Left main coronary artery occlusion

Patients with complete occlusion of the left main coronary artery are candidates for massive myocardial infarction and sudden death and are thought to have a uniformly poor prognosis. Complete occlusion of the left main coronary artery was identified in 2 male patients among 2,546 patients undergoing cardiac catheterization over a period of 14.5 years in our institution. Both patients had angina pectoris. Left ventricular end-diastolic pressure was markedly elevated in one, and the ejection fraction was moderately to markedly reduced in both. Significant collateral flow to the left coronary system from the right coronary artery was present in both patients. Our study supports previous reports that left main coronary artery occlusion is rarely encountered during cardiac catheterization.     

Cardiogenic shock in an elderly man caused by left main coronary artery occlusion with spontaneous dissection of right coronary artery

We present a case of an 85-year-old man with acute myocardial infarction and cardiogenic shock due to left main coronary artery occlusion, with spontaneous dissection of the right coronary artery.     

Chronic effort-induced angina as presentation of a totally occluded left main coronary artery: a case report and review

In this report, the case of a 40-year-old patient with chronic total occlusion of the left main coronary artery is discussed. Total occlusion of the left main coronary artery is a rare finding at coronary angiography. When present, patients most often have extensive collateral circulation from the right coronary artery. The mainstay of treatment is surgical with coronary artery bypass grafting.     

Transluminal percutaneous coronary angioplasty of the left coronary artery]

This paper describes our preliminary experience with left main coronary angioplasty in 8 patients (9 procedures). In 6 patients the left main coronary artery was "protected" either by previous by-pass surgery (4 patients) or by collateral vessels from the right coronary artery (2 patients). Three patients had a total occlusion of the left main coronary artery and 2 of them had a recent or acute myocardial infarction and the coronary angiogram suggested a thrombotic occlusion of the infarct-related artery. Three patients were not considered surgical candidates and an additional patient, who was in cardiogenic shock, required an emergency coronary angioplasty as "rescue" procedure. A successful dilatation was achieved in 6 patients (including a patient with successful deployment of a Palmaz-Schatz stent) but, unfortunately, one them eventually died 7 days later from a femoral sepsis related to the procedure. However in the 2 remaining patients--with a total occlusion of the left main coronary artery in relation with a myocardial infarction--the dilatation procedures were unsuccessful. One patient underwent a successful repeat coronary angioplasty for restenosis of left main coronary artery. Our preliminary experience confirms previous reports suggesting the value of coronary angioplasty in patients with left main coronary artery disease providing a careful selection of possible candidates is performed prior to the procedure.     

Stenting for left main coronary artery occlusion in adolescent: A case report

Acute total or subtotal occlusion of left main coronary artery (LMCA) is a catastrophic and mostly fatal event. Patients may present with cardiogenic shock and die whenever this event occurs. Survival is strongly dependent on the presence of collateral blood flow to the left coronary artery or a dominant right coronary artery, and emergency intervention for preserving the left ventricular function. Here, we present a case of a 14-year-old boy with subtotal occlusion of the LMCA accompanying acute myocardial infarction probably caused by congenital syphilis according to his positive serum syphilis antibody. His survival was closely associated with a dominant right coronary artery and timely thrombolytic therapy. Finally, he was treated with angioplasty and paclitaxel-eluting stent implantation. He was followed up after stenting and was doing quite well at the time when we wrote this paper.     

Vital recognition of complete occlusion of the left main coronary artery]

Left main coronary artery occlusion is found in about 0.05% of all coronary arteriograms. In this case report left main occlusion was associated with a dominant right coronary artery and good collaterals to the circumflex and left anterior descending coronary arteries, which seems to be essential for survival in this lesion. Our case belongs to the minority of patients who have survived a myocardial infarction in the presence of left main occlusion.     

An anomalous left main coronary artery with coronary torsion originating from the right sinus Valsalva

A 52-year old woman developed inferior ST elevation myocardial infarction and was found to have both an anomalous left coronary artery originating from the right sinus of Valsalva, and total atherosclerotic occlusion of the proximal right coronary artery. Coronary angiography showed the torsion of left main coronary artery. Multislice computed tomography was used to assess the left main coronary artery.     

