Clinical and angiographic features of coronary artery disease after chest irradiation

Coronary artery disease (CAD) developed in 15 patients at a mean of 16 years (range 3 to 29) after chest irradiation. The mean dose of radiation was 42 +/- 7 grays; irradiation was performed for Hodgkin's disease in 9 patients, lymphoma in 2, breast carcinoma in 3 and cystic hygroma in 1 patient. Mean age was 48 years (range 26 to 63) at diagnosis of CAD; 4 patients were younger than 35 years. Nine were women. Ten presented with angina, 3 with acute myocardial infarction, 1 patient with syncope and 1 with dyspnea. Twelve had no more than 2 risk factors of atherosclerosis. At coronary angiography, 8 had at least 50% diameter narrowing of the left main coronary artery and 4 had severe ostial stenosis of the right coronary artery. Eight patients also had valvular heart disease, 4 pericardial disease and 4 complete heart block. Mean left ventricular ejection fraction was 67 +/- 11% (range 53 to 80%). Nine had undergone coronary artery bypass grafting, but surgery was difficult or impossible in 3 because of severe mediastinal and pericardial fibrosis. Radiation-associated CAD is characterized by a high incidence of left main and right ostial coronary disease and often occurs in women with relatively few conventional risk factors for CAD.     

Left main coronary artery stenosis following mediastinal irradiation

The association of mediastinal radiation therapy and coronary artery disease has been documented over the past three decades. This report describes a case of left main coronary artery stenosis eight years after radiation therapy in a 27-year-old woman. The patient was a young woman with no risk factors for coronary artery disease who had development of new-onset angina at rest. At coronary arteriography, the patient was found to have a tight ostial left main stenosis. The association of mediastinal radiation therapy with fixed and vasospastic coronary artery disease is reviewed. With many patients treated by radiation therapy now surviving their thoracic malignancies, an enlarging young population may be susceptible to the early development of ischemic heart disease.     

Post-radiotherapeutic left main coronary ostial stenosis: clinical and histological study

Pericardial abnormalities remain the most common manifestationof radiation-induced cardiac disease, but coronary artery lesionsare not rare. In this report we describe a left coronary ostialstenosis which appeared five years after mediastinal irradiationfor breast carcinoma in a 50-year-old woman. The patient underwentcoronary angiography. A pressure drop was observed as the leftcatheter tip engaged the left coronary ostium; so, only nonselectivecoronary opacifications were performed showing an isolated,marked narrowing of the left coronary ostia. During surgery,a circumferential aortotomy allowed the examination of the leftcoronary ostium which appeared severely stenosed. The coronarytree was otherwise normal. A termino-terminal saphenous veingraft was anastomosed on the left stem and its proximal partwas implanted on the ascending aorta. The coronary ostium andthe proximal part of the left main stem were excised and themacroscopic examination of the proximal part of the left coronaryartery confirmed the diagnosis of severe ostial stenosis. Microscopicexamination of the coronary ostium showed a severe intimal thickeningwithout any evident lesion of the media. This intimal thickeningconsisted of fibrous tissue without extracellular lipid deposit.Microscopic examination of the aorta near the coronary ostiumalso demonstrated an intimal thickening without any lesion ofthe media. Coronary ostial stenosis appears to be a rare lesion;its incidence has varied between 0·13 and 2·7%in angiographic studies and there is co-existing disease inmultiple coronary vessels in the majority of cases. This coronarylesion in a middle-aged woman after a mediastinal irradiation,its histologic aspect (pure intimal fibrous thickening), andthe secondary appearance of complete atrio-ventricular block,fits the pattern previously ascribed to radiotherapy. Only twoother cases of coronary ostial lesion almost certainly secondaryto mediastinal irradiation have been reported.     

