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Five coronary ostia: Duplicate left anterior descending and right conus coronary arteries
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BRIEF REPORTS
contraction, left anterior hemiblock, and intermittent P-R interval prolongation. Pacemaker rhythm was seen infrequently. On admission, he had sinus tachycardia (110 beats/min ) with occasional ventricular premature contractions. The abdomen was tender, with maximum tenderness over the pacemaker pouch. Bowel sounds were active. The leukocyte count was 13,700 ceUs/mm 3. The abdominal radiograph (Fig. 1) had a pattern of small bowel obstruction. Initial conservative management o/partial intestinal obstruction included nasogastric suction and fluid replacement. After 5 days, 'laparotomy was performed which revealed a "knuckle" of bowel that was adherent to a suture that had been placed through the peritoneum at the time o/generator implantation. This segment of bowel was necrotic and ruptured during surgery. Postoperatively, septic peritonitis, wound dehiscence and evisceration, septic shock, and death occurred (19 days later).
We describe a previously unreported complication from pacemakers: intestinal obstruction related to an intraperitoneal suture placed during generator implantation in the abdominal wall. A related complication has been described. 1 Excessively deep suturing at the time of pacemaker generator implantation should be avoided. Pacemaker-related adhesions may exist in patients who present with evidence of bowel obstruction or other abdominal disease and who have abdominal wall pacemaker generators. A long symptom-free interval since pacemaker implantation does not exclude this possibility.
Five Coronary Ostia: Duplicate Left Anterior Descending and Right Conus Coronary Arteries
arose from the right aortic sinus of Valsalva, and a typical left main artery (with left anterior descending [LAD] and left circumflex divisions) and a duplicate LAD coronary artery arose from the area of the left sinus. Both LAD arteries descended in parallel fashion over the anterior ventricular surface to the cardiac apex. Five aortic coronary ostia have previously been reported in at least 9 subjects at necropsy,1,2 but in each the multiple ostia resulted from triplicate conus arteries. Advantages of multiple separate coronary arteries include extra sources of myocardial blood and potential use as collateral arteries. Disadvantages relate to difficulties in recognition and cannulation during coronary angiography or cardiopulmonary bypass procedures.
Bruce F. Waller, MD
Multiple aortic coronary ostia are occasionally observed at necropsy. Duplication of an entire major epicardial coronary artery producing an extraaortic ostium, however, has not previously been reported. Recently, I examined the heart of a 57-year-old man who never had symptoms of cardiac dysfunction and died of lymphoma. At necropsy, 5 separate coronary ostia were present (Fig. 1). A right coronary artery and 2 conus arteries From the Departments of Pathology and Medicine, Indiana University School of Medicine, and The Krannert Institute of Cardiology, Indianapolis, Indiana. Manuscript received December 14, 1982; revised manuscript received January 10, 1983, accepted January 21, 1983.
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References 1. Samaan H. An intragastric cardiac pacemaker. Thorax 1973;28:113114.
References 1. Crainiclanu A. AnatomischeStudien0her die Coronararterienund Experimentelle Untersuchungen iiber ihre DiJrchlassigkeit.Virchows Arch Path Anat 1922;238:1-75. 2. Baroldi G, Soomazzoni G. Coronary Circulation in the Normal and Pathologic Heart. WashingtonDC: Office of the Surgeon General, Departmentof the Army, 1967:25.
FIGURE 1. Coronary arterial anatomy in a 57°year-old man with 5 coronary ostia (IVAH #81-117). a, diagram showing distribution of 6 epicardial coronary arteries resulting from duplicate conus (C1+2) and left anterior descending (LAD1+2) arteries, b, drawing of ascending aorta showing location of 5 coronary ostia. The duplicate LAD2 artery arises slightly above the aortic sinotubular junction, c, photograph of opened ascending aorta showing separate origin of 5 coronary arteries. AV = aortic valve; LC = left circumflex; LM = left main; R = right.