Total occlusion of the left main and proximal right coronary artery: Case report and review of the literature

Chronic total left main coronary artery occlusion at angiography is very rare, and there are only four cases reported with concomitant total right coronary artery occlusion. We describe a case of total left main and proximal right coronary artery occlusion and review the clinical and angiographic characteristics of this condition which represents the most severe form of coronary artery disease compatible with life. © 1996 Wiley-Liss, Inc.     

Single coronary ostium - a right coronary artery arising from the left main coronary artery

Single coronary ostium is a very rare congenital anomaly with an incidence of 0.024% in angiographic series. This is the third case of Shirani-Roberts subtype IB4: solitary ostium in the left coronary sinus associated with a retroaortic-coursing right coronary artery that arises from the left main coronary artery. The patient is a 45-year-old male with no past medical history, and who was seen in the clinic for evaluation of a murmur. Echocardiography showed rheumatic heart disease with mild mitral regurgitation and moderate aortic regurgitation; no shunts were present. Coronary and aortic root angiography did not show a vessel originating from the right coronary cusp. The right coronary artery originated from the left main coronary artery and had an aberrant course which was dorsal to the ascending aorta. No associated congenital heart disease was present.     

Chronic occlusion of the left coronary artery

Chronic occlusion of the left main coronary artery is rare with less than 100 reported cases. the treatment is essentially surgical but medical management has been proposed. This case report illustrates the prognostic benefit of surgical management in view of the risk of secondary occlusion of the proximal right coronary artery.     

Transcatheter closure of coronary artery fistulas

BACKGROUND: Transcatheter closure of coronary artery fistulas has emerged as a successful alternative to surgery. We describe various techniques and short-term findings in 15 patients who were taken up for transcatheter closure of these fistulas. METHODS AND RESULTS: Fifteen patients (aged 2-55 years; 12 males) with coronary artery fistulas underwent percutaneous transcatheter closure between June 1997 and December 2002. Site of origin of these fistulas were: right coronary artery in 7, left anterior descending coronary artery in 4, left main coronary artery in 2 and left circumflex coronary artery in 2 patients. Drainage site of these fistulas were: right ventricle in 9, right atrium in 4 and pulmonary artery in 2 patients. Out of these 15 fistulas, 14 were congenital and one was iatrogenically produced following inadvertent cutting balloon angioplasty of a septal perforator in a patient with chronic total occlusion of left anterior descending coronary artery. Various occlusion devices used to close these fistulas were: conventional metallic coils in 10, floppy tips of coronary angioplasty guidewires in 2, Amplatzer duct occluder in 1 and Amplatzer septal occluder in 2 patients. One of our patients had a coronary artery fistula draining by two openings into the right atrium, both of which were successfully closed using 2 Amplatzer duct occluders. Check angiogram after the procedure revealed complete occlusion in 13 (86.6%) and small residual flow in 2 patients. Follow-up studies at 3-55 months (mean 18 months) showed complete abolition of shunt in all patients with no evidence of recanalization leading to recurrence of shunt. CONCLUSION: Transcatheter closure of coronary artery fistulas is feasible and safe in the anatomically suitable vessels. Use of floppy tips of coronary angioplasty guidewires reduces the cost of the procedure significantly. which is an important consideration in developing countries like India.     

Anterior ST-segment elevation with right coronary artery occlusion: a unique case of isolated right ventricular infarction

Anterior ST-segment elevation is the classic electrocardiographic feature of anterior left ventricular myocardial infarction due to occlusion of the left anterior descending artery. However, anterior ST-segment elevation has also been described in patients with right coronary artery occlusion, in whom concomitant inferior ST-segment elevation is also typically present. A case of proximal right coronary artery occlusion resulting in anterior ST-segment elevation without inferior ST-segment elevation is reported in this article. It is hypothesized that the inferior left ventricular wall was protected by left-to-right collaterals, as seen on coronary angiography, with resultant isolated right ventricular infarction upon proximal right coronary artery occlusion. In conclusion, this report presents a unique case of an isolated right ventricular infarction resulting in an electrocardiographic pattern mimicking anterior-wall left ventricular infarction.     

