Left Main Coronary Stenosis Research Articles

Left main coronary artery stenosis associated with extremely long fusiform aneurysm

Coronary artery aneurysm is defined as coronary dilatation, which exceeds the diameter of normal adjacent segment or the diameter of the patient's largest coronary vessel by 1.5 times [Syed M, Lesch M: Coronary artery aneurysms: a review. Prog Cardiovasc Dis 1997; 40:77–10 84 [1]]. Most studies show an incidence of 1% to 2% [Barettella MB, Bott-Silverman C. Coronary artery aneurysm: an unusual case report and a review of the literature. Cathet Cardiovasc Diagn 1993; 29:57–61 [2]]. Left main coronary aneurysms (LMCA) are even more rare; in a study by involving 22,000 coronary angiograms an occurrence rate of 0.1% has been found [Topaz O, DiSciascio G, Cowley MJ, Goudreau E, Soffer A, Nath A et al. Angiographic features of left main coronary artery aneurysms. Am J Cardiol 1991; 67:1139–1142 [3]]. The majority of patients present with ischemic symptoms secondary to the coexisting atherosclerotic lesions and most of the coronary aneurysms are incidentally diagnosed by coronary angiography. This report details the exceptional case of a 62-year-old patient with “unusually long fusiform” aneurysm of the left main coronary artery associated with critical left main coronary artery distal stenosis involving the ostia of left anterior descending and left circumflex coronary artery. With this case the possible anatomic determinants of the type, location, and mechanism of aneurysm formation were also discussed.

Left Main Coronary Stenosis or Left Coronary Artery from Pulmonary Artery?

Left Main Coronary Stenosis or Left Coronary Artery from Pulmonary Artery?

Prevalence of Narrowing ≥50% of the Left Main Coronary Artery Among 17,300 Patients Having Coronary Angiography

We sought to investigate the prevalence of left main coronary artery significant stenosis (LMSS) (>or=50% of the luminal diameter) in an angiographic series of patients, to describe the associated coronary stenoses, and to assess the influence of age and gender on these findings. The angiograms of 17,323 consecutive patients from January 1, 1984 to December 31, 2003 were retrospectively analyzed. LMSS was found in 823 patients (4.8%) and was more predominant in men (p <0.001). Men with LMSS (median age 63 years, interquartile range 57 to 69) were younger than the women (median age 67 years, interquartile range 61 to 72, p <0.001). Logistic regression analyses revealed male gender (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.46 to 2.18, p <0.001) and age (OR 1.05, 95% CI 1.04 to 1.06, p <0.001) as independent predictors of LMSS. In the total series, luminal narrowing >or=50% in the right coronary artery, the left circumflex artery, the left anterior descending artery, the intermediate artery, first and second obtuse marginal branch, posterior descending artery, and posterolateral branch was significantly more frequent in association with LMSS. Approximately half of the patients with LMSS also had triple-vessel disease. Co-existent disease in 3 major vessels with minor branches was more evident in men (men/women OR 1.77, 95% CI 1.08 to 2.88, p = 0.02). In contrast, LMSS without lesions in any of the other coronary arteries was found in [corrected] 4.7% of patients with LMSS, and this was more frequent in women (men/women OR 0.31, 95% CI 0.15 to 0.61, p = 0.001). In conclusion, men presented more frequently with LMSS and at a younger age than women. Also, LMSS with co-existent triple-vessel disease was more common in men.

Comparison of Simple and Complex Stenting Techniques in the Treatment of Unprotected Left Main Coronary Artery Bifurcation Stenosis

