Ostial stenosis of the left main coronary artery after mediastinal radiotherapy. Apropos of a case

Coronary artery disease (CAD) is a well-known complication of mediastinal irradiation. We report a case of subocclusive ostial stenosis of the left main coronary artery, in a 27 years old man, who had been irradiated 14 years before for a stage 4 Hodgkin's disease. Among the 68 reported cases of CAD attributed to radiotherapy, 11 involved an ostial stenosis of either right coronary artery, or left main coronary artery or both. Thus mediastinal irradiation seems to be a definite cause of ostial coronary artery stenosis; several types of myocardial revascularization have been suggested for this kind of CAD.     

Severe coronary artery disease after radiation therapy of the chest and mediastinum: clinical presentation and treatment.

OBJECTIVE--To define the clinical and angiographic features and the therapeutic problems in patients with coronary artery disease after therapeutic irradiation of the chest. DESIGN--An observational retrospective study. SETTING--The cardiac catheterisation laboratory, university medical school. PATIENTS--15 subjects (8 men and 7 women, aged 25-56 years, mean 44) examined in the cardiac catheterisation laboratory, who had significant coronary artery disease years after having radiation treatment to the chest and anterior mediastinum. In the early stages of the study angiography was performed because of typical symptoms of ischaemic heart disease. Later on it was performed because of a high index of suspicion in people with signs of extensive radiation heart damage. MAIN OUTCOME MEASURES--Clinical and electrocardiographic evidence of ischaemic heart disease; echocardiographic signs of pericardial, myocardial or valvar involvement; angiographic evidence of coronary arterial stenosis, with special attention to the ostia; haemodynamic and angiographic signs of pericardial, myocardial, and valvar disease. Survival and symptomatic and functional status were ascertained after medical or surgical treatment. RESULTS--The patients were relatively young and had no risk factors. Seven patients had no signs or symptoms of ischaemic heart disease. Ten patients had ostial stenosis, which was associated with extensive involvement of other cardiac structures in nine of them. Seven required surgical treatment for coronary artery disease. Two died, one at surgery and the other one six months later. Five patients had complications associated with irradiation. CONCLUSIONS--Coronary arterial disease can be reasonably ascribed to the effects of chest irradiation when the patients are young and free from risk factors, especially if the obstructions are ostial and there is important damage to other cardiac structures. In patients with damage to other cardiac structures angina and infarction are often absent and coronary angiography seems to be mandatory. Patients often require surgical treatment and postoperative complications are common.     

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.     

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.     

The effects of rapid volume expansion on the right and left cardiac filling pressures after coronary artery bypass surgery

Rapid volume expansion is a diagnostic procedure which can reveal typical hemodynamics of pericardial constriction in patients with pericardial disease who have normal hemodynamics in their baseline state. We studied 20 patients with previous coronary artery bypass surgery in order to determine whether this operation results in some degree of pericardial constriction which could be demonstrated by rapid volume expansion. After infusing 1 L of physiologic saline solution over six minutes, the right atrial pressure increased by 5 +/- 2 mm Hg, the right ventricular diastolic pressure by 4 +/- 3 mm Hg, the pulmonary capillary wedge pressure by 7 +/- 3 mm Hg, and the left ventricular diastolic pressure by 7 +/- 4 mm Hg (mean +/- SD). Equalization of the left and right cardiac pressures was not observed, and the normal respiratory variation of the pressures was not altered by rapid volume expansion. Thus, the pericardial manipulation associated with the performance of coronary artery bypass surgery does not commonly result in the development of subclinical pericardial constriction.     