BRIEF REPORTS
contraction, left anterior hemiblock, and intermittent P-R interval prolongation. Pacemaker rhythm was seen infrequently. On admission, he had sinus tachycardia (110 beats/min ) with occasional ventricular premature contractions. The abdomen was tender, with maximum tenderness over the pacemaker pouch. Bowel sounds were active. The leukocyte count was 13,700 ceUs/mm 3. The abdominal radiograph (Fig. 1) had a pattern of small bowel obstruction. Initial conservative management o/partial intestinal obstruction included nasogastric suction and fluid replacement. After 5 days, 'laparotomy was performed which revealed a "knuckle" of bowel that was adherent to a suture that had been placed through the peritoneum at the time o/generator implantation. This segment of bowel was necrotic and ruptured during surgery. Postoperatively, septic peritonitis, wound dehiscence and evisceration, septic shock, and death occurred (19 days later).
We describe a previously unreported complication from pacemakers: intestinal obstruction related to an intraperitoneal suture placed during generator implantation in the abdominal wall. A related complication has been described. 1 Excessively deep suturing at the time of pacemaker generator implantation should be avoided. Pacemaker-related adhesions may exist in patients who present with evidence of bowel obstruction or other abdominal disease and who have abdominal wall pacemaker generators. A long symptom-free interval since pacemaker implantation does not exclude this possibility.
Five Coronary Ostia: Duplicate Left Anterior Descending and Right Conus Coronary Arteries
arose from the right aortic sinus of Valsalva, and a typical left main artery (with left anterior descending [LAD] and left circumflex divisions) and a duplicate LAD coronary artery arose from the area of the left sinus. Both LAD arteries descended in parallel fashion over the anterior ventricular surface to the cardiac apex. Five aortic coronary ostia have previously been reported in at least 9 subjects at necropsy,1,2 but in each the multiple ostia resulted from triplicate conus arteries. Advantages of multiple separate coronary arteries include extra sources of myocardial blood and potential use as collateral arteries. Disadvantages relate to difficulties in recognition and cannulation during coronary angiography or cardiopulmonary bypass procedures.
Bruce F. Waller, MD
Multiple aortic coronary ostia are occasionally observed at necropsy. Duplication of an entire major epicardial coronary artery producing an extraaortic ostium, however, has not previously been reported. Recently, I examined the heart of a 57-year-old man who never had symptoms of cardiac dysfunction and died of lymphoma. At necropsy, 5 separate coronary ostia were present (Fig. 1). A right coronary artery and 2 conus arteries From the Departments of Pathology and Medicine, Indiana University School of Medicine, and The Krannert Institute of Cardiology, Indianapolis, Indiana. Manuscript received December 14, 1982; revised manuscript received January 10, 1983, accepted January 21, 1983.
'
Pulm°nary ~
a
~
e
~
~
LAO2j~;
References 1. Samaan H. An intragastric cardiac pacemaker. Thorax 1973;28:113114.
References 1. Crainiclanu A. AnatomischeStudien0her die Coronararterienund Experimentelle Untersuchungen iiber ihre DiJrchlassigkeit.Virchows Arch Path Anat 1922;238:1-75. 2. Baroldi G, Soomazzoni G. Coronary Circulation in the Normal and Pathologic Heart. WashingtonDC: Office of the Surgeon General, Departmentof the Army, 1967:25.
FIGURE 1. Coronary arterial anatomy in a 57°year-old man with 5 coronary ostia (IVAH #81-117). a, diagram showing distribution of 6 epicardial coronary arteries resulting from duplicate conus (C1+2) and left anterior descending (LAD1+2) arteries, b, drawing of ascending aorta showing location of 5 coronary ostia. The duplicate LAD2 artery arises slightly above the aortic sinotubular junction, c, photograph of opened ascending aorta showing separate origin of 5 coronary arteries. AV = aortic valve; LC = left circumflex; LM = left main; R = right.