We assessed the safety and feasibility of various stenting techniques using the sirolimus-eluting stent (SES) in the treatment of unprotected left main coronary artery (LMCA) bifurcation stenoses. One hundred sixteen patients with unprotected LMCA bifurcation stenoses underwent SES implantation. A simple stenting technique (simple group, n = 67) across the left circumflex artery (LCx) and a complex technique (complex group) comprising "kissing" stenting (n = 24) or a "crush" (n = 25) technique were used. Baseline clinical and angiographic characteristics were similar for the 2 groups, except for more multivessel involvement and narrower LCxs in the complex group. The procedural success rate was 100%. Angiographic restenosis rate at 6 months was lower in the simple group (5.3%) than in the complex group (24.4%, p = 0.024). In the complex group, restenosis rates were similar for the kissing (25.0%) and crush (23.8%) techniques (p = 1.0). There were no incidents of death or myocardial infarction during follow-up (median 18.6 months). Target lesion revascularization was performed in 6 patients only in the complex group (0% vs 12.2%, p = 0.005). At 18 months, survival rates without target lesion revascularization were 100 +/- 0% in the simple group and 85.7 +/- 5.6% in the complex group (p = 0.004). In conclusion, SES implantation for unprotected LMCA bifurcation stenoses appears to be safe and effective. Compared with the complex stenting technique, the simple technique was technically easier and appeared to be more effective in improving long-term outcomes in patients with normal LCxs.

Electrocardiographic findings of severe left main coronary artery stenosis

Studies have documented the occurrence of ST elevation in lead aVR and/or diffuse ST depression in the setting of acute coronary syndromes (ACS) in patients with left main coronary stenosis (LMCS). We sought to describe the baseline ECG characteristics in LMCS patients outside of the ACS setting. Seventeen patients with ≥90% LMCS and 129 patients with 70–89% LMCS met criteria for the study. None of the 17 patients in the ≥90% LMCS group and 2/129 patients in the 70–89% LMCS group had ST elevation in aVR. None of the 17 patients in the >90% LMCS group and 3/129 patients in the 70–89% LMCS group had ST depression in ≥6 leads. Twenty-four percent of patents in the >90% LMCS group and 29% of patients in the 70–89% LMCS group had normal ECGs. While patients with severe LMCS outside of the ACS setting did not demonstrate ischemia, many exhibited normal ECGs.

Outcome of unprotected left main percutaneous coronary intervention in surgical low-risk, surgical high-risk, and acute myocardial infarction patients.

Percutaneous coronary intervention (PCI) of left main (LM) coronary artery stenosis may become an alternative to the standard therapy, coronary artery bypass graft surgery (CABG). The purpose of the present study was to describe the outcome after LM PCI in three cohorts of patients: patients with low surgical risk, patients with high surgical risk or patients considered inoperable, and patients with acute ST elevation MI. 104 consecutive patients who had LM PCI at the Department of Cardiology, Skejby University hospital between 1999 and 2004 were investigated. The patients were divided into three groups according to PCI indication and operability: surgical low risk patients and suitable lesions for PCI (n=27), poor CABG candidates (age > 80 years, severe comorbidity or inoperability) (n=50), and patients presenting with AMI (n=27). In the three groups mean ages+/-SD were: 60+/-14, 76+/-9, and 68+/-12 years, respectively. At thirty days follow-up the cumulative incidence of major adverse cardiac events (MACE); cardiac death, MI, or target lesion revascularization (95% CI) were 4 (1-24)%, 16 (8-30)%, and 41 (25-61)%, respectively. At 6 months the cumulative incidence of MACE were 4 (1-24)%, 27 (17-43)%, and 41 (25-62)%. PCI of LM coronary artery stenosis can be performed with good outcome in patients with low surgical risk and with acceptable outcome in surgical high risk patients or patients considered inoperable. Patients with AMI and culprit lesion in the LM have a high mortality in the acute phase, but mid-term prognosis is good if the patient is successfully treated with PCI. This follow-up study underlines the importance of risk stratification in the heterogeneous group of patients undergoing LM PCI.