Ostial lesions of left main and right coronary arteries: demographic and angiographic features

In 258 patients with left main tract disease, the atherosclerotic risk factors were compared between patients with ostial and nonostial lesions of the left main coronary artery. Also, it was done for patients with ostial right coronary artery. Women were more likely to have ostial left main coronary artery and/or ostial right coronary artery. A multivariate logistic regression analysis revealed that the female sex (odds ratio: 2.336) and hypertriglyceridemia (odds ratio: 1.004) were independent risk factors of ostial left main coronary artery lesion. For ostial right coronary artery lesion, the female sex and family history of coronary artery disease were independent predictors. Ostial left main coronary artery and right coronary artery lesions were strongly correlated. The demographic and clinical profiles of ostial stenosis suggest that this group may represent a distinct entity, different from the more common atherosclerotic left main trunk stenosis (LMTD). The female sex and serum triglyceride level can be considered as independent predictors of ostial left main tract disease.     

Isolated left main coronary stenosis and mediastinal irradiation.

This report draws an association between mediastinal irradiation and isolated left main coronary artery stenosis. The report highlights two patients who developed selective left main coronary artery stenosis post mediastinal treatment. In the animal model, it has been shown that high serum cholesterol levels at the time of, or soon after, irradiation are necessary to initiate arteriosclerotic plaque formation.     

Primary and elective stenting of unprotected isolated left main coronary ostial stenosis in acute coronary syndrome

Direct surgical angioplasty or coronary artery bypass graft has been done in patients who have left main coronary ostial stenosis. Recent reports have demonstrated that stenting of unprotected left main coronary artery stenosis has been attempted as an alternative to bypass surgery in selected patients with normal LV function. We report two patients with isolated left main coronary ostial stenosis who are undergoing primary and elective stenting, respectively. Major cardiac events did not occur during a 3-month follow-up. This study suggests that stenting of isolated left main coronary ostial stenosis in acute coronary syndrome is feasible and results in excellent outcomes.     

Solitary ostial coronary artery stenosis in women]

Among 6,200 patients undergoing coronary arteriography using the Sones technique at the Juntendo University Hospital and the Juntendo Urayasu Hospital from 1975 to 1988, 121 patients (1.95%, 111 males and 10 females) were found to have significant (> or = 50%) stenosis in their left main trunks (LMT). Patients with systemic inflammatory disease such as syphilis or Takayasu's arteriitis, aortic valvular disease, or a history of mediastinal irradiation were excluded from this study. Stenotic lesions of the LMT were categorized into 7 types according to their locations and appearances. 1. The most common type was stenosis localized just before the branching from the left circumflex artery (42 patients or 34.7%). 2. Although the incidence of left coronary ostial stenosis was not very high (13 patients, 10.7%) as a whole, that for the female patients was the highest (30.8%) of the 7 types. Nine patients showed atherosclerotic irregularities with or without significant stenosis in the distal coronary arterial trees. Four patients, including 3 women, were diagnosed as "primary solitary ostial stenosis" of which the cause is unknown. All of the 3 women were premenopausal, and their clinical profiles were as follows: Case 1 (45-year-old): She was hospitalized because of anterior chest pain during exertion or at rest. Her electrocardiogram (ECG) showed severe ischemic ST-T changes. Coronary cineangiography disclosed a 95% stenosis in the left coronary ostium, and the distal portion of the coronary artery was normal. She had not experienced angina after her coronary artery bypass operation. Case 2 (45-year-old): She was hospitalized because of exertional chest pain.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mid-Term Outcome of Surgical Coronary Ostial Plasty: Our Experience

Abstract The conventional coronary artery bypass procedure that uses venous or arterial conduit for isolated critical stenosis of the left main coronary artery (LMCA) restores a less physiological perfusion of the myocardium and uses an appreciable length of bypass material, Coronary ostial plasty has been described as an alternative surgical technique in proximal obstructive coronary artery disease without calcifications. Here we report 23 patients (15 males and 8 females aged 37–78 years; mean age 57 years) who underwent surgical ostial plasty. Ostial reconstruction with fresh pericardial patch was performed in all patients: 15 patients with LMCA stenosis, 6 patients with right coronary (RC) ostial stenosis. and 2 patients with both RC artery and LMCA stenosis. In seven cases, coronary artery bypass grafting was added for contralateral distal stenosis with a total of five arterial conduits and six venous grafts. One patient died; the ostial plasty and grafts were patent at necropsy. Thal-lium-201 myocardial scintigraphy under stress at 30 days to 6 months after operation demonstrated good myocardial perfusion in 21 of 22 patients. Coronary angiography at follow-up (49 ± 8 months) demonstrated good surgical ostial plasty results in 21 of 22 patients and good coronary flow in 19 of 22 patients; angiographic study at mid-term follow-up revealed only one failure of the surgical ostial plasty technique associated with venous graft obstruction. In 2 other patients CABG failure due to venous graft obstruction (1 patient) or distal stenotic lesions of the left coronary artery (1 patient) was noted. The overall successful outcome of the surgical ostial plasty was 22 of 23. We believe that surgical angioplasty of the coronary ostia may be used in the presence of proximal noncalcified obstructive lesions as an alternative technique, which offers a more physiological revascularization; it also spares grafting material and allows subsequent percutaneous transluminal angioplasty or coronary artery bypass surgery. (J Card Surg 7999; 14:294–300)     