Surgical revascularization for acute total occlusion of left main coronary artery

We report our experience with emergency surgical revascularization in 3 patients who were in cardiogenic shock as a result of acute total occlusion of the left main coronary artery. Because they were in profound shock, 2 patients required mechanical support with extracorporeal membrane oxygenation before the operation. Another patient was given moderate inotropic support and treated with an intraaortic balloon pump before surgery, because he had a dominant right coronary artery with extensive collateral circulation to the left coronary artery. All 3 patients underwent surgical revascularization within 20 hours of acute occlusion. Two patients survived, although 1 of them required extracorporeal membrane oxygenation support for 5 days postoperatively. The 3rd patient, despite successful weaning from extracorporeal membrane oxygenation immediately after coronary revascularization, died of hypoxic encephalopathy due to prolonged preoperative resuscitation. Immediate surgical revascularization was an effective treatment in our 3 patients who were in cardiogenic shock due to acute total occlusion of the left main coronary artery. Such factors as abundant collateral vessels from the right coronary artery to the left coronary artery, complete surgical revascularization within 20 hours of acute occlusion, and mechanical circulatory support were deemed important to recovery of left ventricular function. Two of our 3 patients survived.     

Occlusion of the common trunk of the left coronary artery. Physiopathological features and clinical findings

The total occlusion of the left main coronary artery is rarely observed (approximately 0.05% of coronary angiographic studies). We have tried to draw the clinical and pathophysiological outline of this condition, starting from our experience and reviewing the published reports. A hard selection, principally by the high mortality in patients with left main coronary stenosis, limits the number of those who present total occlusion. These subjects show a remarkable variability in their clinical presentation. It is not possible to find out a significant correlation with a single risk factor, clinical manifestation or electrocardiographic picture. Therefore, these patients cannot be distinguished from other subjects affected by severe atherosclerotic ischemic heart disease. The angiographic finding of a dominant right coronary artery is most frequent. A rich collateral circulation to the left coronary is usually observed. From a pathophysiological point of view, the efficiency of coronary collateral circulation is confirmed by the significant correlation of its extent with the left ventricular function. An important role is also played by the rate of progression of left main stenosis in total occlusion and by the presence of right coronary lesions. Even if statistical evidence is still lacking, surgical treatment is unanimously indicated and achieves satisfying results. The use of nonsurgical recanalization techniques, such as intracoronary thrombolysis and transluminal angioplasty, may be lifesaving in those patients in whom left main coronary occlusion suddenly occurs.     

Left main coronary artery atresia diagnosed by multidetector computed tomography

Left main coronary artery atresia is an extremely rare disease. Differential diagnosis of left main coronary artery atresia from atherosclerotic occlusion of left main coronary artery is difficult even if performing invasive coronary angiography. We present a case of a 48-year-old male with left main coronary artery atresia. Echocardiography showed left ventricular dysfunction. Invasive coronary angiography showed absence of left main coronary artery. A multidetector computed tomography showed a string-like structure at the site of left main coronary artery. A diagnosis of left main coronary artery atresia was made, and he underwent coronary artery bypass grafting. At the operation, a thin and not-sclerotic left main coronary artery was observed. Echocardiography, performed after the surgery, showed normalization of the left ventricular systolic function. Multidetector computed tomography might be a useful method to diagnose left main coronary artery atresia.     

Angor with occlusion of the left main coronary artery treated with angioplasty

The occlusion of the left main coronary artery is rare and generally fatal. However, some subjects do survive. The two conditions necessary for survival appear to be the existence of a dominant right coronary artery and above all a rapidly functional left-right collaterality. The time lapse between occlusion and the introduction of an efficient collateral system is fundamental to patient survival. If the time lapse is too long, there is a risk of myocardial infarction, often complicated by cardiogenic shock, with a poor prognosis even after deocclusion. In this study, the case is reported of a patient with left main coronary artery occlusion presenting as unstable angor without an increase in enzymatic levels, and with a totally functional left-right collaterality. Deocclusion angioplasty was successfully performed. Finally, the short- and medium-term results of left main coronary artery angioplasty have been discussed.     

