Pa reduction on preoperative coronary angiography. One patient had atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. The mean procedure time was 140 ± 69 min. All were completed totally endoscopically off-pump without intraoperative conversions. The mean MB length was 4.5 ± 1.4 cm, and the mean depth was 1.6 ± 0.9 cm. Of the patients, 76% were extubated in the operating room. The mean intensive care unit and hospital length of stay were 0.97 ± 0.58 and 1.73 ± 1.1 days, respectively. There were no mortalities or strokes. There was 1 postoperative take-back for bleeding. At midterm follow-up (19 ± 14 months), 28 patients completed the SAQ; 86% reported "much less angina" during activity compared with before surgery, and 93% reported taking no antianginal medication since surgery. CONCLUSIONS: In appropriate patients with hemodynamically significant LAD-MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. Further studies are warranted.

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The Dressler-de Winter sign is an electrocardiogram (ECG) pattern characterized by upsloping ST-segment depression in leads V1-V6 followed by tall, hyperacute T waves, typically indicating an occlusion of the left anterior descending artery (LAD). We present a case involving an inferoposterior ST-segment elevation myocardial infarction (STEMI) with a variant of the de Winter sign, a concept of ST-segment continuum in the precordial leads. Despite initial ECG findings suggesting right coronary artery (RCA) or left circumflex artery (LCX) involvement, coronary angiography confirmed occlusion of the wrap-around LAD distal to the first septal (S1) and diagonal branch (D1) and revealed a left dominant system accompanied by a small non-dominant RCA. This case highlights the diagnostic complexity in accurately localizing the culprit artery in STEMI cases exhibiting the de Winter sign. Understanding such ECG variants is crucial for analyzing the mechanisms of acute ischemia and ensuring accurate assessment of the culprit vessel for effective revascularization.

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Coronary artery anomalies (CAA) define a wide array of congenital abnormalities that stem from the origin, course, and distribution of coronary arteries. CAAs can lead to severe complications such as arrhythmias, myocardial ischemia, and even sudden cardiac death. We describe the case of a 58-year-old female who presented to the emergency department with chest discomfort and shortness of breath and received a workup for acute coronary syndrome. She underwent a cardiac catheterization, which incidentally found an anomalous left anterior descending artery with a right sinus of Valsalva origin, an absent left circumflex coronary artery, and a dominant right coronary artery of unusually large caliber and distribution. There were no identified atherosclerotic plaques. This anomalous configuration of the coronary arteries is exceptionally rare. She required medical management with daily oral acetylsalicylic acid 81 mg, atorvastatin 80 mg, twice daily metoprolol tartrate 50 mg, and hydrocodone/acetaminophen 7.5mg/325 mg oral tablet to be taken every 4 h, as needed for severe pain. Despite optimal medical management, she continued to have chronic angina. A surgical evaluation by a cardiovascular surgeon deemed her anomaly to be inoperable.

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The dual left anterior descending (LAD) artery is a rare anatomic variant of the LAD artery that refers to the duplication of the LAD into a short and long LAD. These two vessels, differentiated based on their lengths, ultimately provide blood supply to the areas normally covered by the LAD. In this case report, we describe an unusual case of a type IV dual LAD system with an additional finding of a separate origin for the short LAD and left circumflex (LCx) artery. These two findings have not been reported together in the literature previously. During diagnostic procedures like coronary angiography or when interpreting cardiac imaging, awareness of these anomalies prevents confusion with pathological conditions such as coronary artery disease or stenosis. Additionally, it is crucial for cardiologists and surgeons to identify these aberrant vessels to avoid any wrongful interventions.

