Complete occlusion of the left main coronary artery.

In this report, we describe the clinical, hemodynamic, and angiographic findings in three patients with atherosclerotic complete occlusion of the left main coronary artery. This rare entity was only seen in three out of 7,000 coronary angiograms. The three patients had extensive right-to-left collateralization. Two patients underwent saphenous vein bypass surgery and are asymptomatic, while the third patient died awaiting surgery. We suggest that patients with complete left main occlusion must undergo surgery as soon as possible.     

Detection of left coronary artery stenosis by transoesophageal echocardiography

The ability of transoesophageal echocardiography to visualizethe left coronary artery was retrospectively analysed in 60consecutive patients without clinical evidence of coronary arterydisease. The left main coronary artery was visualized in 56patients, the proximal circumflex in 34 patients and the proximalanterior descending artery in nine patients. Patency of thesearteries was established in all these patients. Subsequently,a prospective study was undertaken in 23 patients with angiographicallyproven left coronary artery disease. Both the left main coronaryartery and the circumflex artery were adequately visualizedwith transoesophageal echocardiography in all 23 patients, whereasthe anterior descending artery was identified inthree patients.The extent of stenosis in the left main coronary artery andthe circumflex arterywas correctly diagnosed in 18 patients.In five patients the degree of stenosis was overestimated. Thesefindings indicate the potential of transoesophageal echocardiographyto detect or exclude stenosis of both the left main coronaryartery and circumflex artery.     

Anomalous origin of the left anterior descending coronary artery from the pulmonary artery

Three children were identified as having anomalous origin of the left anterior descending coronary artery (LAD) from the pulmonary artery (PA). Two had had congestive heart failure in infancy with clinical diagnosis of endocardial fibroelastosis and all had abnormal ECGs. The correct diagnosis was delayed in each case, and two patients required selective coronary angiography. Surgery was accomplished in the three children although ECG abnormalities have persisted and one child has dyskinesis of the left ventricular apex. Because this diagnosis may be difficult to make when intercoronary anastomoses are inadequate to outline the left anterior descending coronary flow into the PA, patients with clinical findings suggestive of anomalous coronary artery may require selective coronary studies to exclude this anomaly.     

Anomalous origin of the left coronary artery from the right sinus of valsalva

We present the clinical, angiographic and surgical findings in a 63-year-old man with anomalous origin of the left main coronary artery from the right sinus of valsalva. The course of the left main artery was abnormal in that it passed between the aorta and the pulmonary artery; in addition, there was obstructive disease involving the left main coronary artery. The association of these two entities in this age group is unusual.     

Intravascular ultrasound for angiographically indeterminant left main coronary artery disease

The precise diagnosis of the presence of significant left main coronary artery disease has profound prognostic and therapeutic implications. Coronary cineangiography has shown to be imprecise and inaccurate to determine the percent stenosis of the left main coronary artery. We report a case with significant left main coronary artery disease in whom coronary cineangiography was in discordance with the clinical data and intravascular ultrasonography. Based on the intravascular ultrasound findings, the patient underwent coronary artery bypass graft surgery. Therefore, the intravascular ultrasonography may be the procedure of choice for assessing indeterminant left main coronary artery lesions by coronary angiography.     

Total occlusion of the left main coronary artery. A clinical, hemodynamic and angiographic profile

Although left main coronary artery stenosis has been extensively revicwed, total occlusion of the left main coronary artery has received scant attention. Six patients were diagnosed at cardiac catheterization as having total occlusion of the left main coronary artery over a period of seven years at two institutions. They ranged in age from 32 to 72 years, and all had symptoms ranging from NYHA Class 1-IV at initial presentation. One patient died three days after coronary artery bypass graft surgery. Of the remaining five, two treated medically are alive four and 40 months after catheterization, and three treated with coronary artery bypass graft surgery are alive three, 66 and 68 months after catheterization. Electrocardiogram showed prior myocardial infarction in three patients, stress tests were positive in three of four patients, and hyperlipidemia was present in the five tested. In the three patients without prior myocardial infarction, left ventricular function was preserved (ejection fractions = 0.52, 0.55 and 0.64; left ventricular end-diastolic pressures = 6, 9 and 14 mm Hg). Injection of the right coronary artery in this group revealed extensive collaterals filling the left coronary artery. The three patients with prior myocardial infarction had impaired left ventricular function (ejection fractions = 0.18, 0.30 and 0.33; left ventricular end diastolic pressures = 26, 35 and 35 mm Hg) and sparse intercoronary collaterals. Patients with total occlusion of the left main coronary artery have a varying clinical presentation and may have prolonged survival. In patients with good collaterals, left ventricular function may be preserved.     

Atherosclerotic aneurysm of the left main coronary artery

A large calcified atherosclerotic aneurysm of the left main coronary artery was successfully treated by aortocoronary saphenous vein bypass grafting. This is the second such reported case. The implications of this clinical entity are discussed.     

