Abnormal coronary termination
Introduction
Introduction to coronary artery dysfunction Coronary artery termination abnormalities or coronary artery fistulas include the main branch or branch of the left and right coronary arteries directly into the heart chamber, coronary sinus, pulmonary artery, pulmonary vein, superior vena cava, or bronchial vessels. The most common is the right coronary artery, right ventricular fistula, which accounts for about 25%, and the coronary artery that enters the left heart chamber is the least common. With the extensive development of coronary angiography, the number of cases of coronary artery spasm reported in the literature is increasing. In a few cases, coronary artery fistula can involve several coronary arteries. Most of the coronary arteries exist alone, but about 25% of cases can be associated with congenital or acquired heart disease such as cardiac septal defect and valvular disease. basic knowledge Sickness ratio: 0.0001% Susceptible people: no specific population Mode of infection: non-infectious Complications: congestive heart failure, acute pulmonary edema, lung abscess, brain abscess, pericardial effusion, arrhythmia
Cause
Abnormal cause of coronary artery termination
Cause:
The cause of the disease is mainly caused by abnormal embryonic development. In the early stage of the embryo, the myocardial sinusoidal space communicates with the heart chamber and the epicardial blood vessels. As the heart develops, the blood vessels distributed on the surface of the heart are emitted from the root of the aorta. Development gradually compresses the sinusoidal space into small passages, which become the intracoronary coronary artery and capillaries. If the developmental disorder, the local wide sinusoidal space continues to exist, causing abnormal traffic between the coronary artery and the heart cavity to form a coronary artery termination abnormality.
Prevention
Coronary artery termination abnormality prevention
There is no special prevention method for this disease. Early detection and early treatment are the key to prevention.
Complication
Abnormal complications of coronary artery termination Complications Congestive heart failure, acute pulmonary edema, lung abscess, brain abscess, pericardial effusion, arrhythmia
The disease can be complicated by congestive heart failure and bacterial endocarditis, as well as some postoperative complications:
(1) When there are multiple stenosis-like vascular plexus in the fistula of the coronary artery fistula, the coronary artery fistula can be connected to the right heart chamber, which may lead to increased blood circulation in the pulmonary circulation, increased pulmonary artery pressure, and access to the left ventricle. Caused by left heart load weight gain and left ventricular hypertrophy, the duration of the disease is long, the fistula is gradually increasing, the flow rate is increased, and the heart load is aggravated, which can cause congestive heart failure. Congestive heart failure means that the heart can not beat the same vein at that time. And the blood supply required for the metabolism of body tissues, often caused by the weakening of myocardial contractility caused by various diseases, so that the blood output of the heart is reduced, insufficient to meet the needs of the body, and thus a series of symptoms and signs, myocardial failure Divided into left heart failure and right heart failure, left heart failure is mainly characterized by fatigue and fatigue, difficulty breathing, initial labor fatigue, and eventually evolved into difficulty breathing at rest, only sitting breathing, paroxysmal dyspnea It is a typical manifestation of left heart failure, more than a sudden onset of sleep, chest tightness, shortness of breath, cough, wheezing, especially serious can evolve into acute pulmonary edema Severe asthma, sitting breathing, extreme anxiety and coughing foamy mucus (typically pink foamy sputum), purpura and other symptoms of lung stagnation, right heart failure mainly manifested as lower extremity edema, jugular vein engorgement Loss of appetite, nausea and vomiting, oliguria, nocturia, separation of drinking water and urination.
(2) About 5 to 10% of cases of coronary artery spasm may be complicated by bacterial endocarditis. When bacteria (microorganisms) enter the bloodstream and are housed in the heart and reproduce here and cause infection, cardiogenic endocarditis Occurred, the normal heart has a smooth inner membrane, making it difficult for bacteria to attach to it. However, patients with congenital heart disease may have rough areas on the endocardium due to abnormally missing or leaking valves. The pressure causes the rough surface to be present even after surgery, due to the formation of scar tissue or a patch that guides blood flow, which is a tempting and suitable place for bacteria to reside and reproduce. The main clinical manifestations are: 1 cardiac manifestations: early no more murmurs, new murmurs appear in short-term after individual onset and quickly become high-profile, rough, and heart failure. 2 staphylococcal infection can be complicated by lung abscess, brain abscess and other migration abscess, manifested as cough, difficulty breathing, convulsions, hemiplegia and so on.
(3) increased white blood cells, progressive anemia, multiple positive blood culture positive rate.
(4) For patients undergoing surgery, early complications include: femoral artery thrombosis, percutaneous pericardial effusion caused by guiding wire, myocardial ischemia, residual spasm, embolism caused by coil dislocation, mild rise of creatine kinase High transient transient T wave inversion, and transient arrhythmia, in order to safely and effectively embolize coronary artery spasm, reduce complications, should be appropriate anticoagulation, gentle operation, avoid repeatedly twitching the guide wire, try to place the coil At the distal end of the tunnel, correctly select the coil, and be careful not to get the coil out of the coronary artery. The diameter of the coil is usually about 130% of the minimum diameter of the coronary artery to be used to prevent residual spasm and spring. The ring is detached, and a plurality of coils can be selected according to the condition.
