Coronary artery dilatation is an uncommon finding and is incidentally found during diagnostic coronary angiography or at necropsy.
The pathogenesis of dilatation of coronary arteries is still not very
well understood and therapeutic strategies are not clear. It is useful to know the difference between aneurysm and ectasia. In this
report we demonstrate the diagnostic workup of an asymptomatic
patient with a remarkable snakelike dilatation of the right coronary
artery with unique convolute. For the first time we used intracoronary injection and simultaneous echocardiographic visualization
of contrast agent (Sonovue) to proof a fistula to the coronary sinus.
Like our patient, most of the patients are asymptomatic in absence
of coronary artery disease and we decided on a conservative approach because of his very complex anatomy
Surgery for aneurysmal right coronary fistula and constrictive pericarditis Abdulsalam Taha
CRCM, March 2014
View on scirp.org
Abstract:
Coronary artery fistula (CAF) is a direct communication between a coronary artery and the lumen of any of the cardiac chambers, the coronary sinus, the pulmonary artery, the superior vena cava or the proximal pulmonary veins. The majority of these fistulas are congenital in origin although they may occasionally be detected after cardiac surgery. Congenital CAF is a rare anomaly and aneurysmal formation in the fistula is even rarer. Majority of CAF are isolated lesions, however, congenital or acquired heart diseases may coexist. Herein, we report a case of huge congenital aneurysmal right CAF connected to the right atrium in an Iraqi man of 62 associated with tuberculous effusive-constrictive pericarditis to whom off pump pericardiectomy was performed followed by ligation of right coronary artery and vein graft implantation to its posterior descending branch under cardiopulmonary bypass. To the best of our knowledge, such association was not previously reported. CAF can be repaired surgically with minimum risk and excellent outcome. Surgery is advised whenever coronary fistula is diagnosed unless it is very small to avoid the potential complications.
Key words: coronary artery fistula, ectasia, aneurysm, pericarditis, pericardiectomy
CHAPrER 21 r Cardiovascular SystemUsing the CPT and ICD-10.docxsleeperharwell
CHAPrER 21 r Cardiovascular System
Using the CPT and ICD-10-CM/ICD-9-CM manuals, code the fallowing:
41. Valvuloplasty of the aortic valve using transventdcular dilation with
cardiopulmonary bypass.
CPT Code:
,/
i+
y'+2. Xeptacement aortic valve, with cardiopulmonary bypass, with prosthetic
valve.
CPT Code:
43. Valvuloplasty, tricuspid valve, with ring insertion.
CPT Code:
d p"puirof a coronary arteriovenous fistula, without cardiopulmonary
bypass.
CPT Code:
d *r"rnal electrical cardioversion.
CPT Code:
47. Percutaneous balloon angioplasty; one coronary vessel.
CPT Code:
t*{. Cpp.(Cardiopulmonary resuscitatio4).
CPT Code:
49. Electrocardiogram with interpretation and report only.
CPT C6de:
C rrrurs graft of the common carotid-ipsilateral iriternal carotid artery
using synthetic vein.
CPT Code:
5L. Ligation of temporal artery.
CPT Code:
Odd-numbered answers are located in Appendtx B, while the full arrrwer key ts only avallable tn the TEACE
Instructor Resources on Evolve.
Copyrlght @ 2015 by Saunde$, an imprint of Elsevier Irrc. All rights reseryed.
45. Routine ECG with
components.
CPT Code:
L2leads with both the professional and technical
CHAPTER 21
a
I Cardiovascular System
,/
v52. Ligation of a common iliac vein.
CPT Code:
53. Open ftansluminal balloon angioplasty aorta.
CPT Code:
,An. Coronary artery bypass, single artery, for coronary atherosclerosis of
native coronary artery in a transplanted heart.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
four veins, no arteries. Diagnosis of acute55. Coronary artery bypass,
coronary insufficiency.
& cpr code(s):
& tco-ro-cM code(s):
(& ICD-q-cM Code(s):
teriovenous fistula of a'Iower extremity.
CPT Code(s):
ICD-10-CM Code(s):
ICD-9-CM Code(s):
& Ur". to declde number of codes necessary to conectly answer the question.
Odd-numbered ansyyers are located in Appendix B, while the full anxwer key is only avallable in the TEACH
Instructof Resources on Evolve,
&
&
@
/
g/SO. nepair of injury to intra-abdominal blood vessel, inferior vena cava,
hepatic vein, with a vein graft.
& cpr code(s):
& tco-ro-cM Code(s):
(& ICD-o-cM code(s):
57. Percutaneous insertion of an intra-aortic balloon assist device due to
initial episode of acute myocardial infarction apd cardiogenic shock.
& cpr code(s):
& tco-ro-cM code(s):
/ (& ICD-o-cM code(s):
I
VSa. nepair of a traumatic ar
Copy,right @ 2015 by Saunders, an impdnt of Elsevier Inc. Al1 rights teserved.
59. Repair congenital
CHAITTER 21 r
atrial septal defect, secundum, with
Cardiovasculat System
bypass and patch.
& cpr code(s):
& Ico-to-cM code(s):
.1& lco-o-cM code(s): )
ffiO. Repair of a patent ductus arteriosus by division on a 16-year-old patient.
& cpr code(s):
& Ico-ro-cM code(s):
1& Ico-e-cM code(s):
61. Reoperation of one arterial coronary bypass graft and one vein bypass
graft for arteriosclerosis of native arteries, 3 months following the initial
procedure.
& cpr Code(s):
& tco-ro-c.
