Total occlusion of proximal left main and right coronary artery

Total occlusion of the left main coronary artery (LMT) is rarely demonstrated with coronary angiography. All patients with LMT occlusion are of necessity dependent upon collateral circulation from the right coronary artery, which in approximately two thirds of patients is jeopardized because of marked obstruction of the right coronary artery. The ultimate example of collateral flow is provided by the following case. A 64-year-old man, who had total proximal left main and right-coronary artery occlusion, underwent coronary artery bypass grafting. On coronary angiogram, his jeopardized collateral artery was conus branch and only the LAD was graftable for coronary artery bypass surgery. One saphenous vein graft was bypassed to the LAD. Postoperatively, the left ventricular function improved considerably and the ejection fraction of the left ventricle rose to 46% from 23% preoperatively.     

Chronic total occlusion of left main coronary artery

Chronic total occlusion of left main coronary artery is a very rare angiographic finding as majority of these patients do not survive long enough to undergo coronary angiography. We describe a patient with angiographic findings of chronic total occlusion of left main coronary artery with left coronary circulation collateralized from right coronary artery.     

Anomalous right coronary artery originating from the left main coronary artery

A 54-year-old man with no cardiac history presented with exertional angina. Cardiac catheterization revealed an anomalous right coronary artery originating from the left main coronary artery with external compression during its course between the aorta and the pulmonary artery. He was successfully managed with surgical reimplantation of the right coronary artery into the aorta.     

Ligation of a fistula between the left main coronary artery and both the pulmonary artery and the right ventricle

The frequency of coronary artery fistula among all coronary angiography patients is 0.1% to 0.2%; however, involvement of both the pulmonary artery and the right ventricle is a rare clinical entity. A 53-year-old man patient was admitted to our clinic with rarely occurring chest pain, palpitations, and dyspnea. A coronary angiogram showed a fistula between the left main coronary artery and both the pulmonary artery and the right ventricle. We performed a ligation of this fistula without cardiopulmonary bypass. Aorta and right ventricle sutures were made, and the proximal and distal portions of the fistula were obliterated with 5-0 Prolene sutures and previously prepared Teflon felt. The patient recovered and was discharged without any complications. The surgical indications for coronary artery fistulas are symptomatic disease, an aneurysmic coronary artery, signs of heart failure, and ischemia. The surgical options in such cases--depending on whether the fistula is complicated or not--are simple ligation or transarterial ligation under cardiopulmonary bypass.     

Acute myocardial infarction due to left main coronary artery occlusion

OBJECTIVE: Acute myocardial infarction due to left main coronary artery occlusion remains catastrophic and mostly fatal due to severe cardiogenic shock and arrhythmia. METHODS: We studied 13 patients undergoing coronary artery bypass grafting for acute myocardial infarction due to left main coronary artery occlusion to clarify the optimal management of these difficult patients. RESULTS: In-hospital mortality was 46.2% (6/13). Revascularization was achieved by catheter intervention followed by bypass surgery in 7, and bypass surgery alone in 6. Two bypass surgery patients without catheter intervention had collateral flow to the left coronary artery, with the right coronary artery dominant. The time from onset to recanalization in the survival group was significantly shorter than in the early death group. CONCLUSIONS: Emergency intervention to preserve left ventricular function or right coronary artery dominant and collateral blood flow to left coronary arteries is important for improving the prognosis of patients with acute myocardial infarction due to left main coronary artery occlusion. If residual left main coronary artery stenosis is significant or other proximal coronary stenosis exists after catheter intervention, early coronary bypass surgery may improve long-term survival.     

Angioplasty of the left main coronary artery for isolated left main coronary artery disease

Operative technique and results of angioplasty of the left main coronary artery (LMCA) for isolated LMCA disease are reported. Nine consecutive patients, six men and three women, were operated upon. Their ages varied from 46 to 69 years, mean 51 years. All had 50% to 90% stenosis of the LMCA and Class III angina. Cardiopulmonary bypass and a cold cardioplegic solution were used for all operations. There were no operative deaths or infarctions. Follow-up ranged from 0.5 to 4 years, mean 1.9 years. Except for the first patient, who has new stenosis of the proximal anterior descending artery, all patients are free of angina. Repeat angiography in five patients showed a widely patent LMCA with excellent runoff. Our preliminary results suggest that angioplasty of the LMCA can be carried out with low operative risks. The technique appears to be a promising alternative to coronary artery bypass grafting in isolated LMCA disease.     

Surgical osteoplasty of the left main coronary artery using the right internal thoracic artery

A 39-year-old female with a history of progressive refractory angina required medical treatment. A coronary angiography showed 75% left coronary ostial stenosis without any other atherosclerotic lesions. The isolated ostial stenosis of the left main coronary artery was reconstructed by patch angioplasty, using a proximal segment of the right internal thoracic artery. The transaortic patch angioplasty was performed using a superior approach, which allowed a good exposure of the left coronary artery to the aorta without difficulty. A postoperative coronary angiography showed satisfactory patency, and a small biopsy of the ostial tissue demonstrated findings compatible with fibromuscular dysplasia. Based on this outcome, a proximal segment of the internal thoracic artery appears to provide a suitable patch material for enlarging the left coronary ostium.     

