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Paper text:
a 48-year - old previously healthy woman visited our emergency department due to intractable substernal chest pain .
laboratory tests showed elevated serum cardiac enzymes , which indicated non - st elevation myocardial infarction ( creatine kinase - mb=14.8 ng / ml , troponin i=3.44 ng / ml ) .
she had no risk factors for coronary artery disease including a history of smoking , diabetes mellitus , hypertension , and dyslipidemia .
she had visited another hospital due to chest pain 8 days before admission to our institution .
a diagnosis of unstable angina was made and a coronary angiogram was performed , which revealed coronary artery lesions involving the left anterior descending ( lad ) , diagonal , and ramus intermedius coronary arteries ( fig .
her intractable chest pain persisted despite medical treatment including aspirin and the continuous infusion of heparin and nitroglycerin by our emergency department .
1b ) and multiple luminal narrowings even in the left internal thoracic artery ( ita ) .
because of the intractable chest pain associated with the rapidly progressing nature of the coronary lesions , the patient was referred for urgent myocardial revascularization .
she underwent off - pump coronary artery bypass ( opcab ) using a skeletonized right ita graft as a blood source .
the patient was given an initial dose of heparin ( 1.5 mg / kg ) and periodically received supplemental doses to maintain an activated clotting time longer than 250 seconds during opcab . because her skeletonized right ita was too short to reach the target left coronary arteries , a segment of the reversed saphenous vein was anastomosed to the end of the right ita in an i - fashion and grafted to the diagonal and lad coronary arteries , and the ramus intermedius using a sequential grafting technique .
upon opening the coronary arteries , the lumen was almost completely filled with diffuse fresh thrombi . when the fresh thrombi were removed through the coronary arteriotomies , neither coronary artery dissection nor atherosclerotic plaque was found .
the patient was heparinized in the intensive care unit to maintain an activated clotting time longer than 150 seconds , and anticoagulation therapy using warfarin and aspirin was started at 1 day postoperatively .
laboratory markers such as lupus anticoagulant , anticardiolipin antibody , anti - beta2gp1 antibody , complement 3 , complement 4 , and fluorescent antinuclear antibody , were evaluated postoperatively .
a 1-year postoperative angiogram was performed and demonstrated completely resolved lad lesions , a patent graft to the ramus intermedius and diagonal coronary arteries , and a competitive flow pattern in the graft to the lad coronary artery ( fig .
1d ) . a 36-year - old woman with a 6-month history of chest pain visited our hospital due to chest pain of increasing frequency .
she had been diagnosed as having systemic lupus erythematosus ( sle ) at the age of 20 , and had been treated with corticosteroids .
secondary aps manifested as recurrent abortion , an episode of acute pulmonary thromboembolism developed 2 years after the diagnosis of sle , and anticoagulation therapy was added .
her family history included an acute myocardial infarction in her elder brother at the age of 34 years .
her electrocardiogram and serum level of cardiac enzymes were normal ; however , she did have a positive treadmill test .
a preoperative coronary angiogram demonstrated a completely occluded proximal lad coronary artery and multiple stenotic lesions in the obtuse marginal coronary artery ( fig .
the right ita was divided at the proximal section and was anastomosed in a y - fashion to the side of the left ita .
the left ita was anastomosed to the lad coronary artery , and the right ita was anastomosed to the diagonal and obtuse marginal coronary arteries in a sequential fashion .
a 1-year postoperative angiogram was performed and demonstrated that all grafts remained patent ( fig .
a 48-year - old previously healthy woman visited our emergency department due to intractable substernal chest pain .
laboratory tests showed elevated serum cardiac enzymes , which indicated non - st elevation myocardial infarction ( creatine kinase - mb=14.8 ng / ml , troponin i=3.44 ng / ml ) .
she had no risk factors for coronary artery disease including a history of smoking , diabetes mellitus , hypertension , and dyslipidemia .
she had visited another hospital due to chest pain 8 days before admission to our institution .
a diagnosis of unstable angina was made and a coronary angiogram was performed , which revealed coronary artery lesions involving the left anterior descending ( lad ) , diagonal , and ramus intermedius coronary arteries ( fig .
her intractable chest pain persisted despite medical treatment including aspirin and the continuous infusion of heparin and nitroglycerin by our emergency department .