Surgery for aneurysmal right coronary fistula and constrictive pericarditis Abdulsalam Taha
CRCM, March 2014
View on scirp.org
Abstract:
Coronary artery fistula (CAF) is a direct communication between a coronary artery and the lumen of any of the cardiac chambers, the coronary sinus, the pulmonary artery, the superior vena cava or the proximal pulmonary veins. The majority of these fistulas are congenital in origin although they may occasionally be detected after cardiac surgery. Congenital CAF is a rare anomaly and aneurysmal formation in the fistula is even rarer. Majority of CAF are isolated lesions, however, congenital or acquired heart diseases may coexist. Herein, we report a case of huge congenital aneurysmal right CAF connected to the right atrium in an Iraqi man of 62 associated with tuberculous effusive-constrictive pericarditis to whom off pump pericardiectomy was performed followed by ligation of right coronary artery and vein graft implantation to its posterior descending branch under cardiopulmonary bypass. To the best of our knowledge, such association was not previously reported. CAF can be repaired surgically with minimum risk and excellent outcome. Surgery is advised whenever coronary fistula is diagnosed unless it is very small to avoid the potential complications.
Key words: coronary artery fistula, ectasia, aneurysm, pericarditis, pericardiectomy
CHAPrER 21 r Cardiovascular SystemUsing the CPT and ICD-10.docxsleeperharwell
CHAPrER 21 r Cardiovascular System
Using the CPT and ICD-10-CM/ICD-9-CM manuals, code the fallowing:
41. Valvuloplasty of the aortic valve using transventdcular dilation with
cardiopulmonary bypass.
CPT Code:
,/
i+
y'+2. Xeptacement aortic valve, with cardiopulmonary bypass, with prosthetic
valve.
CPT Code:
43. Valvuloplasty, tricuspid valve, with ring insertion.
CPT Code:
d p"puirof a coronary arteriovenous fistula, without cardiopulmonary
bypass.
CPT Code:
d *r"rnal electrical cardioversion.
CPT Code:
47. Percutaneous balloon angioplasty; one coronary vessel.
CPT Code:
t*{. Cpp.(Cardiopulmonary resuscitatio4).
CPT Code:
49. Electrocardiogram with interpretation and report only.
CPT C6de:
C rrrurs graft of the common carotid-ipsilateral iriternal carotid artery
using synthetic vein.
CPT Code:
5L. Ligation of temporal artery.
CPT Code:
Odd-numbered answers are located in Appendtx B, while the full arrrwer key ts only avallable tn the TEACE
Instructor Resources on Evolve.
Copyrlght @ 2015 by Saunde$, an imprint of Elsevier Irrc. All rights reseryed.
45. Routine ECG with
components.
CPT Code:
L2leads with both the professional and technical
CHAPTER 21
a
I Cardiovascular System
,/
v52. Ligation of a common iliac vein.
CPT Code:
53. Open ftansluminal balloon angioplasty aorta.
CPT Code:
,An. Coronary artery bypass, single artery, for coronary atherosclerosis of
native coronary artery in a transplanted heart.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
four veins, no arteries. Diagnosis of acute55. Coronary artery bypass,
coronary insufficiency.
& cpr code(s):
& tco-ro-cM code(s):
(& ICD-q-cM Code(s):
teriovenous fistula of a'Iower extremity.
CPT Code(s):
ICD-10-CM Code(s):
ICD-9-CM Code(s):
& Ur". to declde number of codes necessary to conectly answer the question.
Odd-numbered ansyyers are located in Appendix B, while the full anxwer key is only avallable in the TEACH
Instructof Resources on Evolve,
&
&
@
/
g/SO. nepair of injury to intra-abdominal blood vessel, inferior vena cava,
hepatic vein, with a vein graft.
& cpr code(s):
& tco-ro-cM Code(s):
(& ICD-o-cM code(s):
57. Percutaneous insertion of an intra-aortic balloon assist device due to
initial episode of acute myocardial infarction apd cardiogenic shock.
& cpr code(s):
& tco-ro-cM code(s):
/ (& ICD-o-cM code(s):
I
VSa. nepair of a traumatic ar
Copy,right @ 2015 by Saunders, an impdnt of Elsevier Inc. Al1 rights teserved.
59. Repair congenital
CHAITTER 21 r
atrial septal defect, secundum, with
Cardiovasculat System
bypass and patch.
& cpr code(s):
& Ico-to-cM code(s):
.1& lco-o-cM code(s): )
ffiO. Repair of a patent ductus arteriosus by division on a 16-year-old patient.
& cpr code(s):
& Ico-ro-cM code(s):
1& Ico-e-cM code(s):
61. Reoperation of one arterial coronary bypass graft and one vein bypass
graft for arteriosclerosis of native arteries, 3 months following the initial
procedure.
& cpr Code(s):
& tco-ro-c.
Retrograde access to seal a large coronary perforationRamachandra Barik
The sealing of a large vessel coronary perforation during percutaneous coronary intervention typically requires the
deployment of 1 or more covered stents. A novel approach to seal a life-threatening perforation caused by unnoticed
wire-exit and balloon dilation, utilizing retrograde techniques, without a covered-stent is described.
Vertebral artery pseudo-aneurysms and dissections are known to occur as a result of mechanical
manipulations of the cervical region, traumatic injury, spontaneously and iatrogenic injury because of central
venous catheterization. Central venous lines have become an integral part of patient care, but they are
not without complications. Vertebral artery injury (leading to pseudo-aneurysm and dissection) is one of
the rarer complications of central venous catheter placement. We report a case of inadvertent vertebral
artery catheterization during a dialysis catheter placement which subsequently demonstrated arterial
blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery catheterization.
It was successfully treated with open surgical technique by the vascular surgeon because of the size of
catheter and subsequent requirement of artery repair. There were no neurological sequelae. Open surgical
repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudo-aneurysms
has been described with promising outcomes, but long-term results are lacking. This case report describes
the rare iatrogenic event of vertebral artery injury and reviews its etiology, diagnosis, complications, and management.