Long-term course of syphilitic aortic insufficiency with ostial stenosis following surgical treatment

Syphilitic aortic insufficiency and coronary ostial stenosis is a rare condition. It was diagnosed in 8 patients referred for surgery. The infection, acknowledged in 3 cases, was contracted over 15 years prior to admission! The operative indication was aortic valve replacement in 6 cases (Stage II to IV dyspnoea) and coronary insufficiency in 2 cases (Stage III angina pectoris). Two cases of ostial stenosis were not identified at coronary angiography, illustrating the potential diagnostic pitfall of a disease which is often unrecognised nowadays. Preoperative echocardiography of the left main coronary artery, especially its intra-aortic segment, may be of value but was not performed in these old cases. Surgery consisted in aortic valve replacement and coronary revascularisation by decortication of the ostia or coronary bypass (1 case). The evolution was excellent in the 6 survivors, especially with respect to the anginal syndrome which was completely cured without associated treatment. A protocol of echocardiographic surveillance of the left main coronary artery has been instituted in these patients to detect any late postoperative changes after ostial decortication.     

10 plus-years follow-up after patch angioplasty of the left main coronary artery

In ostial or proximal left main coronary artery (LMCA) obstruction, re-establishment of normal antegrade flow via the main trunk may be preferable to distal bypass grafting. The objective of this study was to assess the effectiveness of patch plasty of the left main (LM) trunk of the coronary artery for more than 10 years. Direct widening of the LMCA was recommended to patients with ostial, proximal, or midpoint stenosis of the main trunk. Group I of 16 patients had isolated LM obstruction with no distal disease, and Group II of 15 patients had, in addition, right coronary obstruction. The mean age was 60.9 years (age group, 47 to 83 years). Nineteen patients underwent this operation through an anterior transverse aortotomy. No endarterectomies were performed. In Group II, in addition, a single saphenous vein bypass graft was placed in the right coronary artery. There were no operative deaths. Follow-up period extends from 10 to 18 years (mean 11.2). Eight patients had angiography from 3 to 9 years after surgery and all show adequate LM trunk caliber. Noncardiac deaths occured in five patients (26.3%) at 2 months, and 1, 4, 6, and 7 years after surgery. Two women with isolated ostial stenosis diagnosed as a spasm have not shown progression of coronary disease 7 to 9 years after the operation. Widening of the LMCA should be considered in selective cases, only when ostial, proximal, or midportion stenosis of the main vessel exist, even if a right coronary bypass graft is required.     

Concomitant aortic valve replacement and surgical angioplasty of left main coronary ostium

The association of calcific aortic valve disease and isolated coronary ostial stenosis is rare. A 80-year-old woman was found to have severe aortic stenosis with critical narrowing of the ostium of the left main coronary artery. She was successfully managed by simultaneous aortic valve replacement and patch angioplasty of the left main coronary artery, using a patch of autologous pericardium fixed in glutaraldehyde. Angiographic control at 1 month coupled with intravascular echographic imaging showed adequate relief of the ostial stenosis and patency of the left main trunk.     

