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.     

Left main coronary arterial patency assessed with cross-sectional echocardiography

To assess the ability to visualize the left main coronary artery with cross-sectional echocardiography, 123 patients scheduled to undergo coronary arteriography were studied prospectively. The left main coronary artery was visualized with a phased array sector scanner. Coronary arteriography revealed a normal left main coronary artery in 108 of the 123 patients and more than 50 percent stenosis of this vessel in 15 patients. The left main coronary artery was adequately visualized with crosssectional echocardiography in 62 (57 percent) of the 108 patients with an arteriographically normal artery and in 9 (80 percent) of 15 patients with more than 50 percent stenosis of this vessel. Cross-sectional echocardiography indicated a normal left main coronary artery In 59 of the 108 patients with a normal left main vessel on coronary arteriography. In three patients thought to have greater than 50 percent stenosis of the distal left main coronary artery on cross-sectional echocardiography, coronary arteriography revealed significant stenosis of the proximal left anterior descending coronary artery and a normal left main coronary artery. In all nine patients with more than 50 percent stenosis of the left main coronary artery on coronary arteriography and adequate visualization of this vessel on cross-sectional echocardiography, the latter technique revealed narrowing of the lumen of this vessel. It is concluded that: (1) When the left main coronary artery is adequately visualized with crosssectional echocardiography, the presence or absence of more than 50 percent stenosis of this vessel can be assessed. (2) Stenosis of the proximal left anterior descending coronary artery may mimic a distal left main coronary arterial stenosis. (3) Studies on larger numbers of subjects with left main coronary artery disease will help to delineate further the role of cross-sectional echocardiography in evaluating a patient with suspected disease of this artery.     

Sensitivity, specificity and predictive value of two-dimensional echocardiography in detecting coronary artery aneurysms in patients with Kawasaki disease

Seventy-seven patients with Kawasaki disease were prospectively evaluated from 1978 to 1983 to determine the sensitivity, specificity and predictive value for detecting coronary artery aneurysms with two-dimensional echocardiography. Seventy (91%) underwent selective coronary arteriography and are included in this report. The study was divided into two periods because of increased experience and the use of a systematic approach with two-dimensional echocardiography in the second period as compared with the first. Aneurysms were demonstrated in nine patients (13%). The coronary artery system was divided into six regions: proximal third of the main right coronary artery, distal right coronary artery, left main coronary artery, left anterior descending coronary artery, circumflex coronary artery and distal left coronary artery. The sensitivity and specificity were high when imaging the proximal regions, and improved from the first period to the second. Both sensitivity and specificity were lower for the more distal regions of the right and left coronary arteries. Overall, the sensitivity of two-dimensional echocardiography was 100% because there were no patients in our study who had isolated distal coronary artery aneurysms. Two-dimensional echocardiography is a sensitive and specific test for detecting aneurysms in the proximal portions of both the right and left coronary arteries, and is useful in selecting patients for invasive investigation with selective coronary arteriography.     

Percutaneous unprotected left main angioplasty with drug-eluting stents in a nonagenarian: feasible and safe despite recurrent restenosis

The management of severe coronary artery disease in the very elderly is challenging and the most appropriate revascularization strategy highly debated. To date, coronary artery bypass surgery has been the treatment of choice for significant stenosis of unprotected left main (ULM) coronary. Whether this holds true also in very old patients is unknown. The Authors hereby report the case of a 91-year-old diabetic man who underwent coronary angiography in June 2005 for subacute unstable angina. Angiography disclosed a critical stenoses in the distal unprotected left main, left anterior descending, and distal left circumflex, which were treated with a paclitaxel-eluting stent and a bare-metal stent (BMS), respectively. Four months later, recurrent angina lead to a second angiography which showed critical restenosis in the left anterior descending and significant ostial stenosis in the left circumflex. Another paclitaxel-eluting stent was implanted in the left anterior descending, followed by kissing balloon in the left main, achieving a good angiographic result. Six months later angina recurred again: at angiography diffuse restenosis in the left main, left anterior descending and left circumflex was documented. A crushing technique was thus employed to deliver 2 sirolimus-eluting stents, achieving a satisfactory final result. Since then, and to date for more than 17 months since the last procedure, this nonagenarian has remained free from anginal chest. This case highlights the potentials and drawbacks of percutaneous coronary intervention for unprotected left main disease, suggesting nonetheless, that this revascularization strategy can be safely repeated even in elderly patients.     