Coronary Artery Bypass Grafting in Dextrocardia. Is There a Challenge?semualkaira
Dextrocardia with situs inversus is a rare congenital condition, even though known since 1606 when Fabricious first described it. The incidence of coronary artery disease in this group of patients is the same as in general population. First Coronary Artery Bypass Grafting (CABG) in patient with Dextrocardia was performed in 1980. Performing the procedure it is a very challenging task for the surgeon in the terms of planning, choice of conduits, and simultaneous presentation of other congenital conditions.
Coronary Artery Bypass Grafting in Dextrocardia. Is There a Challenge?semualkaira
Dextrocardia with situs inversus is a rare congenital condition, even though known since 1606 when Fabricious first described it. The incidence of coronary artery disease in this group of patients is the same as in general population. First Coronary Artery Bypass Grafting (CABG) in patient with Dextrocardia was performed in 1980
Coronary Artery Bypass Grafting in Dextrocardia. Is There a Challenge?semualkaira
Dextrocardia with situs inversus is a rare congenital condition, even though known since 1606 when Fabricious first described it. The incidence of coronary artery disease in this group of patients is the same as in general population. First Coronary Artery Bypass Grafting (CABG) in patient with Dextrocardia was performed in 1980. Performing the procedure it is a very challenging task for the surgeon in the terms of planning, choice of conduits, and simultaneous presentation of other congenital conditions.
A Road from Coronary to Pulmonary: A Rare Imaging Presentationpateldrona
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Its association with Pulmonary Atresia is considered to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases, systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation.
A Road from Coronary to Pulmonary: A Rare Imaging Presentationclinicsoncology
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Its association with Pulmonary Atresia is considered to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases, systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation. Such patients commonly undergo a Cardiac CT as an imperative pre-operative investigation for detailed information of these collaterals which helps plan further management. Here, we present a Case Report of an adult female patient with Pentalogy of Fallot wherein, a Cardiac CT showed the presence of dilated coronary-to-pulmonary collateral circulation. i.e. CAPA apart from the normally visualized MAPCA’s, an extremely rare occurrence.
A Road from Coronary to Pulmonary: A Rare Imaging Presentationgeorgemarini
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Its association with Pulmonary Atresia is considered to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases, systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation. Such patients commonly undergo a Cardiac CT as an imperative pre-operative investigation for detailed information of these collaterals which helps plan further management. Here, we present a Case Report of an adult female patient with Pentalogy of Fallot wherein, a Cardiac CT showed the presence of dilated coronary-to-pulmonary collateral circulation. i.e. CAPA apart from the normally visualized MAPCA’s, an extremely rare occurrence.
A Road From Coronary To Pulmonary: A Rare Imaging Presentationkomalicarol
Tetralogy of Fallot (TOF) is the most common cyanotic congenital
heart disease. Its association with Pulmonary Atresia is considered
to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases,
systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation. Such patients
commonly undergo a Cardiac CT as an imperative pre-operative
investigation for detailed information of these collaterals which
helps plan further management. Here, we present a Case Report of
an adult female patient with Pentalogy of Fallot wherein, a Cardiac CT showed the presence of dilated coronary-to-pulmonary collateral circulation. i.e. CAPA apart from the normally visualized
MAPCA’s, an extremely rare occurrence.
Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Servi...Dr. Muhammad Bin Zulfiqar
Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Services Institute of Medical Sciences Services Hospital Lahore
In this presentation we will discuss the role of imaging in TA.
Managment Of Long Term Care In Era Covid-19komalicarol
COVID-19 gives the chance to address long-term care categories
that are sometimes disregarded and undervalued, such as nursing
and residential homes, as well as homecare. Each method of delivering long-term care must meet the highest possible standards
of ongoing care and quality of life. More study and evaluation are
needed to aid decision-making and policy-making, particularly on
the cost-effectiveness and cost-quality elements for each country,
region, or system.
Renal failure and Quality ofLlife Indicators in Kidney Transplantationkomalicarol
Health-related quality of life (HRQL) contains many aspects of
patients' health such as physical, psychological, social functioning
and a general well-being. Progress in renal transplantation and immunosuppressive therapies have increased significantly in recent
decades, resulting in allograft survival rates at one year is now
over 90%. Numerous clinical trials have established the importance of quality of life in a variety of diseases, and it is extremely
popular to evaluate quality of life in clinical trials as a measure of
patients' subjective state of health. The purpose of the study was
to identify factors associated with quality of life after renal transplantation.
More Related Content
Similar to Loops Around the Heart – A Giant Snakelike Right Coronary Artery Ectasia with Unique Convolute and Fistula to the Coronary Sinus
Retrograde access to seal a large coronary perforationRamachandra Barik
The sealing of a large vessel coronary perforation during percutaneous coronary intervention typically requires the
deployment of 1 or more covered stents. A novel approach to seal a life-threatening perforation caused by unnoticed
wire-exit and balloon dilation, utilizing retrograde techniques, without a covered-stent is described.
Vertebral artery pseudo-aneurysms and dissections are known to occur as a result of mechanical
manipulations of the cervical region, traumatic injury, spontaneously and iatrogenic injury because of central
venous catheterization. Central venous lines have become an integral part of patient care, but they are
not without complications. Vertebral artery injury (leading to pseudo-aneurysm and dissection) is one of
the rarer complications of central venous catheter placement. We report a case of inadvertent vertebral
artery catheterization during a dialysis catheter placement which subsequently demonstrated arterial
blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery catheterization.
It was successfully treated with open surgical technique by the vascular surgeon because of the size of
catheter and subsequent requirement of artery repair. There were no neurological sequelae. Open surgical
repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudo-aneurysms
has been described with promising outcomes, but long-term results are lacking. This case report describes
the rare iatrogenic event of vertebral artery injury and reviews its etiology, diagnosis, complications, and management.