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Coronary artery disease is the leading global cause of mortality and Fractional Flow Reserve (FFR) is widely regarded as the gold standard for assessing coronary artery stenosis severity. However, due to the limitations of invasive FFR measurements, there is a pressing need for a highly accurate virtual FFR calculation framework. Additionally, it's essential to consider local haemodynamic factors such as time-averaged wall shear stress (TAWSS), which play a critical role in advancement of atherosclerosis. This study introduces an innovative FFR computation method that involves creating five patient-specific geometries from two-dimensional coronary angiography images and conducting numerical simulations using computational fluid dynamics with a three-element Windkessel model boundary condition at the outlet to predict haemodynamic distribution. Furthermore, four distinct boundary condition methodologies are applied to each geometry for comprehensive analysis. Several haemodynamic features, including velocity, pressure, TAWSS, and oscillatory shear index are investigated and compared for each case. Results show that models with average boundary conditions can predict FFR values accurately and observed errors between invasive FFR and virtual FFR are found to be less than 5%.

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The isolated origin of the left coronary artery (LCA) ostium at the level of the sinotubular junction (STJ) has been described previously. Congenital absence of the left circumflex (LCx) coronary artery has also been documented with superdominant right coronary arterial circulation, either in the presence or absence of coronary artery obstruction. Earlier literature has linked the association of an absent LCx coronary artery with a superdominant right coronary artery (SRCA) but not with a hypoplastic LCx coronary artery (HLCx). The present case report details the case of a 37-year-old thin, athletic male with the risk factors of diabetes and hypertension who was admitted to the emergency unit of our hospital for losing consciousness while bicycling in the street. The current report establishes a combined association of LCA anomaly origin at STJ level along with HLCx and SRCA condition with the burden of mild to moderate coronary artery disease involving proximal left anterior descending artery, LCx, and mid right coronary artery in the literature for the first time. Further, the case report advocated that the presented case carries the risk of malignancy. Hence, with the advancement of modern imaging technologies, computed tomography angiography should be the first choice of imaging modality rather than coronary angiography to prevent fatal outcomes. Interventional cardiologists, cardiothoracic surgeons, and radiologists should have properly defined knowledge of coronary artery anatomy and associated pathology, as it is important for coronary cannulation or any coronary interventions.

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INTRODUCTION: The Agatston coronary artery calcification score (CACS) is an assessment index for coronary artery calcification (CAC). This study aims to explore the characteristics of CAC in end-stage kidney disease (ESKD) patients and establish a predictive model to assess the risk of severe CAC in patients. METHODS: CACS of ESKD patients was assessed using an electrocardiogram-gated coronary computed tomography (CT) scan with the Agatston scoring method. A predictive nomogram model was established based on stepwise regression. An independent validation cohort comprised of patients with ESKD from multicentres. RESULTS: 369 ESKD patients were enrolled in the training set, and 127 patients were included in the validation set. In the training set, the patients were divided into three subgroups: no calcification (CACS = 0, n = 98), mild calcification (0 < CACS ≤ 400, n = 141) and severe calcification (CACS > 400, n = 130). Among the four coronary branches, the left anterior descending branch (LAD) accounted for the highest proportion of calcification. Stepwise regression analysis showed that age, dialysis vintage, ß-receptor blocker, calcium-phosphorus product (Ca × P), and alkaline phosphatase (ALP) level were independent risk factors for severe CAC. A nomogram that predicts the risk of severe CAC in ESKD patients has been internally and externally validated, demonstrating high sensitivity and specificity. CONCLUSION: CAC is both prevalent and severe in ESKD patients. In the four branches of the coronary arteries, LAD calcification is the most common. Our validated nomogram model, based on clinical risk factors, can help predict the risk of severe coronary calcification in ESKD patients who cannot undergo coronary CT analysis.

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Coronary artery fistulas (CAFs) are abnormal communications of coronary arteries whereby venous circuits bypass the normal capillaries within the myocardium. Coronary artery-to-cardiac vein fistula is the third most common type of CAF, accounting for 7% of cases. Electrocardiographic-gated cardiac computed tomographic (CT) angiography has emerged as a noninvasive alternative method of choice for diagnosis due to its high spatial and temporal resolution and short acquisition time. Herein, we aimed to present a left anterior descending coronary artery opened into the greater cardiac vein at the distal level, consistent with a coronary artery-to-cardiac vein fistula in a 77-year-old woman. Teaching point: Coronary artery CT angiography provides a detailed evaluation of the complex anatomy of coronary artery fistula without the need for invasive methods.