The power of collateral circulation: a case of asymptomatic chronic total occlusion of the left main coronary artery

Total occlusion of the left main coronary artery predominantly presents with recurrent angina or myocardial infarction. Long-term survival and myocardial function depends on the well-developed right to left collaterals. We report a case of a 46-year-old man who was referred because of incidental finding of low ejection fraction during work-up for syncope 5 months prior. The patient denied any recurrence or any other symptom after that episode and claimed an unchanged exercise capacity. He had hypertension, hyperlipidemia, and history of 15-pack/year smoking. Except for class II morbid obesity, he had completely normal vital signs, physical examination, and lab tests on admission. The echocardiogram was suggestive of previous anterior wall myocardial infarction and demonstrated a low left ventricle ejection fraction with diffuse hypokinesis of the left ventricle. The patient underwent cardiac catheterization, which revealed total occlusion of the left main coronary artery, dominant right coronary artery with a 95% stenosis in the proximal segment, and collaterals from the right to the left coronary arteries. The patient was immediately referred for coronary artery bypass surgery. This case demonstrates the power of collateral circulation in protecting the patient from symptoms and death despite total occlusion of the left main coronary artery and severe stenosis of the proximal right coronary artery.     

Survival with total occlusion of the left main coronary artery. Significance of the collateral circulation.

Four patients with total occlusion of the left main coronary artery are described. Angina pectoris was severe (NYHA class 3--4) and had lasted 20 months to seven years. Three patients had experienced a myocardial infarction. All displayed large collaterals arising from a nearly normal right coronary artery and feeding both the left anterior descending and the left circumflex arteries. The left ventricular ejection fractions ranged from 20% to 65%, and all patients had varying degrees of left ventricular asynergy. Coronary artery bypass surgery resulted in a marked improvement in three patients; one patient who underwent an aneurysmectomy died two months after the operation. The data show that total occlusion of the left main coronary artery is compatible with survival if adequate collateral supply develops from the right coronary artery. In this rare angiographic subset collateral circulation is clearly functionally significant.     

Survival with total occlusion of the left main coronary artery. Significance of the collateral circulation

Four patients with total occlusion of the left main coronary artery are described. Angina pectoris was severe (NYHA class 3-4) and had lasted 20 months to seven years. Three patients had experienced a myocardial infarction. All displayed large collaterals arising from a nearly normal right coronary artery and feeding both the left anterior descending and the left circumflex arteries. The left ventricular ejection fractions ranged from 20% to 65%, and all patients had varying degrees of left ventricular asynergy. Coronary artery bypass surgery resulted in a marked improvement in three patients; one patient who underwent an aneurysmectomy died two months after the operation. The data show that total occlusion of the left main coronary artery is compatible with survival if adequate collateral supply develops from the right coronary artery. In this rare angiographic subset collateral circulation is clearly functionally significant.     

Protective role of collaterals in patients with coronary artery occlusion

We reviewed the clinical, hemodynamic and angiographic data of 105 patients with right coronary artery occlusion and of 82 patients with left anterior descending coronary artery occlusion, subdivided into 3 groups by the presence and quality of collaterals to the occluded coronary (absent, poor or good collaterals). We found that patients with right coronary artery occlusion and good collaterals had a lower frequency of diaphragmatic myocardial infarction (60%) than patients with absent collaterals (100%) (P < 0.01). In addition, in patients with old diaphragmatic myocardial infarction, both poor and good collaterals were associated with a lower frequency of severe asynergy of the diaphragmatic left ventricular segments at left ventriculography (54% and 14%, respectively), compared to patients with no collaterals to the right coronary artery (92%, P < 0.02 vs. poor collaterals, P < 0.001 vs. good collaterals). In contrast, in patients with left anterior descending coronary artery occlusion, the presence of either poor or good collaterals to the left anterior descending coronary artery was not associated with a lower frequency of old anterior myocardial infarction, or, in patients with old anterior myocardial infarction, with a less severe asynergy of the anterior left ventricular segments.Our results suggest that collaterals are effective in protecting the diaphragmatic left ventricular wall in patients with right coronary artery occlusion, but not the anterior left ventricular wall in patients with left anterior descending coronary artery occlusion.