Coronary Artery Bypass Grafting in Dextrocardia. Is There a Challenge?semualkaira
Dextrocardia with situs inversus is a rare congenital condition, even though known since 1606 when Fabricious first described it. The incidence of coronary artery disease in this group of patients is the same as in general population. First Coronary Artery Bypass Grafting (CABG) in patient with Dextrocardia was performed in 1980. Performing the procedure it is a very challenging task for the surgeon in the terms of planning, choice of conduits, and simultaneous presentation of other congenital conditions.
Coronary Artery Bypass Grafting in Dextrocardia. Is There a Challenge?semualkaira
Dextrocardia with situs inversus is a rare congenital condition, even though known since 1606 when Fabricious first described it. The incidence of coronary artery disease in this group of patients is the same as in general population. First Coronary Artery Bypass Grafting (CABG) in patient with Dextrocardia was performed in 1980
Coronary Artery Bypass Grafting in Dextrocardia. Is There a Challenge?semualkaira
Dextrocardia with situs inversus is a rare congenital condition, even though known since 1606 when Fabricious first described it. The incidence of coronary artery disease in this group of patients is the same as in general population. First Coronary Artery Bypass Grafting (CABG) in patient with Dextrocardia was performed in 1980. Performing the procedure it is a very challenging task for the surgeon in the terms of planning, choice of conduits, and simultaneous presentation of other congenital conditions.
A Road from Coronary to Pulmonary: A Rare Imaging Presentationpateldrona
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Its association with Pulmonary Atresia is considered to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases, systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation.
A Road from Coronary to Pulmonary: A Rare Imaging Presentationclinicsoncology
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Its association with Pulmonary Atresia is considered to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases, systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation. Such patients commonly undergo a Cardiac CT as an imperative pre-operative investigation for detailed information of these collaterals which helps plan further management. Here, we present a Case Report of an adult female patient with Pentalogy of Fallot wherein, a Cardiac CT showed the presence of dilated coronary-to-pulmonary collateral circulation. i.e. CAPA apart from the normally visualized MAPCA’s, an extremely rare occurrence.
A Road from Coronary to Pulmonary: A Rare Imaging Presentationgeorgemarini
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Its association with Pulmonary Atresia is considered to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases, systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation. Such patients commonly undergo a Cardiac CT as an imperative pre-operative investigation for detailed information of these collaterals which helps plan further management. Here, we present a Case Report of an adult female patient with Pentalogy of Fallot wherein, a Cardiac CT showed the presence of dilated coronary-to-pulmonary collateral circulation. i.e. CAPA apart from the normally visualized MAPCA’s, an extremely rare occurrence.
A Road From Coronary To Pulmonary: A Rare Imaging Presentationkomalicarol
Tetralogy of Fallot (TOF) is the most common cyanotic congenital
heart disease. Its association with Pulmonary Atresia is considered
to be the most severe form, the diagnosis of which plays an important role in determination of the treatment protocol. In such cases,
systemic vascular channels called Major Aortopulmonary Collateral Arteries (MAPCA’s) develop from aorta and its major branches to supply and maintain the pulmonary circulation. Such patients
commonly undergo a Cardiac CT as an imperative pre-operative
investigation for detailed information of these collaterals which
helps plan further management. Here, we present a Case Report of
an adult female patient with Pentalogy of Fallot wherein, a Cardiac CT showed the presence of dilated coronary-to-pulmonary collateral circulation. i.e. CAPA apart from the normally visualized
MAPCA’s, an extremely rare occurrence.
Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Servi...Dr. Muhammad Bin Zulfiqar
Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Services Institute of Medical Sciences Services Hospital Lahore
In this presentation we will discuss the role of imaging in TA.
Managment Of Long Term Care In Era Covid-19komalicarol
COVID-19 gives the chance to address long-term care categories
that are sometimes disregarded and undervalued, such as nursing
and residential homes, as well as homecare. Each method of delivering long-term care must meet the highest possible standards
of ongoing care and quality of life. More study and evaluation are
needed to aid decision-making and policy-making, particularly on
the cost-effectiveness and cost-quality elements for each country,
region, or system.
Renal failure and Quality ofLlife Indicators in Kidney Transplantationkomalicarol
Health-related quality of life (HRQL) contains many aspects of
patients' health such as physical, psychological, social functioning
and a general well-being. Progress in renal transplantation and immunosuppressive therapies have increased significantly in recent
decades, resulting in allograft survival rates at one year is now
over 90%. Numerous clinical trials have established the importance of quality of life in a variety of diseases, and it is extremely
popular to evaluate quality of life in clinical trials as a measure of
patients' subjective state of health. The purpose of the study was
to identify factors associated with quality of life after renal transplantation.
A case of childhood Burkitt's lymphoma with gingival swelling as the first sy...komalicarol
Burkitt's lymphoma (BL) is a highly infiltrative malignant lymphoma caused by germinal B-cell differentiation. There are several oral symptoms of BL, including tooth mobility, pain, gingival swelling, maxillofacial swelling and pain, and facial sensory
disturbances. In this paper, we report a case of BL in a 4-year-old
child who initially presented with gingival swelling. The diagnosis of BL/leukemia (stage IV) was confirmed by the bone marrow
examination, bone marrow flow cytometry, and B lymphocytoma
mutation gene screening test. After chemotherapy, the general
condition improved, and then there was swelling and pain in the
right cheek. Considering the recurrence of the disease, the patient
died half a year later. This case is characterized by BL with oral
symptoms as the first symptom, emphasizing the important role of
physicians in early detection of systemic disease
Neuropsychiatric Profiles of Brivaracetam: A Literature Reviewkomalicarol
Anti-seizure medications (ASMs) can cause cognitive or behavioral adverse drug reactions, which is a significant consideration
when selecting an appropriate ASM. Brivaracetam (BRV) is a
newer synaptic vesicle protein 2A ligand, which is expected to
have less neuropsychiatric adverse effects due to its mechanism of
action. To understand the impact of BRV on cognition and behavior compared with other ASMs, we conducted literatures searching
from PubMed and MEDLINE databases. After the screening process, a total of two animal studies, one randomized controlled trial, one pooled-analysis of clinical trials, one controlled study and
nine observational studies were included. Animal studies showed
that BRV did not worsen cognition or behavior performance in rodents. Human studies showed that BRV had less cognitive adverse
events compared with other second or third generation ASMs. In
addition, currently available evidence suggests that behavioral disturbance is less common with BRV compared with levetiracetam.
