Amy H. Kragel

Anomalous origin of either the right or left main coronary artery from the aorta with subsequent coursing between aorta and pulmonary trunk: Analysis of 32 necropsy cases

Anomalous origin of either the left main coronary artery (LMCA) or right coronary artery (RCA) from the aorta with subsequent coursing between the aorta and pulmonary trunk is a rare and sometimes fatal coronary artery anomaly. Thirty-two cases of these anomalies were reviewed, with particular attention to the exact location and shape of the anomalistically positioned ostium and coronary dominance. The LMCA (7 cases) arose either from behind the right coronary sinus (6 cases) or as a single ostium with the RCA straddling the right-left commissure and right coronary sinus (1 case). In 5 of the 7 cases, the anomaly was fatal. In 6 cases of anomalous origin of the LMCA, the RCA was dominant and in 4 the anomaly was fatal. In only 1 case of anomalous origin of the LMCA was the left circumflex coronary artery dominant, and in this case the anomaly also was fatal. The RCA (25 cases) arose either from behind the left coronary sinus (8 cases), above the left coronary sinus (5 cases), from above the right-left commissure (10 cases) or as a single ostium with the LMCA above the right-left commissure and left coronary sinus (2 cases). In 8 of these 25 cases the anomaly was fatal. In 7 cases of anomalous origin of the RCA, the left circumflex coronary artery was dominant and in no case was the anomaly clinically significant. In 1 case, both the RCA and left circumflex coronary artery were hypoplastic and the anomaly was fatal. Coronary dominance, not ostial shape, was useful in separating the clinically significant from the clinically insignificant anomalies.

Morphologic comparison of frequency and types of acute lesions in the major epicardial coronary arteries in unstable angina pectoris, sudden coronary death and acute myocardial infarction

The frequency and type of acute lesions in the four major (right, left main, left anterior descending, left circumflex) epicardial coronary arteries were examined at necropsy in 14 patients with unstable angina pectoris, 21 patients with sudden coronary death and 32 patients with a fatal first acute myocardial infarction. None of the 67 patients had a grossly visible left ventricular scar (healed myocardial infarct) and only the group with acute myocardial infarction had left ventricular myocardial necrosis. Although the frequency of intraluminal thrombus was similar in patients with unstable angina (29%) and sudden death (29%) and significantly lower than in those with acute infarction (69%) (p = 0.02), the thrombus in the patients with unstable angina and sudden death consisted almost entirely of platelets and was nonocclusive, whereas the thrombus in the group with acute infarction consisted almost entirely of fibrin and was occlusive. The frequency of plaque rupture was insignificantly different in the groups with unstable angina (36%) and sudden death (19%), and was significantly lower than in the group with acute infarction (75%) (p = 0.02). The frequency of plaque hemorrhage was insignificantly different in the groups with unstable angina (64%) and sudden death (38%) and was significantly lower than in the group with acute infarction (90%) (p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Morphometric analysis of the composition of coronary arterial plaques in isolated unstable angina pectoris with pain at rest

Coronary artery plaque morphology was studied in 354 five-mm segments of the 4 major (left main, left anterior descending, left circumflex and right) epicardial coronary arteries in 10 patients with isolated unstable angina pectoris with pain at rest. The 4 major coronary arteries were sectioned at 5-mm intervals and a drawing of each of the resulting 354 Movat-stained histologic sections was analyzed using a computerized morphometry system. The major component of plaque was a combination of dense acellular and cellular fibrous tissue with much smaller portions of plaque being composed of pultaceous debris, calcium, foam cells with and without inflammatory infiltrates and inflammatory infiltrates without foam cells. There were no differences in plaque composition among any of the 4 major epicardial coronary arteries. Plaque composition varied as a function of the degree of luminal narrowing. Linear increases were observed in the mean percent of dense fibrous tissue (from 5 to 50%), calcific deposits (from 1 to 10%), pultaceous debris (from 0 to 10%) and inflammatory infiltrates without significant numbers of foam cells (from 0 to 5%), and a linear decrease was observed in the mean percent of cellular fibrous tissue (from 94 to 22%) in sections narrowed up to 25% to more than 95% in cross-sectional area. Multiluminal channels were seen in all 10 patients (28 [19%] of the 146 sections narrowed greater than 75% in cross-sectional area and in 36 [10%] of all 354 segments); occlusive thrombi in no patient; nonocclusive thrombi in 2 patients (1 section each of 2 arteries); plaque rupture in 2 patients (4 segments from 2 arteries); and plaque hemorrhages in 6 patients (11 sections from 10 arteries).

