226
Intermtional
CARD10
Journal of Cardiology, 26 (1990) 226-229 Elsevier
10144
Coronary arterial occlusion and myocardial infarction in acute myocarditis John M. Morgan,
Huon H. Gray and Ravi G. Pillai
Brompton Hospital, London. U.K. (Received
1988; revision accepted 24 February
18 October
1989)
Coronary arterial occlusion may occur experimentally during acute myocarditis but has not been documented in man. We report the case of a young female with severe myocarditis who later required cardiac transplantation and in whom coronary occlusion was demonstrated arteriographically before transplantation and by pathological examination of the heart after explantation. Key words:
Myocarditis;
Myocardial
infarction;
Coronary
Introduction
arteriography
chemicals.
Myocardial
infarction
during
acute
myocarditis
may
On examination,
peripherally
vasoconstricted,
sure 90/60)
with a sinus
occur either from a direct viral effect on the myocardium
central
or indirectly
sure was markedly
with
as a result of virally-induced
resulting
myocarditis
ischaemia
may
cardiographic
[l].
present
changes
arterial
spasm
with
acute
Patients
with
symptoms
suggestive
and
of acute
electro-
myocardial
both of which may resolve
spontaneously
[2].
We report
our experience
of myocardial
in-
farction
occurring
onstration
during
of coronary
acute
arterial
myocarditis
oedema.
with dem-
occlusion.
Case Report
admitted of
to her local
malaise,
infection
cardiac She
hospital
symptoms
of
history.
with a one-week
an
with an elevated
to this hospital
upper
tamponade
venous
secondary relevant
only
present,
She was on no medication
taking
the contraceptive
recent
travel
abroad,
Correspondence Brompton Hospital,
pill. drug
There
abuse
to: Dr. J.M. Fulham Road,
tract
of
effusion.
occasional
al-
past or family
heart
The
The chest
at the upper
limit
clear
poorly All
lung
valves
a
with
the ad-
rub or murmurs.
Results
of
haemoglobin count
sinus
rhythm,
branch
block
and anterior
radiograph and
Both
showed
no evidence ventricles
normal
left
a heart size
(cardiothoracic
ratio
0.5)
of pulmona&ry
were
dilated
and
echocardiography.
and
other
there
9.3/nl 11%,
serum alkaline 50&200),
investigations
10.5 g/d1 (normal
monocytes
total
showed
was
a small
effusion.
aspartate creatine
(neutrophils
glutamyl
were
4%,
follows: white
lymphocytes
22%
metamyelocytes
l%),
329 IU/l
(normal
transferase
aminotransferase dehydrogenase
as
red cell indices), 62%,
eosinophils
phosphatase
gamma
hydroxybutyrate
Morgan, Cardiac Dept., London SW3 6HP, U.K.
normal
on cross-sectional
appeared
pericardial
cell
fields
congestion.
was no history
of
were
of normal
contracting
3-14).
to toxic
pres-
waveform,
but there was no peripheral
right bundle
ST elevation.
and had not been or exposure
presand a
venous
with a normal
sounds
electrocardiogram
axis deviation,
She was and was
diagnosis
to a pericardial
who drank
and had no other
pain.
pressure
was
history
respiratory
with a provisional
was a non-smoker
cohol
Caucasian
and vague chest and abdominal
hypotensive referred
female
of 37 o C. The jugular elevated
being
(lOO/min)
of a third sound but no friction
venous fit 24-year-old
(blood
The chest was clear on auscultation.
with
A previously
The
unwell,
hypotensive tachycardia
liver edge was just palpable dition
infarction,
of a case
temperature
she appeared
59
129 IU/l
383 IU/l
range [N] IU/I (N
(N 50-140).
phosphokinase
69 IU/l
(N O-50).
electrolytes,
urea, creatinine,
calcium,
immunoglobulins
and protein
electrophoresis
Microscopy revealed
and culture
no organism.
