Coronary ostial stenosis

From January 1970 to December 1986, 2.7% (228/8509) of all patients having coronary artery bypass grafting had atherosclerotic coronary ostial stenosis of 50% or more. There were 126 males (55%) and 102 females (45%) with mean ages of 60.2 +/- 9.0 and 59.2 +/- 10.2 years (P = NS), respectively. The left ostium was involved in 176 (77.2%) patients, the right in 41 (18.0%) and both in 11 (4.8%). Isolated ostial stenosis (no associated coronary disease of 50% or more) was present in 38/228 (17%) with females predominating (29/38, 76%). Isolated ostial stenosis occurred more frequently on the right (10/41, 25%) than on the left (18/176, 16%). Associated coronary disease occurred in a single vessel in 42 patients, in two vessels in 72 and in three vessels in 76 resulting in a mean of 2.0 diseased vessels per patient. If patients with isolated ostial stenosis are excluded there were 2.3 diseased arteries per patient. There were 687 grafts performed in these patients, an average of 2.3 grafts per patient. One month surgical mortality was 4.8% (11/228), but has been 2% (2/104) in the last 4 years. Nine of 27 late deaths were noncardiac with a mean follow-up of 49 +/- 44 months. Ostial stenosis is hemodynamically equivalent to left main disease when the left ostium is involved. Symptomatic ostial lesions, whether right or left, require operative therapy.     

Coronary ostial stenosis after aortic valve replacement, revisited

Coronary artery occlusive disease that develops after an uncomplicated aortic valve replacement is well recognized. We present a case that required two further coronary operations and two salvage angioplasty procedures for a continuing fibrotic process in the ascending aorta. The literature and pathology are reviewed.     

Coronary ostial enlargement to prevent stenosis after prosthetic aortic valve replacement

Iatrogenic left and/or right coronary artery ostial stenosis after aortic valve replacement is a rare but life-threatening complication. Although usually related to trauma to the ostium/a during cannulation for administration of cardioplegia, it may be rarely due to direct obstruction by the prosthetic annular ring or stent. We report herein an alternative technique to manage this complication when due to the latter event, successfully utilized at our institution over the last eleven years.     

Coronary artery bypass grafting combined with operation for non-cardiac disease

During the last two years and six months, ten patients underwent operation for both coronary artery disease and non-cardiac surgery. There were six patients with vascular disease, three with gastric cancer and one with cholelithiasis. Six patients had simultaneous operation of both coronary artery bypass grafting (CABG) and non-cardiac surgery, and four underwent non-cardiac surgery mean of 105 days after CABG. The number of significant lesions of coronary artery in patients with simultaneous or two-staged operation was 2.2 +/- 0.8 or 2.8 +/- 0.5 per patient, respectively. The operative time in patients with simultaneous operation was 361 +/- 49 minutes. However, in patients with staged operation the time for cardiac surgery was 380 +/- 36 minutes and the time for non-cardiac operation was 388 +/- 83 minutes. There were no patients with complications after either cardiac or non-cardiac operation. In patients having surgical indications for both coronary artery and non-cardiac diseases, CABG should be performed prior to the non-cardiac surgery. In patients with normal cardiac function and sufficient operative time after CABG, concomitant operation seemed to be recommended. In case with advanced malignant disease or incompetent cardiac function, staged operation would be selected for good surgical result.     

Nonsyphilitic coronary ostial stenosis.

From October 1970 to June 1977, a total of 15 patients (12 women) were seen with atherosclerotic coronary ostial stenosis (14 left, one right). All patients had angina and two had aortic valve disease. Additional coronary arterial disease was present in nine. One patient declined surgery and died four months later after myocardial infarction. All patients had coronary bypass grafts and two had aortic valve replacement. One patient with valve replacement and one with preoperative cardiogenic shock died postoperatively. Angina recurred nine months postoperatively in one patient; the others (11) are free of angina. Postoperative catheterization from two weeks to 4.5 years in ten of 12 showed 11 of 13 vein grafts and eight of nine internal mammary artery grafts to be patent. In three patients, only a single left-sided coronary bypass was placed to the left anterior descending artery, because the circumflex branches were too small. Ideally, two left-sided bypass grafts should be placed for left ostial disease.     

Coronary ostial stenosis after aortic valvuloplasty (comprehensive aortic root and valve repair)

Comprehensive aortic root and valve repair (CARVAR) surgery using specially designed aortic rings was introduced as a new surgical technique for aortic valve disease. We present five consecutive cases of iatrogenic coronary ostial stenosis after CARVAR surgery in patients with aortic stenosis. The preoperative coronary angiography confirmed that all the patients had normal coronary arteries. They underwent aortic valvuloplasty by aortic leaflet extension and insertion of specially designed inner and outer rings at the level of the sinotubular junction. Within 6 months after surgery, all the patients complained of resting chest pain and dyspnea with changes of electrocardiography. Repeated coronary angiography demonstrated right coronary artery (RCA) ostial stenosis in one patient and left main (LM) ostial stenosis in the other four patients. Intravascular ultrasonography demonstrated severe ostial stenosis and extensive echogenic tissue in the extravascular area. Four patients with LM ostial disease successfully underwent coronary bypass graft surgery, and percutaneous coronary intervention with stenting was performed in one case of RCA ostial stenosis. Because the mechanism of this complication is not fully confirmed, more clinical study is required to confirm the safety issues of CARVAR surgery.     