Spontaneous left main coronary artery dissection

Spontaneous coronary artery dissection is a rare and generally fatal disease. A review of the literature demonstrates that the aetiopathogenesis of the disease is unknown and that the histology is rarely described. It usually occurs in young women during the post-partum period or while taking oral contraceptives. The treatment depends on the clinical presentation and the results of the angiography. We report here a case of spontaneous dissection of the left main stem coronary artery, with extension into the left coronary territory which which occurred in a 43-year-old woman.     

Iatrogenic left main and proximal right coronary artery stenoses after aortic valve replacement.

Iatrogenic left main coronary artery stenosis after aortic valve replacement is an infrequent but potentially life-threatening complication. A 44-year-old woman who had normal coronary arteries documented by preoperative coronary angiogram, and who developed severe stenosis of the left main coronary artery and subtotal occlusion of the proximal right coronary artery after aortic and mitral valve replacements is presented. Coronary lesions were clinically manifested 4 months after the first operation. Accurate diagnosis was confirmed by repeat coronary angiography. She underwent successful coronary artery bypass grafting.     

Embolic occlusion of the left main coronary artery following an isolated aortic valve replacement

Coronary occlusion after aortic valve replacement due to embolization is a rare complication. We report the case of a patient who developed acute heart failure due to occlusion of the left main coronary artery following an aortic valve replacement. Successful treatment was achieved with emergent coronary bypass surgery.     

Surgical treatment of left main and left main equivalent coronary artery disease.

There is a tendency to equate left main (LM) and left main equivalent (LME) coronary artery disease in terms of the surgical risk and benefit. Eighty-seven patients with LM disease were compared to 78 patients with LME disease as to operative mortality rate and long-term benefits. One hundred percent follow-up was obtained. Although the two groups were similar preoperatively with regard to age, sex, and ventricular function, the operative results in the two groups differed. There was a significantly higher operative mortality rate in the LM group of patients (12.6% versus 2.5%). However, the incidence of graft patency and relief of symptoms was lower in the LME group of patients. The late mortality rate was 4% in both groups. LME disease appears to represent a subgroup of patients with three-vessel disease and cannot be equated with LM disease.     

Patient with pseudo-retrograde coronary flow in the normal right coronary artery and left circumflex artery: pitfall of retrograde coronary flow to detect coronary artery occlusion

A 75-year-old lady with hypertension and paroxysmal atrial fibrillation underwent echocardiography to evaluate cardiac function. Transthoracic Doppler echocardiography revealed retrograde coronary flow in the right coronary artery (RCA) and left circumflex artery (LCX). Computed tomographic coronary angiography demonstrated normal but tortuous coronary arteries. This tortuosity of the coronary arteries was thought be a cause of pseudo-retrograde coronary flow in the RCA and LCX. The present case demonstrates a pitfall of retrograde coronary flow for the detection of coronary artery occlusion in daily practice.     

Aberrant origin of the left main coronary artery arising from the right coronary artery associated with coronary artery disease: a case report

Coronary artery anomalies are not frequent, nevertheless they are associated with increased and potentially lethal cardiac events. Recognition of these anomalies is fundamental in patients undergoing diagnostic or interventional coronary angiography. Most patients presenting with coronary anomalies are asymptomatic, but the risk of myocardial ischemia and sudden death requires the treatment of those patients. Different therapeutic options have been discussed, including surgery, conservative therapy, and interventional approaches. In this report, an aberrant origin of the left main coronary artery arising from the right coronary artery associated with coronary artery atherosclerosis and its surgical correction is described.     

Congenital left main coronary artery to coronary sinus fistula

Congenital coronary artery fistula is an extremely rare anomaly that may involve any of the coronary arteries and any of the cardiac chambers. We report the case of a 14-year-old female patient with a symptomatic congenital coronary fistula starting from the left main coronary artery and draining to the coronary sinus. The patient underwent surgical ligation of the fistula and had an excellent outcome.     

Emergency off-pump coronary artery bypass (OPCAB) for left main coronary occlusion using rapid aorto-coronary perfusion

64 year old female with occluded left main after first injection brought to the operating room in extremis on IABP and maximum inotropes. LAD grafted with sapenous vein and immediate aorto-coronary perfusion. Circumflex grafted and patient taken to ICU. Patient discharged on POD #6 after echo shows normal ventricular with no wall motion abnormality.     

Direct ostioplasty of the left main coronary artery using the right internal thoracic artery as patch material

Three female patients underwent operations for nonatherosclerotic isolated left main coronary artery stenosis. Transaortic patch angioplasty was performed via an anterior approach using the most proximal segment of the right internal thoracic artery as patch material. Six months after surgery coronary angiography revealed good results in all three cases. The internal thoracic artery can be used to enlarge the left coronary ostium safely, if heavy calcification is not present.