Identification of patients with left main and three vessel coronary disease with clinical and exercise test variables

To determine whether clinical and exercise test variables either separately or in combination could reliably detect the presence of left main or three vessel coronary disease, 5 clinical and 11 exercise test variables were compared with the findings of coronary arterlography in 436 patients. Patients with left main coronary artery disease (n = 35) had an earlier onset of S-T segment depression (2.1 ± 1.4 versus 2.8 ± 1.7 min, p < 0.05), which was more prolonged (8.7 ± 3.6 versus 6.9 ± 3.3 min, p < 0.05) and appeared in a greater number of electrocardiographic leads (6.4 ± 2.2 versus 5.0 ± 2.2 leads, p < 0.001), than did patients with three vessel coronary disease (n = 89). Individual clinical or exercise test variables were unable to detect left main coronary disease because of their low sensitivity or predictive values. The pattern of 2 mm or greater downsloping S-T segment depression—which starts in stage 1, lasts at least 6 minutes into recovery and is displayed in at least five electrocardiographic leads—was highly predictive (74 percent) and reasonably sensitive (49 percent) for the detection of either left main or three vessel coronary disease. These criteria have a sensitivity of 74 percent and predictive value of 32 percent for the detection of isolated left main coronary artery disease.It is concluded that combining several exercise test variables facilitates the detection of severe coronary disease. The specific presence of left main coronary artery disease nevertheless remains largely unpredictable even with this approach.     

Length of main left coronary artery in relation to atherosclerosis of its branches. A coronary arteriographic study.

The relation between the length of the main left coronary artery and the presence of atherosclerosis in its branches or the presence of complete left bundle-branch block was studied by selective coronary arteriography in 43 persons. The length of the main left coronary artery was found to be significantly shorter in patients with coronary atherosclerosis than in subjects without angiographic evidence of coronary artery disease. In patients with electrocardiographic evidence of complete left bundle-branch block, the length of the left main coronary artery was significantly shorter than that in both previous groups. In view of these findings, it is suggested that a short main left coronary artery should be considered as a congenital factor predisposing to the development of coronary artery disease. The possible mechanisms leading to atherosclerosis of the left coronary arterial branches in the presence of a short main trunk are discussed.     

Length of main left coronary artery in relation to atherosclerosis of its branches. A coronary arteriographic study.

The relation between the length of the main left coronary artery and the presence of atherosclerosis in its branches or the presence of complete left bundle-branch block was studied by selective coronary arteriography in 43 persons. The length of the main left coronary artery was found to be significantly shorter in patients with coronary atherosclerosis than in subjects without angiographic evidence of coronary artery disease. In patients with electrocardiographic evidence of complete left bundle-branch block, the length of the left main coronary artery was significantly shorter than that in both previous groups. In view of these findings, it is suggested that a short main left coronary artery should be considered as a congenital factor predisposing to the development of coronary artery disease. The possible mechanisms leading to atherosclerosis of the left coronary arterial branches in the presence of a short main trunk are discussed.     

Survival with total occlusion of left main coronary artery

Complete occlusion of the left main coronary artery is considered to be a terminal event in most cases. We describe two patients with this lesion who underwent successful coronary bypass surgery with complete relief of symptoms and long-term survival. The angiographic findings and clinical management of the two patients are discussed.     

Length of the left main coronary artery: Its relation to the pattern of coronary arterial distribution

The length of the left main coronary artery was correlated with the pattern of coronary arterial dominance in 100 cases. Patients with either a dominant left circumflex vessel or balanced circulation had a left main coronary artery that was significantly shorter than that of patients with a dominant right coronary arterial circulation. The importance of this finding in patients undergoing aortic valve replacement is discussed.     

Transesophageal echocardiography for evaluation of the left coronary artery]

The aim of the study was to evaluate the clinical usefulness of transesophageal echocardiography in the imaging of the left main coronary artery. The group tested--consisted of 26 patients with angina pectoris and 8 controls. The identification and adequate images of the left main coronary artery were obtained in 33 of 34 (97%) patients. In 5 of 26 patients with angina pectoris we observed stenosis of the left main coronary artery. The diameter stenosis of the lesion was judged to be greater than 50%. In addition, we tried to asses Doppler-derived parameters of blood flow. We have demonstrated that the pulsed Doppler study of the left main coronary artery is feasible. Comparison of patients with angina pectoris with the control group showed lower systolic flow velocities (35 +/- 10 cm/s vs. 55 +/- 15 cm/s) and slightly higher diastolic flow velocities (75 +/- 20 cm/s vs. 70 +/- 10 cm/s). This transesophageal examination holds promise for detecting pathologic vascular status. Although the sensitivity and specificity of this findings cannot be determined by our study, we believe that transesophageal echocardiography can provide a reference for the evaluation of patients with known or suspected ischemic heart disease. Further studies including larger groups of patients are recommended.     