Composition of atherosclerotic plaques in coronary arteries in women <40 years of age with fatal coronary artery disease and implications for plaque reversibility

This study analyzes the composition of atherosclerotic plaques in the 4 major epicardial coronary arteries in 8 women less than 40 years of age (mean 34) with fatal coronary artery disease (CAD) and compares these data to previous studies of 37 adults greater than 45 years of age (mean 59) with fatal CAD. Histologic sections were taken at 5-mm intervals from the entire lengths of the right, left main, left anterior descending and left circumflex coronary arteries. With the use of a computerized morphometry system, analysis of the 4 major epicardial coronary arteries showed the major component of plaque to be a combination of cellular (mean percent total plaque area = 65%, standard error = 6%) and dense (19%, standard error = 6%) fibrous tissue. Arterial segments narrowed greater than 75% in cross-sectional area from these young women were compared with similarly narrowed arteries from 37 older patients (32 men [86%]) with fatal CAD previously reported by this laboratory, and showed significantly more cellular fibrous tissue and lipid-rich foam cells, and lesser amounts of dense fibrous and heavily calcified tissue. The large amount of lipid-containing foam cells and relative lack of acellular scar tissue in coronary plaques in these young women suggests a greater potential for reversibility of these plaques in this subset of patients with CAD.

Comparison of coronary and myocardial morphologic findings in patients with and without thrombolytic therapy during fatal first acute myocardial infarction

The hearts of 61 patients (39 men aged 64 +/- 11 years) who died from 5 hours to 42 days (median 3 days) after a fatal first acute myocardial infarction without having undergone percutaneous transluminal coronary angioplasty or coronary bypass surgery were studied to compare clinical and cardiac morphologic features of patients receiving thrombolytic therapy with tissue-plasminogen activator (t-PA) to those not receiving thrombolytic therapy. Comparison of findings in the 23 patients who received t-PA intravenously 3 +/- 1 hours after onset of symptoms, with the 38 patients who did not, showed similar baseline characteristics with respect to: age, gender, history of hypertension; location of the infarct; heart weight; severity and numbers of coronary arteries narrowed; and frequencies of plaque rupture, plaque hemorrhage and coronary thrombi. Among the patients receiving t-PA, however, there was a greater frequency of platelet-rich (fibrin-poor) thrombi in the infarct-related coronary arteries (6 of 11 vs 4 of 25 thrombi; p = 0.02), more nonocclusive than occlusive thrombi (6 of 11 vs 4 of 25 thrombi; p = 0.02), and a lower frequency of myocardial rupture (left ventricular free wall or ventricular septum) (5 of 23 [22%] vs 18 of 38 [46%]; p = 0.045).

Anomalous Origin of Either the Right or Left Main Coronary Artery from the Aorta Without Coursing of the Anomalistically Arising Artery Between Aorta and Pulmonary Trunk

Clinical and necropsy findings are described in 12 adults (10 men) in whom either the left main coronary artery or the right coronary artery arose abnormally from the aorta and the anomalistically arising artery coursed thereafter either normally or abnormally, but if abnormally not between the pulmonary trunk and ascending aorta. None of the 12 patients had symptoms of myocardial ischemia that unequivocally could be attributed to the anomalously arising coronary artery. One patient, a 19-year-old man, however, died suddenly and no abnormality other than the anomalistically arising right coronary artery from the posterior aortic valve sinus was found.