Cardiopulmonary support in PTCA for severe coronary artery disease: its efficacy]

Percutaneous transluminal coronary angioplasty (PTCA) assisted by cardiopulmonary femorofemoral bypass was performed in 4 patients who were considered to be candidates for this technique because of their severe coronary artery diseases, including 2 with left main trunk disease, one with cardiogenic shock, and one with severe 3-vessel disease. Here we report the efficacy of cardiopulmonary support in PTCA. Case 1: An 85-year-old man with persistent unstable angina despite maximal doses of medications. Stenosis of the left anterior descending coronary artery (90%) was resolved by PTCA with cardiopulmonary bypass and intraaortic balloon pumping (IABP). Case 2: An 83-year-old man with unstable angina had high grade stenoses in the distal left main, left anterior descending and right coronary arteries. Although IABP was instituted for sustained chest discomfort and ST depression, the patient developed congestive heart failure. PTCA of the left main coronary artery with cardiopulmonary bypass was successfully performed. Case 3: A 64-year-old man with acute myocardial infarction. PTCA of the occluded left anterior descending coronary artery resulted in shock despite IABP, which was resolved by cardiopulmonary bypass with percutaneous insertion of cannulae, the technique we developed. Case 4: A 74-year-old man with unstable angina. He had a severe 3-vessel disease and a thrombus in the right coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Case report: Coronary steal secondary to a left main coronary artery–pulmonary artery fistula only manifest after coronary artery bypass surgery

We report the case of a 64 year old man with two vessel coronary artery disease and a left main coronary artery to pulmonary artery fistula. He underwent coronary artery bypass grafting, but the coronary artery fistula was not closed. He developed recurrent angina due to coronary steal from the distal left anterior descending artery by the maturing coronary artery fistula. This was closed percutaneously by stenting the left main coronary artery with covered stents. The clinical implications and potential mechanisms of the coronary steal due to the coronary artery fistula are discussed.     

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.     

Alterations of pressure waveforms along the coronary arteries and the effect of microcirculatory vasodilation

ObjectivesWe sought to investigate the differences of pressure waveforms at a distal point of an epicardial coronary artery comparatively to the ostium and to assess the effect of microcirculatory vasodilation on them.BackgroundPressure waveforms in the systematic circulation and their alterations along the aorta due to wave reflections from the periphery have been extensively studied. However, similar data regarding intracoronary pressure waveforms and the effects of coronary microcirculation on them are limited.MethodsIn 18 patients who underwent diagnostic coronary angiogram or percutaneous coronary intervention in the left circumflex or the right coronary artery, we studied pressure waveforms recorded by a high-fidelity pressure wire, which was advanced to the ostium and to a distal site of the free of significant lesions left anterior descending coronary artery. Pressure recording was performed both at rest and at hyperemia induced by intravenous infusion of adenosine. Analysis of pressure waveforms at the frequency domain was performed with Fast Fourier Transform.ResultsAt baseline conditions, distal pressure waveforms were characterized by higher pulsatility, higher presystolic wave and higher amplitude of the 11th to the 15th harmonics. Hyperemia increased the pulsatility, compressed the notch and decreased the amplitude of higher than the 10th harmonics of distal waveforms.ConclusionsThis study identifies differences of pressure waveforms between proximal and distal sites of free of significant lesions coronary arteries, which are affected by the status of coronary microcirculation and may therefore facilitate assessment of microvascular disease.     

Natural history of left anterior descending coronary artery obstruction: significance of location of stenoses in medically treated patients

We examined the prognostic significance of an obstructive lesion in the proximal left anterior descending (LAD) coronary artery. Five-year or longer follow-up data were examined from 311 patients with greater than 70% obstruction of the LAD treated without surgery. Mortality was compared in subsets with lesions proximal to and distal to the first septal perforating artery. Survival curves were worse in patients with proximal than with distal LAD disease (p less than 0.05); lesion location remained a significant determinant of survival when ejection fraction, age, and sex were controlled using a Cox regression model. However, when patient subsets were examined, survival with proximal LAD disease was worse than with distal obstruction only in the presence of an associated right coronary artery lesion and an ejection fraction of less than 40% (p less than 0.01). Patients with proximal LAD plus right coronary lesions had a 5-year mortality rate (34.08 +/- 8.9%) that was not significantly (p greater than 0.05) different from that of a group of 66 patients with greater than 50% narrowing of the left main coronary artery (24.02 +/- 4.3%). Thus, proximal LAD disease is more significant than is a distal lesion only in the presence of right coronary obstruction. This two-vessel combination results in a mortality rate as high as that associated with left main coronary artery obstruction.     