Nondiagnosed left main ostial stenosis partly due to the use of 5 French coronary angiographic catheters

Two cases have been reported in which the use of 5 F angiographic catheters is associated with a failure to diagnose an ostial stenosis of the left main coronary artery (LMCA). In both cases, the erroneous diagnosis led to an inappropriate indication for percutaneous transluminal coronary angioplasty (PTCA) on other stenosed vessels, and the ostial left main lesion was unexpectedly discovered when using 8F guiding catheters. It is supposed that the ability of performed 5F catheters to pass easily through an ostial lesion makes detection of such proximal stenosis much more difficult. We suggest that the choice of 5F catheters must be approached with caution when left main disease is potentially expected from the clinical features.     

Left main coronary artery ostial stenosis: the role of transoesophageal echocardiography

Transoesophageal echocardiography (TEE) using colour flow Doppler and intracoronary flow velocity measurements by pulsed Doppler may be helpful in detecting coronary artery disease. We present a case of a middle-aged man in whom left main ostial stenosis was detected by TEE after two non-diagnostic coronary angiographies. The main message of our case is that TEE was performed and was diagnostic after two non-diagnostic coronary angiographies. If ischaemia is confirmed TEE should be performed in cases of negative coronary angiographies to rule out left main ostial stenosis.     

J-SAP study 1-2: outcomes of patients with stable high-risk coronary artery disease receiving medical-preceding therapy in Japan.

BACKGROUND: Stable coronary artery disease (CAD) is classified into 2 types: high-risk (ie, 3-vessel disease, left main trunk lesions, or ostial lesions of the left anterior descending (LAD)) and low-risk (1- or 2-vessel disease other than ostial lesions of the LAD). Generally, the former is treated with coronary artery bypass grafting-preceding therapy (CABG), but not medical-preceding therapy (Medical); however, this is based on evidence from 30 years ago or more and does not reflect the recent progression of Medical and CABG. In addition, a randomized study has not been performed in Japan. METHODS AND RESULTS: In high-risk CAD, the long-term outcomes of 77 Medical patients and age-, sex-, coronary-lesion-, symptom- and risk-factor-matched 99 CABG patients were surveyed over 3 years (mean: 3.4 years) starting in 2000 at 37 nationwide hospitals. The incidences of cardiac death and cardiac death+non-fatal acute coronary syndrome (9.1% and 11.7% in Medical, and 2.0% and 3.0% in CABG, respectively) were significantly higher and the improvement in clinical symptoms was significantly lower in Medical than CABG. CONCLUSIONS: CABG is recommended in patients with high-risk CAD from the view of long-term prognosis; however, it should be remembered that the long-term outcome in Medical has considerably improved.     

Coronary Ostial Stenosis after Aortic Valve Replacement: Successful Treatment of 2 Patients with Drug-Eluting Stents

Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention.Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option.Key words: Angioplasty, transluminal, percutaneous coronary; aortic valve/surgery; cardiac surgical procedures/adverse effects; coronary artery disease/etiology/prevention & control; coronary stenosis/diagnosis/etiology/therapy; heart valve prosthesis implantation/adverse effects; iatrogenic disease/prevention & control; perfusion/adverse effects/instrumentation; postoperative complications/therapy; treatment outcomeCoronary ostial stenosis is a rare but potentially serious postoperative sequela of aortic valve replacement (AVR). Ostial stenosis can occur in the left main coronary artery (LMCA) or in the right coronary artery (RCA). The condition, first described by Roberts and Morrow in 1967,¹ is believed to occur after 1% to 5% of AVR procedures.^2–7 No underlying cause has been determined. The clinical symptoms of coronary ostial stenosis are usually severe and can appear from 1 to 6 months postoperatively.^8,9 Although the typical treatment is coronary artery bypass grafting (CABG), patients have been successfully treated by means of percutaneous coronary intervention (PCI).^10–15 Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after AVR, discuss their PCI treatment, and offer our conclusion regarding the feasibility of PCI in the treatment of coronary ostial stenosis.     