Congenital absence of the circumflex coronary artery. Clinical and cinearteriographic observations

Two patients found to have congenital absence of the circumflex coronary artery are reported. The clinical, electrocardiographic, vectorcardiographic, and cineangiographic findings are presented. No distinctive clinical or laboratory abnormalities were found except for the unusual anatomical posterior origin of the ostium of the main left coronary artery.     

Iatrogenic left main coronary artery thrombosis during percutaneous coronary intervention

During diagnostic angiographic procedures or percutaneous coronary angioplasty-stenting of the other coronary arteries, the overall risk for a complication related to the left main coronary artery (LMCA) is low; however, if such complications occur, they tend to be life-threatening and contribute to a large part of the total catheter-related mortality. We encountered a case of iatrogenic significant subtotal left main coronary artery thrombotic stenosis in a patient who had undergone prior percutaneous transluminal coronary artery angioplasty-stenting of the left circumflex artery. In light of the literature, an extremely rare clinical presentation of iatrogenic left main coronary artery thrombosis is discussed.     

Atresia of the left main coronary artery: Clinical recognition and surgical treatment

Atresia of the left main coronary artery is an extremely rare anomaly with very few cases presented in the literature. Even more uncommon are reports of successful surgical repair. This article concerns two cases of atresia of the left main coronary artery treated surgically with a favourable outcome. The two patients (a 16 year-old boy and a 43 year-old woman) had a different clinical presentation but identical angiographic and morphologic features. The authors examine the embryogenetic defect underlying this anomaly. The differential diagnosis involves two congenital malformations (single coronary artery and anomalous origin of the left coronary artery from the pulmonary trunk) and acquired atherosclerotic disease of the left main coronary artery; the distinguishing features of these conditions are reviewed. Surgical management by means of internal mammary artery revascularization is discussed in light of recent reports about adequacy of blood flow in internal mammary artery bypass grafts.     

Ectopic and atretic ostium of left main coronary artery: from interleaflet triangle between left and noncoronary cusps

Left main coronary artery atresia is an extremely rare coronary anomaly in which there is no left coronary ostium and the left main trunk ends blindly. Ectopic origin of the left coronary artery from the left ventricle is an even rarer condition. Herein, we describe the case of a 37-year-old woman whose left main coronary artery atresia was not corrected during previous surgical correction of patent ductus arteriosus and aortic insufficiency. Five years after that first operation, the patient developed severe angina and heart failure. She underwent coronary artery bypass grafting with greater saphenous vein directly to the left main coronary artery trunk, along with associated procedures. The operative findings revealed an ectopic and atretic ostium of the left main coronary artery from the interleaflet triangle between the left and noncoronary cusps, which we believe is a specific congenital coronary anomaly.     

Bifurcating aneurysm of the left main coronary artery involving left anterior descending and left circumflex arteries--a case report.

Coronary artery aneurysm is a rare coronary abnormality, usually diagnosed incidentally by coronary angiography. Major causes of coronary aneurysms include coronary ectasia, Kawasaki disease, and atherosclerosis. Most of the discrete coronary aneurysms are of atherosclerotic origin. The incidence of atherosclerotic coronary aneurysms is about 0.2%, and the left main coronary artery is the least frequently involved artery. Only a few cases of left main coronary artery aneurysm have been reported in the literature, and a left main coronary artery aneurysm involving the proximal segments of the left anterior descending and the left circumflex arteries has not been reported previously. The authors describe this finding in a man who presented with worsening exertional angina pectoris. Coronary angiography demonstrated an aneurysm of the distal left main coronary artery extending into the proximal segments of the left anterior descending and the left circumflex arteries. In addition, a significant flow-limiting atherosclerotic lesion was present in the proximal portion of the left anterior descending artery distal to the aneurysm.     

Resting U wave inversion as a marker of stenosis of the left anterior descending coronary artery

Resting 12-lead electrocardiographic records from 849 patients who underwent coronary cineangiographic studies were reviewed for U wave negativity without knowledge of the clinical data or angiographic results. In order to evaluate U wave negativity as an independent electrocardiographic sign, patients with significant Q waves in the anterior leads were excluded from the final data analysis leaving 760 patients. Twenty-seven patients had U wave negativity in leads I, a VL or V₄ through V₆. For the study population, the prevalence of coronary artery disease was 64 percent (484 of 760); the prevalence of significant left anterior descending or left main coronary artery stenosis was 46 percent (350 of 760); and the prevalence of angiographic left ventricular dysfunction was 41 percent (309 of 754). Among 27 patients with resting U wave negativity the prevalence of coronary artery disease was 89 percent (24 of 27); the prevalence of left anterior descending or left main disease was 89 percent (24 of 27); and the prevalence of angiographic left ventricular dysfunction was 80 percent (20 of 25). Among patients selected for coronary cineangiographic study, U wave negativity was a significant predictor (p <0.001) of ?75 percent stenosis of the left anterior descending or left main coronary artery and of left ventricular dysfunction (p <0.001).