Composition of atherosclerotic plaques in the four major epicardial coronary arteries in patients ≥ 90 years of age

Abstract The composition of atherosclerotic plaques in 733 five-mm segments of the 4 major (left main, legt anterior descending, left circumflex and right) epicardial coronary arteries of 18 patients ≥90 years of age was determined by computerized planimetric analysis. By analysis of all coronary segments of all patients >90, the plaques consisted primarily of fibrous tissue (87 ± 8%) with calcific deposits (7 ± 6%), pultaceous debris (5 ± 4%) and foam cells (1 ± 1%) occupying a much smaller percentage of plaque area. Analysis of composition according to the 4 degrees of luminal cross-sectional area narrowing revealed marked step-wise increases in pultaceous debris (from 0 ± 0% at 0 to 25% narrowing to 18 ± 22% at 76 to 100% narrowing, p = 0.0001) and calcific deposits (from 0 ± 0 to 10 ± 15%, p = 0.002), and decreases in fibrous tissue (from 99 ± 3 to 71 ± 23%, p = 0.0001) and area occupied by the media (from 35 ± 8 to 16 ± 8%, p = 0.0001). When the analysis was restricted to sections narrowed >75%, no significant differences were found in plaque components or medial area between patients with (11 patients) and without (7 patients) myocardial infarcts at necropsy.

Myocarditis or acute myocardial infarction associated with interleukin‐2 therapy for cancer

The hearts of eight patients aged 22 to 67 years (mean, 41 years) who died during or within 4 days of interleukin‐2 (IL‐2) based immunotherapy for treatment of renal cell carcinoma or melanoma were studied at necropsy. Death resulted from combined cardiorespiratory failure in two patients, sepsis in four patients, acute myocardial infarction in one patient, and myocarditis in one patient. Transmural left ventricular necrosis was present in one of the two patients with significant atherosclerotic coronary artery narrowing. Noninfectious myocarditis was present in five patients: the inflammatory infiltrate was lymphocytic in four and composed of a mixture of eosinophils and lymphocytes in one. Although treatment‐related deaths associated with high‐dose IL‐2 therapy are uncommon (1.5% in 652 consecutive patients), the potential for significant myocardial ischemia or myocarditis exists, and careful monitoring for arrhythmias or myocardial failure is warranted.

Coronary arteries in unstable angina pectoris, acute myocardial infarction, and sudden coronary death

The amount of coronary arterial narrowing observed at autopsy in patients with UAP, AMI, and SCD is generally enormous.l As shown in Table I, from a study of 80 patients at autopsy with these three coronary events (SCD in 31, AM1 in 27, and UAP in 22), an average of 2.9 of the four major (right, left main, left anterior descending, and left circumflex) coronary arteries were severely (>75 % decrease in cross-sectional area) narrowed at some points, and no significant differences were observed among the three coronary subsets1 Patients with UAP had a much higher frequency of severe narrowing of the left main coronary artery (10 of 22 patients [45 % 1) compared with those with AM1 (3 of 27 patients [ll % ]) and SCD (3 of 31 patients [lo%]). A more sophisticated approach to determining degrees of luminal narrowing is to examine the entire lengths of the four major epicardial coronary arteries. One technique involves incising each of the four major coronary arteries transversely at 5 mm intervals and then preparing a histologic section from each 5

Cardiac morphologic findings in patients with acute myocardial infarction treated with recombinant tissue plasminogen activator

The hearts of 52 patients (aged 61 +/- 11 years, 34 men) who participated in the Thrombolysis in Myocardial Infarction (TIMI) Study and died from 5 hours to 260 days (median 2.7 days) after onset of chest pain were studied. One heart became available at cardiac transplantation. Of the 52 patients, 38 received recombinant tissue plasminogen activator (rt-PA) not followed by percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). Eight had PTCA, and 6 had CABG. The infarcts were hemorrhagic by gross inspection (with histologic confirmation) in 23 patients, nonhemorrhagic in 20, not visible grossly in 2 and, in 7, there was no myocardial necrosis by either gross or histologic examination.(ABSTRACT TRUNCATED AT 250 WORDS)