Predictors of right ventricular dysfunction in patients with coronary artery disease and reduced left ventricular ejection fraction

BACKGROUND: The frequency and determinants of right ventricular (RV) dysfunction in patients with coronary artery disease (CAD) and reduced left ventricular (LV) function have not been thoroughly investigated. METHODS: The study population consists of 80 consecutive patients, invasively evaluated at our centre. Entry criteria were: LV ejection fraction < 45%; angiographic evidence of obstructive CAD; disease history of more than 3 months' duration. Exclusion criteria were: recent myocardial infarction and unstable angina. All patients underwent cardiac catheterization with coronary, LV and RV angiography. RV dysfunction was defined as a RV ejection fraction < 35%, which corresponds to the mean-three standard deviations of controls. RESULTS: Sixty-five patients (81%) had multi-vessel disease and 57 (71%) had a previous myocardial infarction. Mean LV ejection fraction was 31 +/- 8%. Mean RV ejection fraction was 46 +/- 11%. Right ventricular dysfunction was present in 14 patients (18%). An occluded proximal right coronary artery was associated with significantly lower RV ejection fraction (38 +/- 12% versus 47 +/- 10%; P = 0.009) but not LV ejection fraction (30 +/- 8% versus 32 +/- 9%; P = 0.444). However, at multivariate analysis, only pulmonary hypertension was an independent significant predictor of RV dysfunction (P < 0.001; OR: 1.13; CI: 1.06 -1.22). CONCLUSION: Right ventricular dysfunction in patients with chronic ischaemic LV dysfunction is detected in less than 20% of cases. Proximal right coronary artery occlusion is associated with a reduced RV ejection fraction. However, the role of right coronary artery disease is overwhelmed by the haemodynamic burden of pulmonary hypertension, which represents the only independent predictor of RV dysfunction in our population.     

Anomalous origin of the right coronary artery from the left coronary sinus is associated with early development of coronary artery disease

BACKGROUND: Anomalous origin of the right coronary artery (RCA) from the left coronary sinus can cause sudden cardiac death. Whether this unique anatomical defect also predisposes to early development of coronary artery disease (CAD) remains uncertain. METHODS: Demography, cardiovascular risk factor profiles and coronary angiograms were reviewed in 1,532 consecutive patients over the past 3 years. RESULTS: Thirteen patients (0.8%) had anomalous RCA from the left coronary sinus, while the rest had normal origin from the right coronary sinus. CAD was found in 9/13 anomalous RCA patients (group A) and in 795/1,519 patients with normal RCA origin (group B). There were no differences in the distributions of age, sex or cardiovascular risk factors between the two groups. The distribution of critical lesions among the 3 major coronary arteries showed no significant differences either. However, among the patients with RCA involvement, the anomalous RCA group was significantly younger (54.8 +/- 4.8 years versus 64.9 +/- 10.1 years; p = 0.022). CONCLUSION: The anomalous RCA from left coronary sinus is associated with early development of CAD. The affected patients are 10 years younger.     

Coronary ostial stenosis: surgical considerations

To investigate the clinical significance of coronary ostial stenosis, we reviewed eight patients with such lesions, including three with isolated stenosis at the orifice of the coronary artery. There were five male and three female patients, with an average age of 46.25 years (range 32–69 years). Their symptoms consisted mainly of angina (6 patients), with dyspnoea and palpitation being the presenting features in the remaining two patients. All patients underwent preoperative coronary angiography which confirmed stenosis at the level of the orifice with absence of reflux of contrast medium into the sinus of Valsalva as the main features. Delay in the appreciation of stenosis of the orifice of the right coronary artery resulted in the death of two patients, whose diagnosis was confirmed at post mortem examinations. Stenosis of the orifice of the right coronary artery was present in seven patients, with two patients also having stenosis of the orifice of the left coronary artery. The remaining patient had isolated stenosis of the left coronary arterial orifice. Coronary artery bypass grafting was performed in five patients, including two who had patch angioplasty to the right coronary artery. The patient with isolated stenosis of the orifice of the left coronary artery had patch angioplasty only. Follow-up of up to three years in the surviving patients showed good functional results. The ease with which it is possible to miss right coronary ostial stenosis is emphasized and angiographic features are reviewed.     