This review revealed that BRV has a limited impact on cognition
and behavior. For patients who are intolerant to levetiracetam
and have levetiracetam-related behavioral side effects, switching
to BRV could be beneficial. However, the heterogeneity between
studies makes the quality of the evidence weak and further trials
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Starting with December 2019 the medical world has faced a
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a comparable symptomatology (SARS- severe acute respiratory syndrome, MERS- Middle East severe acute respiratory syndrome), subsequently named SARS CoV-2, while the disease it
causes- COVID-19. The virus is of animal origin and through an
intermediate host (probably also a mammal) it suffered genetic
changes thus acquiring human cells receptors. In consequence,
SARS CoV-2 virus affects both children and even more frequently where it determines more severe clinical forms of disease. In
children, COVID-19 has various clinical forms, from asymptomatic ones to severe ones, complicated by multisystem inflammatory
syndrome (MIS-C Multisystem Inflammatory Syndrome – Child
or PIMS - TS (Paediatric Multisystem Inflammatory Syndrome
temporally associated with COVID-19) that sometimes can lead
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Asymptomatic patients with severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), are silent carriers of the disease. We
aimed to characterize their dynamics of disease occurrence, viral
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minimally symptomatic patients from Sri Lanka during the first
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Vonlay; A paradigm shift in post endodontic restoration: A case report.komalicarol
Porcelain veneers have long been a popular restorative option that
have evolved into a well- accepted treatment that can be fabricated
in various ways. Onlays are another common treatment modality
used in contemporary dentistry to restore large areas of decay and
to replace old restorations. With the availability of newer highstrength materials such as lithium disilicate and processing technologies like CAD/CAM and heat pressing, dental professionals
are now able to produce highly esthetic, high-strength restorations
that blend seamlessly with the natural dentition while also withstanding posterior occlusal forces. A tooth more complex restoration is required after endodontic treatment when compared to normal tooth restoration, because of factors such as extensive caries,
post-treatment root canal dentin and even the economics condition
of the patient.One such design proposed by Dr.Ronald E Goldstein
is “Veenerlay”or “Vonlay”. Vonlay is a blend of an onlay with an
extended buccal veneer surface for use in premolar region, where
there is sufficient enamel present to bond. This restorative option
requires a much less invasive preparation than a full coverage
crown but provides the same structural benefits. Thus, the aim of
this case report is to present a case of Vonlay following endodontic
treatement of lower mandibular premol
A COVID Journey in Diabetes: T1D Diabetes Patient 44 years - Winning in Insul...komalicarol
Complications of Hypoglycaemia, Hypoglycaemia
and Neuroglycopenia are often encountered by patients treated
with insulin. It is feared by patients and families often leading to
emotional and mental scars and can affect lifestyle and confidence.
Hypoglycaemia can occur in premature babies, persons with hypopituitarism and Addison’s Disease. Low blood glucose can affect
athletes and the elderly leading to falls. Cases are individual and
often difficult for families, clinicians, lawyers and courts to understand.
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Although papillary thyroid carcinoma is a relatively common form of malignancy, metastatic spread to the skull
is exceptional. Here, we report a case of papillary thyroid carcinoma revealed by frontal skull metastasis.
Diabetes and Covid-19 Pandemic - A T1 Patient Perspective - Derek C Beattykomalicarol
A patient treated and cared for by NHS Scotland and NHS England
the author has in his 44 years T1D Diabetes journey experienced
surgery provided by the NHS by way of Vitrectomy, Ophthalmic
laser and correction, and Orthopedic knee correction following
a balance issue associated with IV antibiotic treatment for Otitis
Externa and Osteomyelitis associated with long term T1 Diabetes
with neuropathy. Interestingly IV antibiotic treatment led to glycemic issues offering explanation as to why on occasion glycaemia
abnormalities can occur with antibiotic treatment for infection.
Growth Charts-Curves of Children's Height - How to Construct Themkomalicarol
A person born in 1990, for example, grew to one year old on his/
her birth day in 1991 and 17 years old in 2007. No one grows
to their 17 or 20 years old instantaneously. It takes a long-capricious time of mental and physical activities to grow. As regards
children’s milk consumption, for example, school lunch programs
were put into in practice on national scale only in the late 1990s.
Those in their late adolescence in 2007 were not the beneficiaries
of free milk, when they were in primary school.
Dermatological health in the COVID-19 erakomalicarol
COVID-19 and its impact on dermatological health was reviewed
from theoretical and statistical frameworks in the present study. A
cross-sectional and retrospective work was documented with a selection of sources indexed to Scopus, considering the period from
2019 to 2022, as well as the search by keywords. Approaches were
discussed in order to outline a comprehensive model that considered the differences between the parties involved, as well as their
relationships in a risk context. The proposal contributes to the state
of the question in terms of the prediction of contingencies derived
from the probability and affectation of dermatological health
The Importance of Framing at the Beginning of an Review Dialoguekomalicarol
Long-term care of patients with chronic conditions in general practice rarely focuses on the treatment process. A specific interaction
tool, the Review Dialogue (RD), has been developed to integrate
patients’ health-related problems/risks as well as coping strategies
and to agree upon shared treatment objectives assuming that periodical RDs will help to achieve them. Initiated by the GP, the RD
changes the role expectations of the patient and doctor. Therefore,
the framing of the encounters is of particular importance.
