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Chapter 21. Coronary and Left Ventriculographic Procedures: Special Considerations

A 59-year-old man is admitted to the emergency department with chest pain that has mostly resolved. The ECG shows nonspecific ST-T changes. Of the following, what is an indication for urgent coronary angiography?

A. Frequent PVCs

B. Elevated troponin

C. Decreased ejection fraction on echocardiography

D. Hypotension corrected by IV fluids

The correct answer is B

This patient has a non-ST segment elevation myocardial infarction (NSTEMI) and the timing of catheterization will be related to his event risks. Other indications for catheterization as noted in the 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines for coronary arteriography are summarized below:

  1. Patients with stable angina or asymptomatic individuals with high-risk criteria on noninvasive testing.

  2. Patients resuscitated from sudden cardiac death or having threatening ventricular arrhythmias.

  3. Patients with unstable coronary syndromes of all varieties, including acute myocardial infarction as a preamble to primary angioplasty and those who developed complications of acute infarction.

  4. Patients with ischemia at low levels of exercise in the recovery phase of myocardial infarction.

  5. Patients with suspected or known coronary artery disease undergoing preoperative evaluation.

During coronary angiography, the operator notes a very long ‘left main’ segment. Which is the most common coronary anomaly associated with this finding?

A. Right coronary artery (RCA) originating from the Left coronary sinus

B. Left main originating from the right coronary sinus

C. High take-off of the RCA

D. Circumflex artery originating from the right coronary artery

E. Single coronary originating the non-coronary cusp

The correct answer is D

The most common coronary anomaly is origin of the circumflex artery arising from the right coronary cusp (See Fig. 21-11). The vessel may come from the right coronary artery itself or separately just anterior to the right coronary ostium. Commonly, it arises in a caudal direction, and the multipurpose catheter is frequently helpful in selective cannulation of this vessel.


Figure 21-11. Cineangiographic frames of anomalous circumflex artery (arrow) from the origin of the right coronary artery. Left panel is LAO projection. Right panel is RAO projection.



When the right coronary artery arises from the left coronary cusp, it is anterior to the left coronary ostium ...

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