Cirugía cardíaca en octogenarios: situación actual y perspectivas de futuro

Increasing life expectancy makes cardiac surgery in octogenarians not very uncommon. We evaluated the characteristics and outcomes of patients aged over 80 undergoing cardiac surgery in our centre. We retrospectively analyzed preoperative risk factors, in-hospital morbimortality, and long term survival in 120 patients aged 80 years--mean age (standard deviation): 81.53 (1.83)--who underwent cardiac surgery between 2000 and 2005, in comparison with 2425 younger patients referred to our center during the same period. Preoperatively, octogenarians presented arterial hypertension, renal failure, unstable angina, left main coronary stenosis and New York Heart Association (NYHA) functional class III or IV more frequently than younger patients. Combined cardiac surgery procedures (valvular plus coronary) were also significatively higher (20% vs. 9.85%). Hospital mortality (15.8%) was twice as higher as in the non octogenarian population and postoperative intensive care units and hospital stay was longer. 45% suffered some postoperative complication. In the multivariate analysis, urgent procedure, mitral valve surgery and presentation of any postoperative complication were identified as predictors of mortality, and female sex was identified as a risk factor for postoperative morbidity. Survival at one, 3 and 5 years was 91.20%, 80.73% and 69.20%, respectively. 98.7% of the patients were in I-II NYHA functional class and 92.5% satisfied with overall surgery outcome when they were interviewed. Despite more preoperative co-morbidity and worse functional class, cardiac surgery in octogenarians can be performed with an acceptable mortality. Our patients have a satisfactory quality of life and would undergo a cardiac surgery procedure again. Specific measurements in preoperative and immediate postoperative periods, in order to reduce higher morbidity rates, are advisable.

Concurrent coronary and carotid artery surgery: factors influencing perioperative outcome and long-term results†

To assess risk factors for early and late outcome after concurrent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). Records of all 311 consecutive patients having concurrent CEA and CABG from 1989 to 2002 were reviewed, and follow-up obtained (100% complete). In the group (mean age 67 years; 74% males), 62% had triple-vessel disease, 57% unstable angina, 31% left main coronary stenosis, 19% congestive heart failure, and 35% either a history of vascular procedures or existing vasculopathies. Preoperative assessment revealed transient ischaemic attack in 16%, stroke in 7%, and bilateral carotid disease in 20%. There were 7% emergent and 19% urgent operations, and ascending aorta was described as atheromatous or calcified in 21%. Hospital death occurred in 19 patients, myocardial infarction in seven, and permanent stroke in 12. Significant multivariable predictors of hospital death were aortic calcifications, coexisting vasculopathy, and emergent procedure. Significant predictors of postoperative stroke were calcified or dilated aorta, and of prolonged hospital stay were advanced age, unstable angina, and coexisting vascular disease. For hospital survivors, 10-year actuarial late event-free rates were: death, 50%; myocardial infarction, 84%; stroke, 93%; percutaneous angioplasty, 95%; redo CABG, 98%; and all morbidity and mortality, 48%. Significant multivariable predictors of late deaths were coexisting vasculopathy, age, renal insufficiency, previous cardiac surgery, tobacco abuse, calcified or atheromatous aorta, and duration of intensive care unit stay. Concurrent CEA and CABG can be performed with acceptable operative mortality and morbidity, and good long-term freedom from coronary and neurologic events. Atheromatous aortic disease is a harbinger of poor operative and long-term outcome.

Left Main Coronary Angioplasty in Surgical and Nonsurgical Candidates

The impact of patient- and operator-related clinical variables of success and evaluation of subsequent midterm effects of percutaneous treatment of left main coronary stenosis were assessed at a tertiary-referral high-volume angioplasty center in a retrospective observational study. A total of 118 consecutive surgical and nonsurgical patients with protected and unprotected left main (LM) lesions were treated by operators within a preconditioned expert culture. There were 57 protected and 61 unprotected patients, including 13 patients with an acute myocardial infarction (AMI). Mean age was 67 years (range 33-90). The length of the stenotic segment was 4.8 +/- 2.3 mm, mean lumen diameter was 1.1 +/- 0.6 mm, and percentage diameter stenosis was 63.6 +/- 14.6%. There were 7 (5.9%) in-hospital cardiac deaths that presented with AMI and cardiogenic shock. All 7 patients presented with unprotected LM lesions. Average follow-up was 8 months (range 1-36 months). Major adverse cardiac events (MACE) during follow-up comprised 8 (6.8%) cardiac deaths, 3 (2.5%) myocardial infarctions, 8 (6.8%) subjects with coronary bypass surgery, and 16 (13.6%) repeated angioplasties. The total event rate (MACE, n = 43) at the end of the follow-up period was 36.4%. There were more MACE in the unprotected group than in the protected group (41% vs. 31.6%, P<0.05). This study supports prior data on LM angioplasty. LM stenting in AMI showed less favorable in-hospital and late outcome.