Early detection of interstitial lung disease in asymptomatic patients with 2-...komalicarol
Pulmonary involvement is a common manifestation of Dermatomyositis (DM), the most frequent histologic pattern being Interstitial Lung Disease (ILD) which is a major contributor to
morbidity and mortality in these patients. Therefore, this disease
should be investigated and it is essential to perform pulmonary
function tests (PFTs) and High-Resolution Computed Tomography
(HRCT) early in the course of the disease to make a definitive
diagnosis. Nowadays, 2-deoxy-2-[18F] fluoro-D-glucose positron
emission tomography/computed tomography
Association between Galectin-3 and oxidative stress parameters with coronary ...komalicarol
Galectin-3 (Gal-3), as a mediator of inflammation and fibrosis, has been reported to be a biomarker of severity in
coronary artery disease (CAD). The study aimed to assess the relationships between coronary artery disease (CAD) and risk factors,
including parameters of oxidative stress in Tunisian patients CAD.
The risks of using 2,4?dinitrophenol (2,4?DNP) as a weight loss agent: a lite...komalicarol
The prevalence of obesity has steadily increased in response to
changes in diet and physical activity patterns over the past 10
years, becoming one of the leading causes of morbidity and mortality worldwide. In addition, the popularity of social networks
has increased social and cultural pressure for the search for the
“perfect body”. These factors result in the search for fast and unconventional methods of weight loss, such as the use of weight
loss accelerating drugs. 2,4-Dinitrophenol (2-4-DNP or DNP) is
an industrial chemical used to lose weight quickly. Due to its great
potential for toxicity, its use has been banned in several countries
since 1938
Height is a measure of consumption that incorporates nutritional needs: When ...komalicarol
Japan suffered heavily from WWII. Per capita food supply was
1,450 and 1,700 kcal/day in 1946 and 1947, respectively. Japan’s
economy quickly recovered to the pre-war level in 10 years after
the war, 2,200 kcal/day in average food supply in 1955, making
steady progress toward the end of the century. People in Japan,
the younger generations, in particular, learned to eat more animal
products and children started growing taller in height
Successful management of a broken stylet retained in tracheobronchial tree-a ...komalicarol
In Covid-19 pandemic, the use of video laryngoscope for tracheal
intubation is highly recommended due to the increasing distance
between patient’s airway and operator. An endotracheal tube with
an intubating stylet has been proposed to facilitate tracheal tube
insertion, especially when video laryngoscope was used. Thus in
routine anesthesia practice intubating stylet is used as an aid in tracheal intubation for confirmed or suspected Covid-19 infected patients. At the present time, the disposable plastic covered or plastic
bougie is more recommended but in some institutes, the malleable
aluminum stylets are still in use. Though shearing of part of the
stylet has been reported in past but we report a case with as unrecognized broken piece of stylet into his right main bronchus, which
was later extracted immediately and successfully before causing
adverse symptoms or hurts.
Risk Analysis of Secular Trends for a Later Age at MPV of Weight in an Earthq...komalicarol
The Great East Japan Earthquake occurred in 2011, bringing unprecedented damage to the Tohoku region of Japan. Today, after 11
years, the scars from that tremendous damage remain. The health
damage to young school children has been particularly great. One
may imagine a slowing trend in physical growth from the effects
of that disaster, but no clear findings have been reported.
DNA Methylation and Epigenetic Events Underlying Renal Cell Carcinomaskomalicarol
Renal cell carcinoma (RCC) refers to a group of tumors that develop from the epithelium of the kidney tubes, including clear cell
RCC, papillary RCC, and chromophobe RCC. Most clear cell renal
carcinomas have a large histologic subtype, genetic or epigenetic
genetic von Hippel-Lindau (VHL). A comprehensive analysis of
the genetic modification genome suggested that chromosome 3p
loss and chromosome gains 5q and 7 may be a significant copy
defect in the development of clear kidney cell cancer. A more potent renal cell carcinoma may develop if chromosome 1p, 4, 9,
13q, or 14q is also lost. Renal carcinogenesis is not associated with
chronic inflammation or histological changes. However, regional hypermethylation of DNA in CpG C-type islands has already
accumulated in cancer-free kidney tissue, implying that the presence of malignant kidney lesions may also be detected by modified
DNA methylation. Modification of DNA methylation in cancerous
kidney tissue may advance kidney tissue to epigenetic mutations
and genes, leading to more serious cancers and even determining
a patient’s outcome
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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2. http://www.acmcasereport.com/ 2
Volume 9 Issue 11 -2022 Case Report
at a CHA2DS2-VASc score of 1 and the patient spontaneously
converted to sinus rhythm a few days later. On sinus rhythm the
12-lead ECG showed a first-degree AV-block and minimal ST-de-
pressions in V5 and V6, otherwise there was no evidence of is-
chemia or arrhythmias. We did a Stress-ECG and saw a very good
physical condition with 170% of the expected performance. The
patient did not show any symptoms, the circulatory behavior was
normal and there was no increase of the ST-depression that already
existed at rest.
Apart from a clearly dilated right atrium (28cm2), no other rele-
vant structural cardiopathy was found in the transthoracic echocar-
diography. However, an unclear color-doppler signal was detecta-
ble in several places around the heart and especially behind the left
atrium. To clarify this further, a transesophageal echocardiography
was performed. There we saw a sign of multiple tortuous vessels
around the heart and an unclear convolute of vessels in the area be-
hind the left atrium. Even after intravenous injection of lung-per-
meable (Sonovue) and non-lung-permeable contrast agent (agitat-
ed NaCl-bubbles), this finding could not be clarified (Figure 1).
To further clarify the anatomy, we performed a computed tomog-
raphy angiography. A massively ectatic Right Coronary Artery
(RCA) was found with a diameter of 17 mm and tortuous course
far into the periphery, with a parasagittal convolute between the
aorta and the left atrium. No other concomitant anomalies were
detectable (Figure 2 and 3).