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Dual left anterior descending artery (LAD) is a rare congenital coronary artery anomaly with a prevalence of approximately 1% in the general population. To date, 10 types of dual LAD artery anomalies have been reported. Among these, type 4 is one of the rarest. Knowledge and recognition of the dual LAD artery are important for correct diagnosis and planning of coronary bypass surgery and percutaneous coronary intervention. We report a case of a 59-year-old male with type 4 dual LAD artery who presented with dyspepsia and sweating for several months and had approximately 50%-70% stenosis in a major diagonal branch off the short LAD artery.

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We present a case of a patient with inferior myocardial infarction (MI) and anomalous left main artery originating from the right coronary sinus. The left main artery and right coronary artery originated from the right coronary sinus but with separate ostia. The patient underwent revascularization of the right coronary artery with balloon angioplasty and a drug-eluting stent. Despite being rare, these anomalies can be life-threatening depending on the course of the artery, and when atherosclerotic disease is present, a revascularization strategy can be challenging. Knowing the existence of the left main artery anomaly is important to choose the right guide catheter to achieve successful cannulation and decrease the risk of complications, radiation exposure, and contrast usage.

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Dual anterior interventricular artery is a rare type of CHD. We reported a fifteen-year-old girl who underwent CT angiography that demonstrated one anterior interventricular artery from aorta and another from pulmonary artery.

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BACKGROUND: Intravascular ultrasound (IVUS) studies show that one-quarter of left anterior descending (LAD) arteries have a myocardial bridge. An MB may be associated with stent failure when the stent extends into the MB. OBJECTIVES: The aim of this study was to investigate: 1) the association between an MB and chronic total occlusion (CTO) in any LAD lesions; and 2) the association between an MB and subsequent clinical outcomes after percutaneous coronary intervention in LAD CTOs. METHODS: A total of 3,342 LAD lesions with IVUS-guided percutaneous coronary intervention (280 CTO and 3,062 non-CTO lesions) were included. The primary outcome was target lesion failure (cardiac death, target vessel myocardial infarction, definite stent thrombosis, and ischemic-driven target lesion revascularization). RESULTS: An MB by IVUS was significantly more prevalent in LAD CTOs than LAD non-CTOs (40.4% [113/280] vs 25.8% [789/3,062]; P < 0.0001). The discrepancy in CTO length between angiography and IVUS was greater in 113 LAD CTOs with an MB than 167 LAD CTOs without an MB (6.0 [Q1, Q3: 0.1, 12.2] mm vs 0.2 [Q1, Q3: -1.4, 8.4] mm; P < 0.0001). Overall, 48.7% (55/113) of LAD CTOs had a stent that extended into an MB after which target lesion failure was significantly higher compared to a stent that did not extend into an MB (26.3% vs 0%; P = 0.0004) or compared to an LAD CTO without an MB (26.3% vs 9.6%; P = 0.02). CONCLUSIONS: An MB was more common in LAD CTO than non-CTO LAD lesions. If present, approximately one-half of LAD CTOs had a stent extending into an MB that, in turn, was associated with worse outcomes.

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BACKGROUND: Resting coronary flow velocity (CFV) in the mid-distal left anterior descending coronary artery can be easily assessed with transthoracic echocardiography. In this observational study, the authors sought to assess the relationship between resting CFV, CFV reserve (CFVR), and outcome in patients with chronic coronary syndromes. METHODS AND RESULTS: In a prospective multicenter study design, the authors retrospectively analyzed 7576 patients (age, 66±11 years; 4312 men) with chronic coronary syndromes and left ventricular ejection fraction ≥50% referred for dipyridamole stress echocardiography. Recruitment (years 2003-2021) involved 7 accredited laboratories, with interobserver variability <10% for CFV measurement at study entry. Baseline peak diastolic CFV was obtained by pulsed-wave Doppler in the mid-distal left anterior descending coronary artery. CFVR (abnormal value ≤2.0) was assessed with dipyridamole. All-cause death was the only end point. The mean CFV of the left anterior descending coronary artery was 31±12 cm/s. The mean CFVR was 2.32±0.60. During a median follow-up of 5.9±4.3 years, 1121 (15%) patients died. At multivariable analysis, resting CFV ≥32 cm/s was identified by a receiver operating curve as the best cutoff and was independently associated with mortality (hazard ratio [HR], 1.24 [95% CI, 1.10-1.40]; P<0.0001) together with CFVR ≤2.0 (HR, 1.78 [95% CI, 1.57-2.02]; P<0.0001), age, diabetes, history of coronary surgery, and left ventricular ejection fraction. When both CFV and CFVR were considered, the mortality rate was highest in patients with resting CFV ≥32 cm/s and CFVR ≤2.0 and lowest in patients with resting CFV <32 cm/s and CFVR >2.0. CONCLUSIONS: High resting CFV is associated with worse survival in patients with chronic coronary syndromes and left ventricular ejection fraction ≥50%. The value is independent and additive to CFVR. The combination of high resting CFV and low CFVR is associated with the worst survival.