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)     

Value of dobutamine stress echocardiography for diagnosis of coronary artery disease in patients with left bundle branch blockage

BACKGROUND: Left bundle branch blockage (LBBB) is a strong predictor of cardiovascular mortality. Non-invasive tests such as exercise-stress testing and scintigraphy studies have no diagnostic value for diagnosis of coronary artery disease (CAD) in patients with LBBB. OBJECTIVE: To study the role of dobutamine stress echocardiography (DSE) in identification of CAD in patients with LBBB. METHODS: Thirty patients (19 men and 11 women, mean age 60 +/- 8 years) with permanent, complete LBBB were studied prospectively with DSE and coronary angiography. RESULTS: Results of DSE were compared with results of coronary angiography for left anterior descending artery and either left circumflex or right coronary artery territories, or both. Significant CAD was found in left anterior descending coronary arteries in 11 patients by coronary angiography; nine of whom were identified by DSE. Significant left circumflex or right coronary artery disease, or both, was found in nine patients; eight of whom were identified by DSE. The sensitivity, specificity and accuracy of DSE for identifying CAD in left anterior descending coronary artery territory were 82, 95 and 90%, respectively. For identifying CAD in the circumflex and right coronary artery territories sensitivity, specificity and accuracy were 88, 96 and 93%, respectively. CONCLUSION: We concluded that DSE is a very sensitive, specific and accurate non-invasive test for identification of CAD, both in left anterior descending and in left circumflex and right coronary artery territories of patients with LBBB.     

Myocardial infarction in young Indian patients: risk factors and coronary arteriographic profile

One hundred four patients (101 men, three women), under 40 years of age, with myocardial infarction (MI), underwent coronary arteriography. Eighty patients had significant obstructive coronary artery disease (CAD) (group 1), 23 had normal coronary arteries (group 2), and one patient had coronary ostial stenosis as a result of nonspecific aortoarteritis (group 3). Coronary risk factors in group 1 included smoking (76.2%), hypercholesterolemia (36.3%), hypertension (32.5%), positive family history (28.7%), and diabetes mellitus (5%). Multiple risk factors were frequent (56.2%). Smoking was common (p less than 0.01) and diabetes mellitus less frequent (p less than 0.05) as compared to older (greater than 40 years) patients with MI and arteriographically proved CAD. The frequency of one-, two-, and three-vessel disease was 33.7%, 26.2%, and 40%, respectively, in group 1. Group 2 patients were almost devoid of coronary risk factors. The only group 3 patient had left coronary ostial stenosis with no risk factors. Similar to their counterparts in developed countries, young Indian patients with MI and obstructive CAD have a high frequency of coronary risk factors, especially smoking and severe multiple-vessel disease. Since normal coronary arteriograms are also frequent in this setting, a detailed evaluation is recommended for purposes of prognosis and management.     

Two- to eight-year survival rates in patients who refused coronary artery bypass grafting

One hundred and fifty patients with coronary artery disease (CAD) who refused bypass grafting were followed prospectively from 2 to 8 years. Mean age was 57 +/- 8 (standard deviation) years. Ejection fraction averaged 70 +/- 14%. Eight percent of patients had 1-vessel CAD and 92% had multiple-vessel CAD. Medical treatment included propranolol, nifedipine, isosorbide dinitrate, dipyridamole and aspirin. Annual mortality was 0% for 1- and 2-vessel CAD and 1.3% for left main equivalent disease, 3-vessel and left main CAD. Treatment significantly reduced the incidence of stable and unstable angina. Fifty-two patients (34%) had a second hemodynamic study 4.2 +/- 1.3 years after initial evaluation. Stenosis progression or new significant obstructions (greater than or equal to 70%) in previously normal coronary arteries occurred in 61% of 123 arteries studied, whereas new occlusions were observed in 12% of the arteries. Nonfatal acute myocardial infarction incidence was 8%. No significant changes occurred in ejection fraction. In conclusion, proper medical treatment in selected patients with advanced CAD but preserved ventricular function is associated with good long-term survival and remission of symptoms, although progression of coronary atherosclerosis does occur in some patients.     