Tests
(N
5-17), Serum
were normal. of blood.
sputum
for tuberculosis
and urine were nega-
221
tive. Serum anti-streptolysin 0 titre was normal and both acute and convalescent serological studies for viral (including Coxsackie) and atypical organism infection were negative. Pregnancy testing was also negative. A clinical diagnosis of acute myocarditis was made and, although the electrocardiogram was compatible with this, the anterior ST changes were felt to be suggestive of ischaemia. The patient underwent cardiac catheterisation within 24 hours of admission to visualise the coronary arterial anatomy and perform a left ventricular biopsy. Left ventricular contrast angiography demonstrated a dilated, poorly contracting ventricle (end-diastolic pressure 22 mm Hg) with no obvious thrombus in the cavity. Endomyocardial biopsy of the left ventricle was performed. The right coronary artery was then selectively cannulated and shown to be normal but coronary flow was sluggish. Within a few seconds of
injecting the left artery the patient suffered a cardiac arrest but was successfully resuscitated after a short period of external cardiac massage. Only one view of the left coronary artery (left anterior oblique projection) was obtained, which showed a normal circumflex artery with sluggish flow prior to cardiac standstill but a left anterior descending artery that was occluded near its origin (Fig. 1). Histological analysis of the biopsy samples revealed changes of severe acute myocarditis (Fig 2). Orthotopic heart transplantation was performed but the patient subsequently died. Examination of the patient’s explanted heart confirmed the presence of severe myocarditis, occlusion of the proximal left anterior descending coronary artery by thrombus without evidence of atheromatous disease or emboli, and infarction of the myocardium in its vascular territory.
Fig. 1. Selective arteriogram of the left coronary artery taken in the left anterior oblique projection.
Fig. 2. Photomicrograph of endomyocardial biopsy showing
Discussion
other
changes
coronary
myocardium In
the
present
endomyocardial severe
acute
case, biopsy
cation
vessel
coronary sluggish,
on
the
(despite
was
same
still
contrast
possible
the occlusion artery
present
anterior
changes
occluded
but either
there
coronary was
no
classifi-
whilst This,
descending
evidence
was
territory
coronary
artery.
of severe
acute
[4] but whether not known. histologically
by which
the left to be or
or in any of the
coronary process. onstration because,
left
with myocardial
atheroma
descending
although
artery
changes
arterial
it has
been
is
wall
was not examined and this inevithe mecha-
It may have been hypotension,
coronary
or as a direct its aetiology,
of
is reported may occur
know precisely
of systemic
in
association
occlusion
occluded.
the
descending
showed
of an arteritis
coagulation,
of coronary
of
in this case the arterial
episodes
Whatever
anterior
infarction
arterial
it became
of
wall
with infarction
The clinical
that we cannot
due to repeated abnormality
the
for evidence
nism
anterior
rest of the heart
coronary
us that
of atheroma
The
of
Unfortunately,
means
but
The
compatible
myocarditis.
acute myocarditis
tably
coronary
found
vascular
sug-
arrest
At autopsy,
artery
the
arteries.
was necrotic,
of the left anterior
together
convinces
at the site of occlusion
flow,
on admission
infarction,
prior to catheterisation.
descending
of diffi-
in the circumflex
injection.
of the left anterior
on
the left anterior
was occluded
did not occur at the time of the cardiac
was present
emboli
anterior
diagnosis
histological
arteriography,
artery
with the electrocardiographic gesting
the
seen
the recognised
even with precise
[3]). At coronary
although
features
confirmed
myocarditis
culty of diagnosis descending
histological
of acute myocarditis
result
of an arteritic
the angiographic occlusion shown
some
embolisation. dem-
is important in animals
[5],
229
coronary arterial occlusion occurring during an episode of acute myocarditis, to our knowledge, has never been previously demonstrated in man.
2
Acknowledgements
3
We are grateful to Dr. M. Honey and Professor M. Yacoub for allowing us to report on this patient, and to Professor M. Davis and Dr. E. Olsen for providing the
4
histological
5
material
and
its interpretation.
References 1 Saffitz JE, myocarditis
Internatmml Elsevier
CARD10
Scwarz causing
DJ, Southworth transmural right
Journal of Cardiology,
infarction without coronary narrowing. Am J Cardiol 1911;52:644-647. Gardiner AJS, Short D. Four faces of acute myopericarditis. Br Heart J 1973;35:433-442. Billingham M. Editorial. Acute myocarditis: a diagnostic dilemma. Br Heart J 1987;58:6-8. Constanzo-Nordin MR, O’Connell JB, Subramanian R, Robinson JA, Scanlon PJ. Myocarditis confirmed by biopsy presenting as acute myocardial infarction. Br Heart J 1985:53:25-29. Burch GE, Tsui CY, Harb JM. Pathologic changes of aorta and coronary arteries of mice infected with Coxsackie B4 virus. Proc Sot Exp Biol 1971;137:657-659.