1b ) and multiple luminal narrowings even in the left internal thoracic artery ( ita ) .
because of the intractable chest pain associated with the rapidly progressing nature of the coronary lesions , the patient was referred for urgent myocardial revascularization .
she underwent off - pump coronary artery bypass ( opcab ) using a skeletonized right ita graft as a blood source .
the patient was given an initial dose of heparin ( 1.5 mg / kg ) and periodically received supplemental doses to maintain an activated clotting time longer than 250 seconds during opcab . because her skeletonized right ita was too short to reach the target left coronary arteries , a segment of the reversed saphenous vein was anastomosed to the end of the right ita in an i - fashion and grafted to the diagonal and lad coronary arteries , and the ramus intermedius using a sequential grafting technique .
upon opening the coronary arteries , the lumen was almost completely filled with diffuse fresh thrombi . when the fresh thrombi were removed through the coronary arteriotomies , neither coronary artery dissection nor atherosclerotic plaque was found .
the patient was heparinized in the intensive care unit to maintain an activated clotting time longer than 150 seconds , and anticoagulation therapy using warfarin and aspirin was started at 1 day postoperatively .
laboratory markers such as lupus anticoagulant , anticardiolipin antibody , anti - beta2gp1 antibody , complement 3 , complement 4 , and fluorescent antinuclear antibody , were evaluated postoperatively .
a 1-year postoperative angiogram was performed and demonstrated completely resolved lad lesions , a patent graft to the ramus intermedius and diagonal coronary arteries , and a competitive flow pattern in the graft to the lad coronary artery ( fig .
a 36-year - old woman with a 6-month history of chest pain visited our hospital due to chest pain of increasing frequency .
she had been diagnosed as having systemic lupus erythematosus ( sle ) at the age of 20 , and had been treated with corticosteroids .
secondary aps manifested as recurrent abortion , an episode of acute pulmonary thromboembolism developed 2 years after the diagnosis of sle , and anticoagulation therapy was added .
her family history included an acute myocardial infarction in her elder brother at the age of 34 years .
her electrocardiogram and serum level of cardiac enzymes were normal ; however , she did have a positive treadmill test .
a preoperative coronary angiogram demonstrated a completely occluded proximal lad coronary artery and multiple stenotic lesions in the obtuse marginal coronary artery ( fig .
the right ita was divided at the proximal section and was anastomosed in a y - fashion to the side of the left ita .
the left ita was anastomosed to the lad coronary artery , and the right ita was anastomosed to the diagonal and obtuse marginal coronary arteries in a sequential fashion .
a 1-year postoperative angiogram was performed and demonstrated that all grafts remained patent ( fig .
aps is a clinical syndrome associated with antibodies against phospholipids , and it manifests as systemic thrombotic disorders including recurrent deep vein thrombosis , pulmonary thromboembolism , brain stroke , and recurrent fetal loss due to placental thrombosis .
a diagnosis is made based on at least one of the clinical features -- vascular thrombosis and/or pregnancy morbidity , and one of the laboratory criteria , which are lupus anticoagulant and/or anticardiolipin antibody .
coronary events have been reported to occur in approximately 5% of aps patients , particularly those under age 45 .
they are usually associated with accelerated atherosclerosis resulting from long - term steroid therapy , dyslipidemia , and hypertension .
in addition , the presence of antiphospholipid antibody is regarded as an independent risk factor for premature atherosclerosis .
coronary events tend to occur secondary to other thrombotic events . in case 1 , the patient previously had neither risk factors of coronary artery disease nor clinical signs of aps .
diffuse coronary thrombosis imitating atherosclerotic coronary artery disease allowed us to perform myocardial revascularization , like to a previous report of a patient with aps and coronary atherosclerosis .
we diagnosed the case 1 patient with aps postoperatively from the intraoperative finding of diffuse coronary artery thrombosis and positive lupus anticoagulant activity on the other hand , the second patient was previously followed for secondary aps .
severe atherosclerotic stenosis occurred in her left coronary artery territories despite long - term steroid and anticoagulation therapy .
in addition to the effect of aps on progressive atherosclerosis , sle - induced myocardial microvasculopathy may have affected the pathogenesis of the case 2 patient .
we report on two women who underwent myocardial revascularization associated with antiphospholipid syndrome ( aps ) with different pathogenic patterns . 
 the first woman presented with acute myocardial infarction , and preoperative angiograms demonstrated rapidly progressing coronary lesions , presumptive unstable plaque , and dissection . 
 operative findings , however , showed fresh thrombi in the coronary arteries , and she was diagnosed postoperatively as having aps . 
 her one - year angiogram demonstrated improved coronary lesions and a competitive flow pattern in the grafts . 
 the second woman presented with unstable angina and had been treated for systemic lupus erythematosus and secondary aps for more than 14 years . 
 she underwent myocardial revascularization due to accelerated coronary atherosclerosis . 
 her one - year angiogram demonstrated patent grafts .