非体外循环冠状动脉旁路移植术在左主干重度狭窄患者中的应用

目的总结左主干重度狭窄冠心病患者行非体外循环下冠状动脉旁路移植术（OPCAB）的治疗效果和临床经验。方法回顾分析2005年1月至2012年6月,83例左主干狭窄〉70％的患者接受了非体外循环下冠状动脉旁路移植术,其中27例急诊手术,三支病变62例,两支病变21例,术中改为体外循环5例;使用主动脉内球囊反搏7例。结果远端吻合口平均（3．34±0．83）个,死亡2例（2．4％）。随访2个月至2年,仅1例心绞痛复发,余者均未出现心绞痛症状。手术效果及手术并发症的发生与非左主干病变组差异无统计学意义（P〉0．05）。结论左主干重度狭窄行非体外循环下冠状动脉旁路移植术临床效果良好。     

Should the left main be covered entirely with drug-eluting stents in percutaneous intervention

Restenosis after percutaneous intervention in the left main coronary artery may present as sudden cardiac death. Although drug-eluting stents have demonstrated promising results, there remains the question about appropriate length of the left main artery to be covered with the stent. We describe a patient who received two drug-eluting stents with the balloon crushing technique in the distal left main coronary artery. Three months later, this patient presented with a new lesion in the segment of the left main artery not covered with stent, but instead at the site where the balloon was inflated in the initial procedure.     

Hemodynamic support with a percutaneous left ventricular assist device during stenting of an unprotected left main coronary artery

Coronary artery bypass grafting prolongs survival in patients with left main coronary artery stenosis. However, this benefit is denied to patients who refuse the procedure or who are poor surgical candidates due to comorbid conditions. We describe a novel technique for the percutaneous revascularization of stenosis in an unprotected left main coronary artery in high-risk patients. The TandemHeart, a percutaneously inserted left ventricular assist device, was used to provide periprocedural hemodynamic support during angioplasty and stenting of an unprotected left main coronary artery for stenosis in a 70-year-old woman. The device was removed immediately after the procedure, and the patient was discharged from the hospital on the 2nd postprocedural day. The potential advantages of angioplasty with the support of percutaneous left ventricular assist devices in high-risk patients are discussed.     

Scintigraphic anatomy of coronary artery disease in digital thallium-201 myocardial images.

One hundred and eight patients with single and multiple vessel coronary artery disease confirmed by arteriography were evaluated by exercise thallium-201 (201Tl) myocardial scintigraphy to determine the scintigraphic appearances of specific coronary stenoses. In general proximal stenoses caused more widespread, but not necessarily more severe, myocardial tracer deficit than distal stenoses. In particular, proximal dominant right coronary artery disease was specifically associated with extensive inferior wall tracer deficit in the anterior scintigram, whereas proximal left circumflex disease caused similar tracer depletion best visualised in the left lateral scintigram. A triad of uptake defects was caused by left anterior descending coronary artery disease: viz. apical tracer deficit (anterior view) in 71% lesions, septal tracer deficit (left anterior oblique view) in 83% of lesions, and anterolateral wall tracer deficit (left lateral projection) in 72% of lesions. The last defect has been termed a 'diagonal window' because it was associated with independent disease of the main diagonal branch of the left anterior descending coronary artery or with disease in the main left anterior descending artery situated proximal to this branch. Diagonal window tracer deficit was the most useful scintigraphic sign distinguishing proximal from distal disease in the left anterior descending coronary artery. False negative scintigraphic defects occurred more commonly in patients with triple vessel disease and in association with well-developed coronary collateral vessels. Certain scintigraphic patterns of 201Tl myocardial accumulation appear invaluable in the noninvasive localisation of stenoses within specific coronary arteries and thus may be useful in predicting life-threatening coronary artery disease which should be confirmed by definite coronary arteriography. The digital 201Tl myocardial scintigram also provides an independent functional guide to the interpretation of coronary arteriograms and may be helpful in the planning of aortocoronary bypass graft surgery.     

Thrombus aspiration alone: a potential strategy in ST elevation myocardial infarction intervention

We are reporting a case of 46 year-old man, smoker with strong family history of coronary artery disease, presenting with acute anterolateral ST elevation myocardial infarction (STEMI). Diagnostic angiography revealed thrombus at the distal left main, occluding the anterior descending and intermediate arteries. Thrombus aspiration was performed with successful return of flow in the left coronary system. Stenting was deferred due to absence of occlusive lesion. He was commenced on glycoprotein (GP) IIbIIIa inhibitor and received intra-aortic balloon pulsation for haemodynamic support. Follow-up angiography revealed good flow in left coronary artery with normal ventricular function and no significant disease. He remained event-free at one-year follow-up. This case demonstrated that in the absence of occlusive lesion, thrombus aspiration alone without angioplasty or stenting is safe and effective with good clinical outcome.     

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.     

Left main coronary artery disease. Risks of angiography, importance of coexisting disease of other coronary arteries and effects of revascularization.