W. Coxsackie viral and left ventricular
26 (1990) 229-231
10145
Ectopic right coronary artery to pulmonary artery fistula masquerading as patent arterial duct Adeniyi 0. Molajo, Jennifer A. Adgey and Jack Cleland Regional Medical Cardiology
(Received
Centre, Royal Victoria Hospital, Belfast, U.K.
28 July 1989; accepted
4 September
1989)
A patient is described in whom communication between an ectopic right coronary artery and the main pulmonary artery presented with clinical features of a patent arterial duct. Full clinical data documented by Doppler echocardiography, cardiac catheterisation and intra-operative findings are described. Key words: Pseudo phy; Angiography
patent
arterial
duct;
Ectopic
right coronary
Introduction Patent arterial duct presents distinct clinical features of a continuous machinery murmur. The detection of diastolic turbulent flow towards a sampling area distal to the pulmonary valve in precordial Doppler echocardiography has been shown to have sensitivity and positive predictive index of 100% in identifying patent arterial duct. We report a patient who had clinical and Correspondence
Cardiology U.K.
Centre,
0167-5273/90/$03.50
to: Dr. A.O. Molajo, Royal Victoria Hospital,
Regional Medical Belfast BT12 6BA,
0 1990 Elsevier Science
Publishers
to pulmonary
artery
fistula;
Doppler
echocardiogra-
Doppler echocardiographic features of patent arterial duct but was shown at angiography and intraoperatively to have an ectopic right coronary artery to main pulmonary artery fistula. Case Report A 25-year-old ophthalmology research assistant was first referred to our centre in 1985 because of the discovery of a cardiac murmur. She had no symptoms. Physical examination revealed the presence of a continuous murmur at the left second intercostal space. Precordial Doppler echocardiography showed the pres-
B.V. (Biomedical
Division)
Intermtional
CARD10
Journal of Cardiology, 26 (1990) 226-229 Elsevier
10144
Coronary arterial occlusion and myocardial infarction in acute myocarditis John M. Morgan,
Huon H. Gray and Ravi G. Pillai
Brompton Hospital, London. U.K. (Received
1988; revision accepted 24 February
18 October
1989)
Coronary arterial occlusion may occur experimentally during acute myocarditis but has not been documented in man. We report the case of a young female with severe myocarditis who later required cardiac transplantation and in whom coronary occlusion was demonstrated arteriographically before transplantation and by pathological examination of the heart after explantation. Key words:
Myocarditis;
Myocardial
infarction;
Coronary
Introduction
arteriography
chemicals.
Myocardial
infarction
during
acute
myocarditis
may
On examination,
peripherally
vasoconstricted,
sure 90/60)
with a sinus
occur either from a direct viral effect on the myocardium
central
or indirectly
sure was markedly
with
as a result of virally-induced
resulting
myocarditis
ischaemia
may
cardiographic
[l].
present
changes
arterial
spasm
with
acute
Patients
with
symptoms
suggestive
and
of acute
electro-
myocardial
both of which may resolve
spontaneously
[2].
We report
our experience
of myocardial
in-
farction
occurring
onstration
during
of coronary
acute
arterial
myocarditis
oedema.
with dem-
occlusion.
Case Report
admitted of
to her local
malaise,
infection
cardiac She
hospital
symptoms
of
history.
with a one-week
an
with an elevated
to this hospital
upper
tamponade
venous
secondary relevant
only
present,
She was on no medication
taking
the contraceptive
recent
travel
abroad,
Correspondence Brompton Hospital,
pill. drug
There
abuse
to: Dr. J.M. Fulham Road,
tract
of
effusion.
occasional
al-
past or family
heart
The
The chest
at the upper
limit
clear
poorly All
lung
valves
a
with
the ad-
rub or murmurs.