Symptom
Coronary artery termination abnormal symptoms Common symptoms Acute heart murmur chills Congestion left ventricular hypertrophy tremor pulse pressure widening palpitations systolic tremor fatigue
First, clinical manifestations
Most patients do not present symptoms clinically, often diagnosed by continuous heart murmurs during physical examination, mild heart enlargement or pulmonary congestion, or accidental coronary angiography. Coronary artery spasm Small cases can be asymptomatic for life, large mouthwash, left-to-right adult cases with more flow can be fatigue, palpitations, shortness of breath and other symptoms, angina and myocardial infarction are rare, the former only seen in 7% of cases The latter is only 3%, 12-15% of cases have symptoms of congestive heart failure, more common in adult patients, about 20% over 20 years old, only 6% under 20 years old, causing the cause of congestive heart failure Mainly long-term left-to-right shunt, a small number of patients due to a large number of points can be congestive heart failure in infancy, and bacterial endocarditis, clinical symptoms of chills, fever and other symptoms.
Second, physical examination
The main signs of coronary artery spasm are continuous murmurs in the anterior region of the heart. Cases of sputum into the right atrium are located in the 2nd and 3rd ribs on the right sternal border, and sputum is in the lower left sternum. When entering the pulmonary artery, the murmur is similar to the patent ductus arteriosus. When the sac is introduced into the left ventricle, only the diastolic murmur can be heard at the lower left edge of the sternum, and the sputum close to the anterior chest wall may cause systolic tremor in the murmur area. The width is relatively rare.
Third, pathological anatomy
Coronary artery spasm usually involves the right coronary artery or its branches, accounting for about 50 to 55%; the left coronary artery or its branches account for about 35%; the left and right coronary arteries or their branches are affected by 5%, 90% Coronary artery fistula is inserted into the right heart chamber, pulmonary or superior vena cava, which is most common in the right ventricle, accounting for 40%, followed by the right atrium 25% and the pulmonary artery 15-20%.
The affected coronary artery is enlarged, distorted, prolonged, the blood vessel wall is thin, the vein is shaped like a vein, the fistula is large, and the blood flow is more severe. The enlarged blood vessel generally has a relatively uniform outer diameter, but sometimes it is close to the fistula. Aneurysmal expansion, but vascular fissure and atherosclerotic lesions are rare.
Coronary artery fistula generally has only a single fistula, the diameter is about 2 ~ 5mm, the edge of the fistula is fibrous tissue, sometimes the fistula forms a sponge-like vascular plexus, accepting the heart chamber of the coronary artery fistula, especially the right atrium, left atrium Or the coronary sinus tends to be highly enlarged, while the left ventricle, right ventricle, and pulmonary artery are not enlarged or hypertrophied until congestive heart failure occurs.
Into the right heart chamber or pulmonary artery, the coronary vasospasm of the systemic venous system, when the diastolic and systolic phases are generated, the blood is rapidly distributed from the aorta into the right circulatory system. The amount of flow depends on the aorta and the coronary artery. The level of pressure difference between the heart chambers and the size of the fistula, generally less flow from left to right, the ratio of pulmonary circulation to systemic blood flow rarely exceeds 1.8, and coronary artery fistula into the left ventricle produces shunt only during diastole, and The flow rate is less, the coronary circulation blood shunt increases the cardiac load, and the coronary artery spasm can also produce blood stealing effect, so that the distal coronary circulation blood flow is correspondingly reduced, the local myocardial blood supply is correspondingly reduced, and the coronary artery fistula is introduced into the right heart chamber. It can cause increased blood circulation in the pulmonary circulation, increased pulmonary artery pressure, and the left ventricle leads to left heart load weight gain and left ventricular hypertrophy. The disease duration is long, the fistula is gradually increased, the flow rate is increased, and the heart load is increased. Congestive heart failure.
About 5 to 10% of cases of coronary artery spasm can be complicated by bacterial endocarditis.
Examine
Coronary artery abnormality examination
(1) Chest X-ray examination: Most cases have no abnormal signs or show mild enlargement of the heart, pulmonary artery bulge and pulmonary vascular congestion. In cases of congestive heart failure, the heart is significantly enlarged, and the right atrium or left atrium is enlarged. Sometimes the edge of the heart is covered by an enlarged, distorted coronary artery, causing irregular contouring of the heart contour on the X-ray film.
(2) Electrocardiogram examination: about half of the cases have normal ECG, and the rest can show signs of excessive load on the right ventricle or left ventricle.
(3) Cardiac catheterization: coronary artery fistula can be inserted into the right heart chamber. In the right atrium, right ventricle or pulmonary artery level, blood oxygen content can be increased, thereby clearing the left to right shunt site, and the pulmonary artery with larger flow rate. The pressure can be slightly increased.
(4) Echocardiography: Cut-to-face echocardiography can show an enlarged coronary artery and an enlarged heart chamber, and ultrasound pulse Doppler examination may show the location of the coronary artery spasm.
(5) Cardiovascular angiography: Retrograde ascending aorta angiography or selective coronary angiography can show that the contrast agent is enlarged into the heart and sometimes aneurysmal-like dilated coronary artery into the heart chamber, which can confirm the diagnosis and check The part of the coronary artery fistula.
Diagnosis
Diagnosis and diagnosis of abnormal coronary artery termination
diagnosis
Diagnosis can be based on medical history, clinical symptoms, and laboratory tests.
Differential diagnosis
Coronary artery spasm with continuous murmur and patent ductus arteriosus, primary, pulmonary artery septal defect, aortic sinus aneurysm rupture, high ventricular septal defect with aortic regurgitation, chest wall or pulmonary arteriovenous fistula are similar, easy Confusion, for the time, location, loudness, nature, conduction direction and clinical symptoms of murmur, the possibility of coronary artery spasm should be considered in differential diagnosis, cardiac catheterization, echocardiography, aortic angiography and selection. Coronary angiography can confirm the diagnosis.