Iatrogenic left main coronary ostial stenosis after a bentall procedure in an asymptomatic young man

Coronary ostial stenosis is a rare but potentially fatal sequela of aortic surgery. The clinical presentation can include acute coronary syndromes, ventricular arrhythmias, congestive heart failure, or sudden death. Herein, we present what we believe is the first reported case of asymptomatic iatrogenic left main coronary ostial stenosis. The patient was an active 34-year-old man who had undergone a modified Bentall procedure and was asymptomatic thereafter. Seven months after that operation, exercise stress testing showed electrocardiographic signs of asymptomatic myocardial ischemia at high workload, and coronary angiography revealed severe nonatherosclerotic left main ostial stenosis. Percutaneous coronary intervention and stenting of the unprotected left main stenosis was successful, and patency at 8 months was apparent on coronary angiography.The conventional treatment for coronary ostial stenosis, coronary artery bypass grafting, carries a high risk of perioperative infarction, morbidity, and death. We found that percutaneous coronary intervention with stenting yielded positive short- and long-term results and may provide an alternative to cardiac surgery in these high-risk patients. We recommend that physicians evaluate even asymptomatic patients for left main coronary ostial stenosis after aortic surgery so that early diagnosis and treatment can avert severe clinical manifestations.     

A case of middle aged women with isolated left coronary ostial stenosis]

A-50-year-old woman was admitted to our hospital for the examination of exertional chest pain. She had no coronary risk factors. No hormonal disorders were observed. Physical and laboratory examinations revealed that she had not suffered from syphilis or aortitis syndrome or any other inflammatory diseases. An exercise electrocardiogram (Master's test) demonstrated ST segment depression in V3-6, II, III and a VF. On coronary angiography, a 75% stenosis of the left coronary ostial stenosis was found, but no abnormality was found in other arterial trees. The patient was diagnosed as having isolated coronary ostial stenosis. She underwent coronary bypass surgery from the aorta to the circumflex artery and the anterior descending coronary artery. She is now completely asymptomatic. A review of the literature together with this patient reveals the following characteristics of patients with isolated coronary ostial stenosis. Firstly, the patients are almost always middle aged woman with no coronary risk factors. Secondly, the involved coronary artery is the left main coronary artery, so its obstruction results in a serious condition. Therefore, though its pathogenesis remains to be determined, isolated left coronary ostial stenosis seems to be a distinct clinical entity.     

The absence of evidence is not the evidence of absence: A case report on the challenges in diagnosing ostial left main stenosis

Because left main (LM) coronary artery stenosis is known to have higher mortality and morbidity compared to lesions in other territories, an early diagnosis and management are crucial to prevent worse outcomes. Due to limitations of coronary angiography (CA), the diagnosis of ostial LM stenosis solely based on CA may result in underdiagnosis of such lesions. Therefore, additional testing is often needed either by pressure wire or intravascular ultrasound (IVUS) to make appropriate diagnosis. We, hereby, present a case of left main ostial stenosis in a 56-year-old male that was missed on multiple coronary angiograms, and highlights many of the considerations in the diagnosis of LM disease.     

The mechanism and significance of ventricularization of intracoronary pressure during coronary angiography

Ventricularization of pressure during coronary angiography has been said to identify the presence of left main coronary artery disease, but the hemodynamic features and the mechanism of this process have not been studied. Twenty consecutive patients with ventricularization were identified prospectively in our laboratory. Four patients had a discrete ostial left main stenosis and 16 patients had stenosis of the entire length of the left main coronary artery. The degree of pressure drop upon cannulation of the diseased left main coronary artery was highly variable; the systolic pressure decreased by 9 to 94 mm Hg, and the diastolic pressure decreased by 6 to 60 mm Hg. The morphology of the ventricularized pressure was distinct. It had a presystolic deflection resembling an a wave. The upstroke of this waveform was slower and the downstroke was steeper than that of the aortic pressure. An identical waveform was observed in dogs after partial occlusion of the left main coronary artery with a balloon-tipped catheter. The waveform of the so-called ventricularized pressure is derived from the aortic pressure, which is altered by its transmission across the left main coronary stenosis. The appearance of ventricularization is an important clue to the presence of left main coronary artery disease.     

Angina pectoris in a case of Takayasu's disease: revascularization by coronary ostioplasty and bypass grafting

A young man with Takayasu's disease had severe right and leftcoronary ostial stenoses. Severe angina was relieved by operationat which the right coronary ostium was enlarged by a pericardialpatch extending across the stenosis from aorta to coronary artery;the aortic end of a vein graft to the left coronary artery wasattached to this patch. This technique may reduce the risk ofrecurrence of ostial stenosis or of stenosis at graft origins.