Since it was unclear where the convolute of the RCA ends, a cor-
onary angiography was performed. There, normal left-sided cor-
onary arteries were visualized, the RCA was grotesquely ectatic
(Figure 4). To find out where the convolute of the RCA ends, we
decided to inject contrast agent (Sonovue) in to the RCAwhile per-
forming echocardiography. To our knowledge, there is no reports
about intracoronary injection and simultaneous echocardiographic
visualization of contrast agent (Sonovue). Immediately after the
injection we could clearly see the contrast agent in the coronary
sinus just before it joins the right atrium (Figure 5). So we could
proof a fistula of the convolute of the RCA into the coronary sinus.
This arterio-venous fistula explains the echocardiographic findings
of the significantly dilated right atrium. In the right heart catheter,
however, no relevant systemic left-right shunt was found and all
pressure values in the systemic and pulmonary circulation were
normal.
Since the patient is completely asymptomatic and because of this
complex anatomy, we decided on a conservative approach with a
regular follow-up.
Figure 1: Transthoracic (TTE) and transesophageal echocardiography (TEE)
TTE with multiple color-doppler signals detectable in several places around the heart. A) Inflow from coronary sinus and probably the flow of the RCA.
B) Flow around the base of the right ventricle and into the coronary sinus. C) Convolute of vessels in the area of the aorta and the left atrium. D) Blood
flow within the convolute of vessels around the heart.
3. http://www.acmcasereport.com/ 3
Volume 9 Issue 11 -2022 Case Report
Figure 2: Coronary CT-angiography
A) Ectatic RCA with tortuous course and a parasagittal convolute of vessels between the aorta and the left atrium. B) Another view showing the con-
volute of the RCA behind the left atrium.
Figure 3: Computed tomography of the heart with 4D angiography
A) Reconstruction of the heart and aorta and the ectatic RCA with tortous course. B) Reconstruction with the focus on the convolute of the RCA be-
tween left atrium and aorta
Figure 4: Coronary angiography of the right coronary artery
A) Grotesquely ectatic RCA with tortuous course. B) Convolute of the RCA ending in the coronary sinus.
4. http://www.acmcasereport.com/ 4
Volume 9 Issue 11 -2022 Case Report
Figure 5: Intracoronary injection and simultaneous echocardiographic visualization of the contrast agent (Sonovue) showing a fistula in to the coronary
sinus
A) TTE shows a part of the RCA and the coronary sinus for orientation. B) TTE shows color doppler flow in the epicardial convolute, the coronary
sinus, and the RCA. C) TTE shows the contrast agent in the RCA and the coronary sinus immediately after the intracoronary injection to the proximal
part of the RCA. D) Visualization of the contrast in the right atrium and right ventricle after exiting the coronary sinus.
Figure 6: Difference between ectasia and aneurysm of coronary arteries
A) Ectasia: Increase of the diameter greater than 1.5 times of the segment of the normal adjacent artery with length > width. B)Aneurysm: focal increase
of the diameter more than 1.5 to 2 times of the normal adjacent segment. C) Fusiform aneurysm with a longitudinal dimension > 200% of its transverse
dimension. D) Saccular aneurysm with a transverse dimension greater than the longitudinal dimension.
4. Discussion
It is important to know the difference between coronary artery ec-
tasia and aneurysm, although they may be a manifestation of the
same pathological process [1]. Usually, the term ectasia is reserved
to a diffuse dilatation of a coronary artery, and an aneurysm is a
focal dilatation of the vessels [2].
There are many definitions of coronary aneurysms, but the most
accepted is the focal increase of the diameter more than 1.5-2
times of the normal adjacent segment [3]. Coronary artery aneu-
rysms are classified on the basis of the composition of the wall, the
shape and the size of the vessel (Table 1). First, coronary artery
aneurysms can be either “true” aneurysms or “false” aneurysms
(pseudoaneurysms), a distinction that is based on the number of
layers in the vessel wall [4]. The vessel wall in true aneurysms is
composed of all three layers, whereas in pseudoaneurysms there is
a loss of the wall integrity as a result of disruption of the external
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Volume 9 Issue 11 -2022 Case Report
elastic membrane for example as a result of coronary interventions
[4]. Second, coronary artery aneurysms can be classified as saccu-
lar or fusiform on the basis of their shape. The saccular aneurysm
has a transverse dimension greater than the longitudinal dimension
of the segment, while the fusiform aneurysm has a longitudinal
dimension > 200% of its transverse dimension [5]. Third, on the
basis of their size, some coronary artery aneurysms are called giant
coronary artery aneurysms when the maximal diameter exceeds
20mm in adults or 8mm in children [6, 7].
Coronary artery ectasia is diagnosed when a segment of the artery
is greater than 1.5 times the diameter of the segment of the normal
adjacent artery with length > width [8]. It has been classified by
Markis into four types depending of the distribution with the worst
outcomes in types I and II because affecting more than one vessel
[9]. Table 1 shows the classification and Figure 6 shows schemat-
ically the difference between ectasia and aneurysm of coronary
arteries.
In this patient, the ectasia can be classified as type III based on
the distribution pattern. However, this only refers to the proximal
course of the RCA. The tortuous course and the convolute cannot
be assigned to any classification. The drain into the coronary sinus
allows this anomaly to be described as an arteriovenous fistula.
The reported frequency of coronary artery aneurysms varies wide-
ly from 0.3% to 5% because of varied angiographic criteria used
to define coronary aneurysms with higher incidence in men than
in women (2.2% vs 0.5%) [9-14]. Coronary artery ectasia is more
common than coronary artery aneurysm [15]. The RCA is the most
frequently involved vessel (40%–61%), which matches with our
case, followed by the LAD (15%–32%) and the RCX (15%–23%)
[9, 18, 19].
