Ischemia in the Territory of the First Major Septal Perforator Branch Anomalously Originating From the First Diagonal Branch Leads to a Transient Leftward Shift of the QRS Axis in the Frontal Plane-A Case Report-

Abstract

rigination of the first major septal perforator branch from a site other than the left anterior descending coronary artery (LAD) is a relatively rare and benign congenital variation. 1 Coronary angiography reveals anomalous vessels originating directly from the aorta and from the proximal portion of the right coronary artery as collateral circulation to the LAD, particularly in patients with proximal LAD disease. 2,3 Anomalous vessels also arise from the proximal circumflex coronary artery, diagonal branch, or obtuse marginal branch. 4 A transient leftward QRS axis shift on the electrocardiogram (ECG) during anginal attacks is a specific predictor of proximal LAD disease. [5][6][7][8] Conduction disturbance caused by ischemia of the anterior fascicle of the left bundle branch, which is supplied by the first major septal perforator branch of the LAD, 9 is thought to be one reason for the axis shift.Here, we describe a patient with a non-Q wave myocardial infarction whose coronary arteriogram documented severe luminal narrowing in the first major septal perforator branch arising anomalously from the first diagonal branch. Exercise ECG showed a transient leftward QRS axis shift. Case ReportA 61-year-old man was referred because of anterior chest pain that started 4 h before admission. His medical history included stable angina pectoris on exertion, hypertension, and gout. The patient's physical examination on admission was unremarkable, except for a high systemic blood pressure of 162/108 mmHg. A radiograph of the chest taken in the supine position showed a cardiothoracic ratio of 62% and no pulmonary congestion. The ECG demonstrated ST-segment elevation in leads V1-4 and STsegment depression in leads I, aVL, V5, and V6. Diphasic or negative T waves in leads I and aVL, and in leads V2-6 were also found.The patient was treated with isosorbide dinitrate (40 mg/day), bisoprolol (2.5 mg/day), and aspirin (162 mg/day). Heparin (10,000 U/day) was also administered intravenously. Creatine kinase, myosin light chain I, and troponin T peaked at 472 IU/L, 9.8 ng/ml, and 2.38 ng/ml, respectively. On the 21st hospital day, he underwent cardiac catheterization. The coronary arteriogram documented severe luminal narrowing in the proximal LAD, first diagonal branch, which originated from the site of just LAD lesion, and first septal perforator branch originating from the first diagonal branch. The left ventriculogram disclosed hypokinesis in the anterolateral, septal, and apical regions with an ejection fraction of 40%.On the 36th hospital day, percutaneous coronary angioplasty (PCI) of the proximal LAD and first diagonal branch was performed. An 8F Judkins-type guide catheter was inserted into the left coronary artery, and an intracoronary injection of isosorbide dinitrate was administered before PCI. After baseline angiography, two 0.014-inch guide wires were advanced through the stenotic lesions in the proximal LAD and the first diagonal branch. First, a 3.5×20-mm balloon catheter was placed within the proximal LAD lesion, and...

Prevalencia de anomalías coronarias detectadas por tomografía computarizada en el Instituto Nacional Cardiovascular - INCOR

“…Algunos estudios de anomalías coronarias no lo describen (4,(15)(16)(17)(18)21) . En esta anomalía, la primera rama septal puede originarse directamente de la aorta, de la porción proximal de la CD (como circulación colateral a la DA), desde el TCI, CX, primera rama diagonal o primera rama obtusa marginal (30,31) . El origen ectópico de la primera rama septal desde el TCI tuvo una prevalencia de 0,07%.…”

Multislice/multidetector-row computed tomography findings of a rare coronary anomaly: the first septal perforator branch originating from the left main coronary artery

“…3). A first septal arising from a non-LAD coronary vessel is a rare albeit benign clinical condition [4]. The site of origin may be aorta, RCA, LCx, diagonal artery, or obtuse marginal artery [4].…”