Results
of
haemoglobin count
sinus
rhythm,
branch
block
and anterior
radiograph and
Both
showed
no evidence ventricles
normal
left
a heart size
(cardiothoracic
ratio
0.5)
of pulmona&ry
were
dilated
and
echocardiography.
and
other
there
9.3/nl 11%,
serum alkaline 50&200),
investigations
10.5 g/d1 (normal
monocytes
total
showed
was
a small
effusion.
aspartate creatine
(neutrophils
glutamyl
were
4%,
follows: white
lymphocytes
22%
metamyelocytes
l%),
329 IU/l
(normal
transferase
aminotransferase dehydrogenase
as
red cell indices), 62%,
eosinophils
phosphatase
gamma
hydroxybutyrate
Morgan, Cardiac Dept., London SW3 6HP, U.K.
normal
on cross-sectional
appeared
pericardial
cell
fields
congestion.
was no history
of
were
of normal
contracting
3-14).
to toxic
pres-
waveform,
but there was no peripheral
right bundle
ST elevation.
and had not been or exposure
presand a
venous
with a normal
sounds
electrocardiogram
axis deviation,
She was and was
diagnosis
to a pericardial
who drank
and had no other
pain.
pressure
was
history
respiratory
with a provisional
was a non-smoker
cohol
Caucasian
and vague chest and abdominal
hypotensive referred
female
of 37 o C. The jugular elevated
being
(lOO/min)
of a third sound but no friction
venous fit 24-year-old
(blood
The chest was clear on auscultation.
with
A previously
The
unwell,
hypotensive tachycardia
liver edge was just palpable dition
infarction,
of a case
temperature
she appeared
59
129 IU/l
383 IU/l
range [N] IU/I (N
(N 50-140).
phosphokinase
69 IU/l
(N O-50).
electrolytes,
urea, creatinine,
calcium,
immunoglobulins
and protein
electrophoresis
Microscopy revealed
and culture
no organism.
Tests
(N
5-17), Serum
were normal. of blood.
sputum
for tuberculosis
and urine were nega-
221
tive. Serum anti-streptolysin 0 titre was normal and both acute and convalescent serological studies for viral (including Coxsackie) and atypical organism infection were negative. Pregnancy testing was also negative. A clinical diagnosis of acute myocarditis was made and, although the electrocardiogram was compatible with this, the anterior ST changes were felt to be suggestive of ischaemia. The patient underwent cardiac catheterisation within 24 hours of admission to visualise the coronary arterial anatomy and perform a left ventricular biopsy. Left ventricular contrast angiography demonstrated a dilated, poorly contracting ventricle (end-diastolic pressure 22 mm Hg) with no obvious thrombus in the cavity. Endomyocardial biopsy of the left ventricle was performed. The right coronary artery was then selectively cannulated and shown to be normal but coronary flow was sluggish. Within a few seconds of
injecting the left artery the patient suffered a cardiac arrest but was successfully resuscitated after a short period of external cardiac massage. Only one view of the left coronary artery (left anterior oblique projection) was obtained, which showed a normal circumflex artery with sluggish flow prior to cardiac standstill but a left anterior descending artery that was occluded near its origin (Fig. 1). Histological analysis of the biopsy samples revealed changes of severe acute myocarditis (Fig 2). Orthotopic heart transplantation was performed but the patient subsequently died. Examination of the patient’s explanted heart confirmed the presence of severe myocarditis, occlusion of the proximal left anterior descending coronary artery by thrombus without evidence of atheromatous disease or emboli, and infarction of the myocardium in its vascular territory.
Fig. 1. Selective arteriogram of the left coronary artery taken in the left anterior oblique projection.
Fig. 2. Photomicrograph of endomyocardial biopsy showing
Discussion
other
changes
coronary
myocardium In
the
present
endomyocardial severe
acute
case, biopsy
cation
vessel
coronary sluggish,
on
the
(despite
was
same
still
contrast
possible
the occlusion artery
present
anterior
changes
occluded
but either
there
coronary was
no
classifi-
whilst This,
descending
evidence
was
territory
coronary
artery.
of severe
acute
[4] but whether not known. histologically
by which
the left to be or
or in any of the
coronary process. onstration because,
left
with myocardial
atheroma
descending
although
artery
changes
arterial
it has
been
is
wall
was not examined and this inevithe mecha-
It may have been hypotension,
coronary
or as a direct its aetiology,
of
is reported may occur
know precisely
of systemic
in
association
occlusion
occluded.
