The serine protease inhibitor antithrombin III (AT-III), an α2-globulin synthesized in the liver and endothelial cells, is the principal in vivo inhibitor of blood coagulation inactivating mainly thrombin. AT-III deficiency presents a rare hereditary or acquired disorder that most often comes to light when a patient suffers recurrent venous thrombosis and pulmonary embolism. Triggers for the onset of the thrombosis include various mechanisms such as pregnancy, delivery, surgery, trauma, and contraceptive pill use. Decreased response to heparin may be the first sign of AT-III deficiency. Since heparin is a conditio sine qua non for cardiopulmonary bypass, rapid consumption of AT-III promoted by heparin may lead to systemic thrombosis. The effect of heparin on graft patency after CABG in patients with AT-III deficiency, particularly with respect to early graft thrombosis, has not been fully investigated. The early detection and timely treatment of this disorder may impact perioperative morbidity. We present a case of simultaneous thrombosis of three venous grafts after elective coronary artery bypass surgery in a patient with AT-III deficiency.

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Introduction. Congenital coronary anomalies are detected in around 5% of all performed coronarographies. Coronary artery anomalies considered as those of great risk are the ones arising from the opposite sinus of Valsalva. These anomalies are detected in around 1% of cases. This case report shows a unique case of a patient with anterior wall STEMI caused by left main coronary artery (LMCA) occlusion which arises from the right coronary cusp and has interarterial course, which was successfully treated with primary PCI. Case Report. A 46-year-old male patient was admitted to the hospital due to STEMI of the anterior region. At the admission the patient was hypertensive (150/100 mmHg) in sinus rhythm (heart rate around 70/min), Killip I. After the initial examination and admitting dual antiplatelet therapy, the patient was transferred for urgent coronarography. Coronarography was performed by using the trans-radial approach. The right coronary artery had no significant stenosis and it was easily cannulated, whereas the left coronary artery could not be cannulated at the usual position. The operator attempted to cannulate the left coronary artery with multiple catheters of various curves, unsuccessfully. The conclusion was that there was a coronary artery anomaly, and the cannulation of the anomalous aortic origin of the left coronary artery (AAOLCA) which arises from the opposite right coronary cusp, was successfully performed with a Multipurpose catheter. Moreover, the left coronary artery was occluded in the distal segment. Two drug-eluting stents were implanted and followed by the development of no-reflow phenomenon and cardiogenic shock. After the stabilization, CT coronarography was performed and AAOLCA with an interarterial course was registered. During the follow-up period SPECT was performed and in the staged procedure, the stent was implanted on the proximal Cx, by using the TAP technique. Conclusion. Patients with STEMI and the anomalies of coronary arteries are very rare. As such, these patients represent a great challenge for revascularization. Possessing the knowledge of anatomic varieties is paramount when it comes to these patients, to treat them adequately with primary percutaneous coronary intervention.

Partial upper median sternotomy represents the optimal surgical method for the interventions on the whole ascendant aorta (including aortic valve) and mitral valve through the roof of the left atrium, with a few significant advantages compared to the full stemotomy surgical approach.

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