Cardiovascular features of homozygous familial hypercholesterolemia: analysis of 16 patients

Familial hypercholesterolemia (FH) is characterized by an autosomal codominant inheritance, an abnormality in low-density lipoprotein (LDL) receptor function, elevated plasma cholesterol levels and premature atherosclerosis. Sixteen patients with homozygous FH were studied to correlate the extent of their atherosclerotic disease with their lipid levels and receptor function. The age range at initial presentation was 3 to 38 years (mean 12), and at the last examination, 6 to 43 years (mean 20). The mean pretreatment total plasma cholesterol concentration for all patients was 729 +/- 58 mg/dl (+/- standard error of the mean), and the mean LDL cholesterol level was 672 +/- 58 mg/dl (normal 60 to 176). High-density lipoprotein cholesterol was 28 +/- 3 mg/dl (normal 30 to 74). In the 7 patients with FH who had symptoms of myocardial ischemia (Group I), the mean pretreatment LDL cholesterol value (817 +/- 62 mg/dl) was higher than that of the 9 asymptomatic patients (Group II) (560 +/- 74 mg/dl). In Group I, 5 of 7 patients had left or right coronary ostial narrowing and 3 had significant left ventricular outflow obstruction. Most coronary arterial narrowing occurred in the right coronary and left anterior descending arteries and the least amount in the left circumflex coronary artery. A femoral bruit was the physical finding that correlated best with the Group I population; brother:sister pairs revealed a milder clinical course for the female. Seven of the 16 patients have survived into their third decade without symptoms. Comparison of these persons with those in whom angina developed reveals a marked heterogeneity in their clinical course, which appears to be associated with receptor negative/defective status.     

冠状动脉口部病变介入治疗中Szabo技术应用的安全性和可行性

目的分析冠状动脉口部病变PCI中造影和血管内超声(intra vascular ultrasonography,IVUS)结果 ,评价Szabo技术的成功率、安全性和可行性。方法回顾性分析Szabo技术治疗冠状动脉口部病变患者39例PCI结果。结果经桡动脉途径31例(79.5%),经股动脉途径8例(20.5%)。罪犯血管为左前降支26例(66.7%),右冠状动脉5例(12.8%),左回旋支及钝缘支3例(7.7%),后降支5例(12.8%)。支架置入后,对30例(76.9%)罪犯血管和9例(23.1%)边支血管进行了IVUS检查。手术成功36例(92.3%)。所有患者造影成功率为100%。IVUS检测罪犯血管准确支架置入到口部患者29例(96.7%)和支架近端轻度凸出患者1例(3.3%)。结论 Szabo技术用于冠状动脉口部病变PCI中是安全可行的,而且具有极高的造影成功率。经过IVUS检查证实大部分支架在冠状动脉口部病变处能准确置入。     

Stenosis of the common trunk with and without ostium involvement: clinical and angiographic characteristics

STUDY OBJECTIVE: To evaluate the clinical and angiographic profile of patients with left main coronary artery stenosis with (LM-OS) and without left coronary ostial stenosis (LM-NOS). DESIGN: Retrospective study of patients submitted to coronary angiography. SETTING: Laboratory of Hemodynamics and Interventional Cardiology at Bellvitge Hospital -Barcelona, Spain. PARTICIPANTS: 4663 consecutive patients (pts) with angiographically defined coronary artery disease. 139 pts had left main stenosis greater than or equal to 50%. Twelve pts were excluded because nonatheroesclerotic disease. Twenty two pts (17%), had LM-OS and 105 (83%) LM-NOS. INTERVENTIONS: Pts records were reviewed, to analyse the following clinical and angiographic variables: age, gender, risk factors to coronary artery disease, history of myocardial infarction, anginal class, presence of unstable angina, basal ECG ischemia, percentage and localization of left main stenosis, number and degree of vessels diseased, indexes of left ventricular function and coronary dominance. MAIN RESULTS: 1. Clinical characteristics--In the LM-OS group 18 pts were male and 4 female, while in the LM-NOS the numbers were respectively 90 and 15, p = ns. As for the gender the age showed also a similarity: 58 +/- 8 and 57 +/- 8 years, p = ns. A history of arterial hypertension was present in 73% of pts with LM-OS and 47% with LM-NOS, p greater than 0.05. With respect to the other clinical variables both groups were similar. The incidence of LM-OS was 0.4%. 2. Angiographic characteristics--The severity of left main stenosis was identical in the two groups: 80 +/- 15 in LM-OS and 75 +/- 16% in LM-NOS (p = NS). Four (18%) of the pts with LM-OS had no associated coronary disease versus 7 (7%) of the LM-NOS (p = 0.08). There were 1.3 +/- 1 diseased vessels in the LM-OS group and 2.1 +/- 1 in the LM-NOS (p greater than 0.01). CONCLUSIONS: In the present series, the clinical and hemodynamic profile of patients with left main disease suggest that the following characteristics are more frequently seen in patients with ostial stenosis: 1) history of arterial hypertension; 2) no associated coronary disease; 3) smaller number of diseased vessels; 4) less significant 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.     