To elucidate the determinants of the poor prognosis of patients with left main coronary artery disease and to assess the efficacy of diagnostic and therapeutic interventions the angiographic features and clinical course of 58 patients with left main coronary artery disease studied between September 1967 and June 1974 were analyzed. Eighty-three coronary arteriograms were obtained in these 58 patients using the Judkins technique; there were no immediate complications although one patient died 3 days after study. Previously cited predictors of left main coronary artery, unstable or nonexertional angina and marked S-T segment depression with exercise were found in a minority of patients; thus, the presence of the disease could not reliably be predicted before arteriographic study. Coexisting disease was found in either two or three other coronary arteries in 46 of 58 patients; only 2 patients had isolated left main coronary artery disease. Because the criteria for operability have changed in recent years, current criteria without knowledge of the treatment actually given or its outcome. The condition of 10 of 58 patients was judged inoperable in retrospect because of severe coexisting distal coronary artery disease (8 patients) or ventricular dysfunction (2 patients). Of 19 patients whose condition was judged operable in retrospect but who were treated without surgery, 9 died, 8 within 18 months; 10 have survived 12 to 83 months. Another 27 patients with a condition judged operable in retrospect had received saphenous vein bypass grafts. In this group, there were four operative and three late deaths. The severity of angina decreased in survivors treated surgically but was unchanged in survivors treated without surgery. The improvement in survival rates of surgically treated patients was not statistically significant. The data indicate that coronary arteriography can be performed at low risk with the Judkins technique even though preangiographic prediction of left main coronary artery disease is unreliable. Coexisting disease in oter major coronary arteries is an important determinant of the poor prognosis of patients with left main coronary artery disease and precludes surgery in 13 percent. Isolated left main coronary artery disease is uncommon. Surgical therapy relieves symptoms more effectively than nonsurgical therapy.     

Hybrid revascularisation in a patient with multivessel and left main coronary disease

According to current guidelines surgical revascularisation is a gold standard of treatment in patients with multivessel and left main coronary disease. Hybrid revascularisation, in two stages: first - minimally invasive direct coronary artery bypass grafting procedure with left internal mammary artery conduit to left anterior descending artery and second stage - percutaneus coronary intervention with drug eluting stent in non-left anterior descending vessels may be safe and effective alternative in patients with multivessel and left main coronary disease.     

Angioplasty of the unprotected left main coronary artery stenosis with standby cardiopulmonary support--a case report

Stenosis of the unprotected left main coronary artery (LMCA) is a classical indication for coronary artery bypass graft surgery (CABG). Percutaneous coronary intervention (PCI) of LMCA may be an alternative to surgical treatment if atherosclerosis of distal segments is very advanced. The periprocedural risk is high, especially if comorbidities are present. However, long-term results remain unclear. The ongoing Syntax trial will clarify whether angioplasty of LMCA with drug-eluting stents can be equivalent to CABG. We present a case of a patient with occluded right coronary artery, severe stenoses of the LMCA, left anterior descending artery and left circumflex artery, and poor left ventricular ejection fraction in whom PCI for stenosis of unprotected LMCA with standby cardiopulmonary support was performed.     

Coronary anatomy and arteriography in patients with unstable angina pectoris.

A prospective series of 188 patients with the syndrome of unstable angina pectoris undergoing coronary arteriography was reviewed to determine the spectrum of anatomic coronary artery disease, suitability for coronary revascularization and in-hospital morbidity and mortality. Thirty-two patients demonstrated normal to moderately diseased coronary arteries. None of these patients sustained myocardial infarction or died. Twenty patients (10.6 percent) had normal coronary arteriograms. Of the 156 patients having severe coronary artery disease (greater than 70 percent stenosis), 20 patients (13 percent) had left main coronary artery disease. One hundred forty-two patients (91 percent) were potential candidates for coronary surgery; 14 were not candidates because of distal vessel disease or poor left ventricular function. During cardiac angiography or in the subsequent hospital period 12 patients sustained a myocardial infarction and 7 of these died. Of these seven, six had left main coronary artery disease and one had three vessel disease. In three patients who died (1.9 percent of those with severe coronary artery disease) the death may have been related to cardiac catheterization because evidence of myocardial necrosis began within 24 hours of study. Thus, patients with the syndrome of unstable angina pectoris usually presented with severe coronary artery disease and were candidates for coronary revascularization. The anatomic severity of coronary artery disease appeared to be the most important factor contributing to myocardlal infarction or death after cardiac catheterization. Mortality after catheterization was primarily associated with left main coronary artery disease.     

Left main coronary artery stenosis: state-of-the-art

Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis. Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome - it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk-benefit ratio of stenting versus coronary artery bypass graft surgery. These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery. The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.