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Purpose This study compares the dosimetry and dose sparing of cardiac substructures in single isocenter and dual isocenter RapidArc™ (Varian Medical Systems, Palo Alto, California, United States) radiotherapy planning for synchronous bilateral breast cancer. Methodology Six synchronous bilateral breast cancer (SBBC) patients received adjuvant radiation with the prescribed dose of 40.05 Gy in 15 fractions to the planning target volume (PTV) without local lymph nodal regions. PTVs and organs at risk (OARs), including both lungs, esophagus, spinal cord, heart, and left anterior descending coronary artery (LAD), both atria and ventricles were contoured. Single isocentric RapidArc (SIRA) and dual isocentric RapidArc (DIRA) plans were made for each patient and dosimetric differences between these two techniques were evaluated. Results There was no statistically significant difference in conformity index (CI) values between SIRA and DIRA plans, with 0.9681±0.01 and 0.9721±0.01 (p=0.505), respectively. SIRA planning showed superior homogeneity with homogeneity Index (HI) values of 0.0999±0.01 compared to DIRA planning with HI values of 0.1640±0.12 (p=0.230). The mean LAD dose of SIRA was valued higher than that of DIRA planning. Lower mean doses were obtained for both lungs in SIRA plans compared to DIRA plans. Meanwhile, doses to the right atrium, left atrium, left ventricle, right ventricle, and esophagus showed no statistical significance between these two techniques, except in the spinal cord. Conclusion Both SIRA and DIRA plans have satisfactory outcomes in sparing OARs. Meanwhile, SIRA techniques have less setup time and overall machine time.

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Key Clinical Message: Dual coronary cameral fistulae (CCFs) are rare abnormal connections between coronary arteries and heart chambers. Management of CCFs remains a topic of debate, emphasizing the need for individualized approach based on presentation. Abstract: We present a rare case of dual coronary cameral fistulae originating from the mid-left anterior descending (LAD) and the mid-right coronary artery (RCA) with drainage into the left ventricle, diagnosed incidentally during coronary angiography.

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We report flow characteristics of an in-situ internal thoracic artery (LITA) graft with angiographically competitive flow to the left anterior descending artery (LAD), based upon intraoperative transit-time flow measurement (TTFM) during coronary artery bypass grafting with aortic valve replacement (AVR) and during re-AVR seven years later. Although intraoperative TTFM of the graft showed lower mean flow and higher pulsatility index, suggesting inadequate anastomosis, fast Fourier transform (FFT) analysis of TTFM waveforms presented gradual waning of the amplitude, as shown in patent grafts. FFT analysis of the TTFM waveforms is helpful to judge the patency of LITA to LAD, even with competitive flow. Learning objective: The internal thoracic artery (LITA) graft to left anterior descending artery (LAD) with angiographically competitive flow shows gradual waning of the amplitude on fast Fourier transform (FFT) analysis of the transit-time flow measurement (TTFM) waveforms, although lower mean graft flow, higher pulsatility index, and higher systolic reversal flow may suggest inadequate anastomosis. FFT analysis of the TTFM waveforms is useful to judge the patency of LITA to LAD, even with competitive flow.