PMC9276961_01
Clinical images before surgery. (A) Emergency electrocardiogram revealing wide QRS complex tachycardia. (B-D) Images of transthoracic echocardiography on HD20 showing staged wall motion hypokinesia (extensive anterior wall, left ventricular lateral wall and apex), LVEF, 45%. (B) Parasternal short-axis view of echocardiography shows that the right coronary artery (blue single arrow) opens in the right coronary sinus, with an inner diameter of approximately 3.3 mm, and the left coronary artery (red double arrow) opens in the right coronary sinus and between the aorta and the pulmonary artery. The inner diameter of the opening is approximately 1.27 mm. (C) Acceleration of blood flow can be observed in the interarterial left main (LM) coronary artery (red arrow). (D) Ultrasound speckle tracking image shows the longitudinal strain of the anterior septum, left ventricular anterior wall, apex, anterior lateral wall, and posterior wall (left coronary artery area) decreases during systoling, whereas the posterior septum and left ventricular inferior wall (right coronary artery area) is normal. Left ventricular global longitudinal strain (GLS), -10%. (E-G) Images of coronary computed tomography angiography (CTA). Cross-sectional view of cardiac (E), Maximum intensity projection (MIP) image (F), and Volume-rendered (VR) image of the cardiac (G) revealing the left coronary artery originating from the right coronary sinus and coursing in an inter-arterial manner, with evident stenosis after being squeezed by the aorta and pulmonary artery. (H) Contrast-enhanced cardiovascular magnetic resonance image (MRI) reveals abnormal enhancement of left ventricular septum, anterior wall, lateral wall, considering the changes in subendocardial myocardial infarction. (I) Dynamic evolution of troponin I during hospitalization in the patient. LVEF, left ventricular ejection fraction; Ao, aorta; PA, pulmonary artery.
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F1
An electrocardiogram showed a wide QRS complex tachycardia (Figure 1A). Echocardiography on HD20 (Figures 1B-D) revealed LVEF, 45%. Coronary computed tomography angiography (CTA) (Figures 1E-G) revealed the varied origin of the left coronary artery, running between the aorta and pulmonary artery, and evident stenosis after being squeezed by the aorta and pulmonary artery. Contrast-enhanced cardiovascular magnetic resonance image (MRI) (Figure 1H) revealed abnormal enhancement of the left ventricular endocardium, suggesting subendocardial myocardial infarction. Figure 1I showed dynamic evolution of troponin I during the patient's hospitalization.
Images of transthoracic echocardiography 1 month post-operatively illustrating staged ventricular wall motion hypokinesia (extensive anterior wall, left ventricular lateral wall, and apex) and LVEF, 40%. (A) After unroofing of the intramural portion, the diameter of the left coronary ostium is approximately 3.94 mm. (B) The LM blood flow is in normal velocity. (C) Ultrasound speckle tracking image shows GLS of the left ventricle, -6.1%.
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F2
Echocardiography 1 month post-operatively (Figures 2A-C) revealed LVEF, 40%, the opening diameter of the LM was 3.94 mm, and blood flow velocity was normal.
The timeline of the case.
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F3
The progress and decision-making of the case above are reflected in the timeline (Figure 3).