The etiology of coronary artery dilatation varies with the geo-
graphic location and the age of the patients. Atherosclerotic an-
eurysms and are most common in western countries and usually
caused by poststenotic dilatation (50%), followed by congenital
(17%) and infectious causes (10%), a special situation is found in
Japan with Kawasaki disease as the predominant cause of coro-
nary artery aneurysm. Vasculitides (other than Kawasaki), connec-
tive tissue disorders and collagenopathies are very rare causes of
coronary artery dilatation [16-18]. The precise mechanism is not
well understood, but the underlying histologic changes seem to be
equivalent to the changes observed in atherosclerotic lesions [9].
Most of the reported cases of congenital aneurysms and ectasia
are based on compensatory dilatation and associated with coronary
fistulas as a connection between a coronary artery and a cardiac
chamber or great vessel [20, 21]. Fistulas originate from the RCA
in 52% of cases, followed by the LAD (30%) and the RCX (18%)
[22]. In 90% of the patients, the drainage is to the right cardiac
chambers with volume overload to the pulmonary vascular bed
[23]. Since our patient has no coronary artery disease, a congenital
ectasia based on a fistula that could possibly have caused this com-
pensatory dilatation is highly likely. However, this tortuous course
and the massive convolute cannot be explained, especially with
normal pressure conditions measured invasively in the systemic
and pulmonary circulation.
Most of the patients remain asymptomatic, and aneurysms are
incidentally found during diagnostic coronary angiography or at
necropsy [2]. When patients are symptomatic, the clinical mani-
festations depend on the underlying cause and the complications
of the dilatation. The natural outcome of atherosclerotic aneurysms
is directly related to the severity of the coexisting obstructive cor-
onary artery disease although no difference in mortality between
patients with or without coronary artery disease was demonstrated
[28, 29]. Rupture of aneurysms seems to be very unpredictable.
Gold standard in diagnosing coronary ectasia is coronary angio-
gram and Intravascular Ultra Sound (IVUS) is the best tool for
assessing luminal size and determining arterial wall changes [30,
31]. Noninvasive technologies such as computed tomography and
magnetic resonance coronary angiography are also used to diag-
nose coronary dilatation and may increase the rate of recognition
because of increased availability of this technologies [32, 33].
Medical management depends on the underlying disease. Espe-
cially with a coexisting obstructive coronary artery disease, the
treatment is performed by the underlying coronary artery stenosis.
In the absence of the obstructive coronary artery disease, treatment
is not well established because of the rarity of this condition [17,
19]. Conservative medical therapy aims to prevent thromboembol-
ic complications with anticoagulant therapy and administration of
antiplatelet drugs [24]. Calcium channel blockers prevent spasm
of the coronary arteries and the use of beta blockers should be
avoided, because they can lead to spasm of the coronary arteries
due to an overlap of the alpha receptor [1, 5, 9]. Both pharmaco-
logical and interventional methods can be used in the case of arte-
rial thrombotic occlusion [34]. Since there are numerous individ-
ual variants of ectasia, there is no defined surgical therapy and the
individual benefit-risk ratio should be calculated very carefully. A
surgery may be considered to avoid complications and is indicated
in patients with obstructive coronary artery disease or evidence of
embolization leading to myocardial ischemia and also in those pa-
tients with very large dilatation with increased risk of rupture [25].
Percutaneous treatment with stents is another option in patients
with a fistula that needs closure [26, 27].
As already mentioned, we chose a conservative therapy in our case
because of the complexity of the anomaly, normal invasive pres-
sure conditions and the patient's absolute lack of symptoms. While
the patient is already on oral anticoagulation as a consequence of
atrial flutter and a CHA2DS2-VASc score of 1 point, there is also
protection against thromboembolic events as a possible complica-
tion of ectasia. Just recently, an article with a similar anomaly was
published [35]. However, the course of the RCA was less spec-
tacular than in our case and the use of intracoronary injection and
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Volume 9 Issue 11 -2022 Case Report
simultaneous echocardiographic visualization of contrast agent
(Sonovue) was required to visualize the fistula in our patient. This
approach was used for the first time. Due to the higher shunt vol-
ume and the patient´s symptoms in the other case report, a surgical
therapy was necessary, as opposed to ours.
Table 1: Classification of coronary artery dilatation
Coronary Artery Dilatation Description
Aneurysm: Focal Dilatation
Vessel Wall Composition:
True Aneurysm Wall with three layers: adventitia, media and intima
False Aneurysm Wall with only one or two layers
Shape:
Saccular Aneurysm Diameter transverse > longitudinal
Fusiform Aneurysm Diameter transverse < longitudinal
Size:
Giant Aneurysm Adult >20mm in diameter
Giant Aneurysm Children >8mm in diameter
Ectasia Diffuse Dilatation
Type I Diffuse ectasia in two or three vessels
Type II Diffuse ectasia in one vessel and localized disease (aneurysm) in other
Type III Diffuse ectasia in only one vessel
Type IV Coronary aneurysm in one vessel
5. Conclusion
Coronary artery dilatation is an uncommon finding and is inciden-
tally found during diagnostic coronary angiography or at necropsy.
However, with the advent of noninvasive methods for the eval-
uation of the coronary arteries, the dilatation is more frequently
found. It is useful to know the difference between aneurysm and
ectasia. In our case we could see the first signs in the echocardiog-
raphy and could proof a remarkable giant snakelike right coronary
artery ectasia with unique convolute in the coronary CT angiogra-
phy and coronary angiography. The drain into the coronary sinus
allows this anomaly to be described as an arteriovenous fistula.
Intracoronary injection and simultaneous echocardiographic vis-
ualization of contrast agent (Sonovue) is used the first time in our
case and could be very helpful to detect fistula of coronary artery
in to great vessel or cardiac chamber. Like our patient, most of the
patients are asymptomatic in absence of coronary artery disease,
which is the most common cause of coronary artery dilatation in
western countries and in adults. The clinical manifestations and
the medical management depend on the underlying disease and the
complications of the dilatation such like thromboembolic events
and ischemia.
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