Coronary ostial stenosis: a complication of aortic valve replacement of coronary perfusion.

Coronary ostial stenosis developing after aortic valve replacement is a clinically well-recognized entity. This non-atheromatous intimal proliferation may be limited to the proximal part of the coronary artery, probably as a complication of intra-operative coronary perfusion. It may also occur in association with widespread intimal thickening in the aortic root, presumedly as a reaction to turbulence around aortic ball valve prostheses. We have encountered this process in 2/508 patients (0.4%), who underwent aortic valve replacement with the Bj?rk-Shiley tilting disc valve prosthesis. The coronary perfusion technique was identical in all the operations.     

An aorto-coronary bypass graft operation of left coronary ostial stenosis due to aortitis syndrome

A 24-year-old female with unstable angina due to aortitis syndrome was reported. The coronary-arteriogram in hospital showed 75 percent stenosis of the left coronary ostium. Following two months' steroid therapy for active inflammation, aortocoronary bypass graft was implanted. After the operation. This patient became free from angina attack. Steroid therapy was continued postoperatively as well. The coronary-arteriogram taken seven months after the operation, revealed the patency of the graft.     

Revascularization for coronary ostial stenosis in Takayasu's disease with calcified aorta.

A case in which a patient with stenoses of the right and left coronary ostia and heavy calcification of the aorta caused by Takayasu's disease was successfully treated by coronary artery bypass grafting is presented. The aortic ends of the two grafts were attached to a xenopericardial patch, which was sutured into the ascending aorta. This technique can be done without fine sutures, which are required for proximal anastomosis of a vein graft, and may reduce the risk of ostial stenosis.     

Angioplasty with autologous pericardium for bilateral coronary ostial stenosis in Takayasu disease

Coronary ostial stenosis is usually treated by conventional coronary artery bypass graft surgery. Although patch angioplasty is a widely accepted alternative surgical treatment, it has been reported sporadically. We encountered bilateral ostial stenosis with Takayasu disease. This report describes successful patch angioplasty using glutaraldehyde-treated autologous pericardium of bilateral coronary ostial stenosis owing to Takayasu disease.     

Coronary ostial reconstruction: technical issues

Coronary ostial reconstruction may be the preferred alternative to reestablish antegrade myocardial revascularization in patients with isolated ostial stenosis. The technical steps of reconstruction are described. The ultrasonic aspirator is a helpful implement in the dissection of the left main and the proximal right coronary arteries. Satisfactory results of coronary ostial reconstruction in the current era seem to fulfill its promise.     

Syphilitic coronary ostial stenosis. Case reports

Two young Coloured men with proven syphilitic coronary ostial stenosis had severe angina pectoris unresponsive to conventional medication. One underwent an aortic valve replacement for severe aortic insufficiency associated with subtotal ostial occlusion of the right coronary artery (RCA), which was corrected by an aortocoronary bypass graft; the left coronary artery (LCA) ostium was normal and patent. The other patient had total occlusion of the LCA ostium which resulted in an extensive transmural anteroseptal and anterolateral myocardial infarction; the RCA ostium was unaffected and the aortic valve appeared normal. He was considered unsuitable for cardiac surgery and continued to receive anti-anginal drug therapy with quite satisfactory improvement in symptoms. Non-atheromatous coronary artery disease must always be sought for and excluded when a non-White patient presents with symptoms of ischaemic heart disease. Although atheromatous coronary artery involvement is becoming increasingly prevalent among 'westernized' Black and Coloured subjects, it is still relatively unusual in comparison with the extremely high incidence in the White population.     

Syphilitic aortitis causing bilateral coronary ostial stenosis

Coronary ostial stenosis in otherwise normal coronary vessels is a rare complication of syphilitic aortitis. A 47-year-old man with no coronary risk factors developed severe isolated ostial stenosis in the left main coronary artery and right coronary artery. He underwent coronary artery bypass grafting using the bilateral internal thoracic arteries and gastroepiploic artery and recovered uneventfully.     

Coronary artery stenosis following aortic valve replacement--a case report

A case with severe left main trunk (LMT) stenosis nine months after aortic valve replacement was presented. The patient, 57-year-old female, underwent aortic valve replacement with a tilting disk valve (Omnicarbon 21 A). Her postoperative course was uneventful, but angina pectoris developed after nine months. Coronary angiography was performed and revealed 99% LMT stenosis. Operation was performed with OTCA to LMT and with a saphenous vein graft to left anterior descending artery. Coronary artery stenosis following aortic valve replacement may be dangerous and it must be treated as soon as the diagnosis is established.