the
descending
showed
of an arteritis
coagulation,
of coronary
of
in this case the arterial
episodes
Whatever
anterior
infarction
arterial
it became
of
wall
with infarction
The clinical
that we cannot
due to repeated abnormality
the
for evidence
nism
anterior
rest of the heart
coronary
us that
of atheroma
The
of
Unfortunately,
means
but
The
compatible
myocarditis.
acute myocarditis
tably
coronary
found
vascular
sug-
arrest
At autopsy,
artery
the
arteries.
was necrotic,
of the left anterior
together
convinces
at the site of occlusion
flow,
on admission
infarction,
prior to catheterisation.
descending
of diffi-
in the circumflex
injection.
of the left anterior
on
the left anterior
was occluded
did not occur at the time of the cardiac
was present
emboli
anterior
diagnosis
histological
arteriography,
artery
with the electrocardiographic gesting
the
seen
the recognised
even with precise
[3]). At coronary
although
features
confirmed
myocarditis
culty of diagnosis descending
histological
of acute myocarditis
result
of an arteritic
the angiographic occlusion shown
some
embolisation. dem-
is important in animals
[5],
229
coronary arterial occlusion occurring during an episode of acute myocarditis, to our knowledge, has never been previously demonstrated in man.
2
Acknowledgements
3
We are grateful to Dr. M. Honey and Professor M. Yacoub for allowing us to report on this patient, and to Professor M. Davis and Dr. E. Olsen for providing the
4
histological
5
material
and
its interpretation.
References 1 Saffitz JE, myocarditis
Internatmml Elsevier
CARD10
Scwarz causing
DJ, Southworth transmural right
Journal of Cardiology,
infarction without coronary narrowing. Am J Cardiol 1911;52:644-647. Gardiner AJS, Short D. Four faces of acute myopericarditis. Br Heart J 1973;35:433-442. Billingham M. Editorial. Acute myocarditis: a diagnostic dilemma. Br Heart J 1987;58:6-8. Constanzo-Nordin MR, O’Connell JB, Subramanian R, Robinson JA, Scanlon PJ. Myocarditis confirmed by biopsy presenting as acute myocardial infarction. Br Heart J 1985:53:25-29. Burch GE, Tsui CY, Harb JM. Pathologic changes of aorta and coronary arteries of mice infected with Coxsackie B4 virus. Proc Sot Exp Biol 1971;137:657-659.
W. Coxsackie viral and left ventricular
26 (1990) 229-231
10145
Ectopic right coronary artery to pulmonary artery fistula masquerading as patent arterial duct Adeniyi 0. Molajo, Jennifer A. Adgey and Jack Cleland Regional Medical Cardiology
(Received
Centre, Royal Victoria Hospital, Belfast, U.K.
28 July 1989; accepted
4 September
1989)
A patient is described in whom communication between an ectopic right coronary artery and the main pulmonary artery presented with clinical features of a patent arterial duct. Full clinical data documented by Doppler echocardiography, cardiac catheterisation and intra-operative findings are described. Key words: Pseudo phy; Angiography
patent
arterial
duct;
Ectopic
right coronary
Introduction Patent arterial duct presents distinct clinical features of a continuous machinery murmur. The detection of diastolic turbulent flow towards a sampling area distal to the pulmonary valve in precordial Doppler echocardiography has been shown to have sensitivity and positive predictive index of 100% in identifying patent arterial duct. We report a patient who had clinical and Correspondence
Cardiology U.K.
Centre,
0167-5273/90/$03.50
to: Dr. A.O. Molajo, Royal Victoria Hospital,
Regional Medical Belfast BT12 6BA,
0 1990 Elsevier Science
Publishers
to pulmonary
artery
fistula;
Doppler
echocardiogra-
Doppler echocardiographic features of patent arterial duct but was shown at angiography and intraoperatively to have an ectopic right coronary artery to main pulmonary artery fistula. Case Report A 25-year-old ophthalmology research assistant was first referred to our centre in 1985 because of the discovery of a cardiac murmur. She had no symptoms. Physical examination revealed the presence of a continuous murmur at the left second intercostal space. Precordial Doppler echocardiography showed the pres-
B.V. (Biomedical
Division)