Origin and distribution anomalies of the left anterior descending artery in 70,850 adult patients: multicenter data collection.

OBJECTIVES: To present the clinical and angiographic properties of the left anterior descending artery anomalies. BACKGROUND: Coronary artery anomalies are discovered in less than 1% of angiography series. Since the number of angiographies and coronary bypass operations are increasing significantly every day, these anomalies are of clinical importance. However, data about left anterior descending artery anomalies in literature is still scarce. METHODS: We reviewed the records of 70,850 patients who had undergone coronary angiographies at 4 different cardiology center from 1999 to 2005 years. RESULTS: Major congenital coronary anomalies were discovered in 171 of these cases (0,24%). The mean age of these patients was 61 +/- 11 (18-84) years. Ninety nine patients (58%) were male. Left anterior descending artery was involved in 12 patients (0.017%). In nine patients with the anomalous LAD there were concomittant congenital coronary artery anomalies. Concurrent coronary artery anomalies encountered were double left anterior descending artery type 4 (2 cases), double left anterior descending artery type 4 with double right coronary artery (1), double right coronary artery (1), double circumflex artery with anomalous left anterior descending artery (1), circumflex artery from right sinus of Valsalva (1), separate septal perforator and myocardial bridging of posterior descending artery (1), intercoronary communication, and ostial atresia of the left anterior descending artery and anomalous circumflex artery (1). CONCLUSION: Our series is the biggest series where relatively sufficient clinical and angiographic information about the LAD anomalies were provided.     

Localization of coronary artery narrowings by applying R-wave amplitude correction to exercise-induced ST depression in angina pectoris and single-vessel coronary artery narrowing

This study investigated whether coronary artery narrowings can be localized by applying R-wave amplitude correction to exercise-induced ST depression in multiple unipolar precordial lead electrocardiography using 20 electrodes covering the left chest wall. Ten normal subjects and 29 patients with stable angina pectoris and single-vessel coronary artery narrowing (greater than or equal to 75% luminal diameter stenosis in only 1-vessel) participated. Of the 29 patients, 5 had left main coronary artery disease (CAD), 14 had left anterior descending CAD, 4 had right CAD and 6 had left circumflex CAD. The exercise-induced ST depression with R-wave amplitude correction was defined as the exercise-induced ST depression divided by the R-wave amplitude. The 20 points of the lead system were divided into 4 areas: the left main, left anterior descending, right and left circumflex coronary arteries. Coronary artery narrowing was supposed to be in an artery corresponding to the area where the maximal value of the exercise-induced ST depression with and without R-wave amplitude correction was situated. By applying R-wave amplitude correction, the diagnostic ability of localization of coronary artery narrowings was improved significantly from 52% to 86% (p less than 0.005). In particular, localization of the left main coronary artery narrowing was correctly diagnosed in 100% (5 of 5) of angina pectoris patients with left main CAD.     

Coronary artery disease associated with aortitis syndrome in older patients

Coronary artery disease associated with aortitis syndrome was studied in relation to the coronary artery lesions and age. Four (21%) of 19 patients with aortitis syndrome had coronary artery disease and the mean age of the 4 patients was 53 +/- 14 years. The coronary artery lesions included ostial stenosis in 2 patients and main branch stenosis in 2, but both types of lesion were isolated. The latter patients were older and had coronary lesions like arteriosclerosis on angiogram. Myocardial infarction and congestive heart failure were not present, but a severe coarctation of the aorta was observed in the latter. It was suggested that coronary artery disease might not be rare past middle age, and might include coronary ostial stenosis caused by aortitis and coronary main branch stenosis probably based on secondary arteriosclerosis whose onset was past middle age.