1157-42 Fractional flow reserve versus intravascular ultrasound for decision-making in equivocal left main coronary stenosis

1157-42 Fractional flow reserve versus intravascular ultrasound for decision-making in equivocal left main coronary stenosis

1081-58 Long-term (seven-year) outcomes after bare metal coronary stenting for unprotected left main coronary stenosis

1081-58 Long-term (seven-year) outcomes after bare metal coronary stenting for unprotected left main coronary stenosis

Intravascular ultrasound-guided directional coronary atherectomy for unprotected left main coronary stenoses with distal bifurcation involvement

Accidents due to the misuse and abuse of agricultural pesticides is a worldwide problem. Although data gaps exist, there is an ever-growing body of information on the incidence and nature of pesticide-caused poisonings in the developing countries of the world. The information gathered in a field study in Ecuador, South America, among rural-based users of pesticides contributes to the understanding of the problem. Factors that contribute to accidental poisonings are detailed and described and are related to accident prevention efforts.

Intravascular ultrasound-guided directional coronary atherectomy for unprotected left main coronary stenoses with distal bifurcation involvement

Stent implantation in unprotected left main coronary artery (LMCA) bifurcation lesions may improve procedural and late clinical outcomes. However, concerns regarding stent-related complications, such as stent jail, subacute thrombosis, and in-stent restenosis remain. Optimal debulking by directional coronary atherectomy (DCA) with intravascular ultrasound (IVUS) guidance may be effective in this complex lesion subset, but this strategy has not yet been established. Our objective was to evaluate the safety and efficacy of IVUS-guided DCA for unprotected LMCA stenoses with distal bifurcation involvement. A total of 67 consecutive patients were included in this study and procedural success was achieved in all cases. Two cardiac deaths (2.9%) were noted and 3 patients (4.5%) underwent repeat angioplasty during hospitalization. There was no Q-wave myocardial infarction or emergency bypass surgery. Non–Q-wave myocardial infarction (creatine kinase-MB >3 times normal) occurred in 13.4% of patients. Stent implantation was necessary in 17 cases (25.4%) to achieve an optimal result. IVUS showed an improved lumen cross-sectional area and a low plaque burden in the LMCA after intervention. All-cause mortality, angiographic restenosis, and the target lesion revascularization rates at 6 months were 7.4%, 23.8%, and 20.0%, respectively. With IVUS guidance, aggressive DCA can be performed safely in unprotected LMCA bifurcation lesions, and optimal angiographic and IVUS results can be achieved with low residual plaque burden, which leads to a low restenosis rate. Optimal lesion debulking by DCA does not necessarily need adjunctive stenting in this specific anatomic subset.

Patent ductus arteriosus and left coronary ostium stenosis: an hybrid approach

Nowadays combination of surgical procedures and interventional cardiology has been increasingly reported in literature for the treatment of coronary artery diseases. To confirm the applicability of such an approach we present a case where several approaches could be considered. A 56-year-old lady with incidental finding of patent ductus arteriosus (PDA) and concomitant left main coronary artery ostium stenosis was scheduled to have PDA transcatheter closure and surgical angioplasty of the coronary ostium. This 'hybrid' approach to such an unusual clinical presentation was successful and at 1 year follow-up the patient is symptoms free and no residual shunts have been detected.

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 nondiagnostic 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.

A Case of Isolated Left Main Coronary Ostial Stenosis Due to Acute Angle Take-off with Clockwise Rotation of Coronary Sinus confirmed by MRI Image

Isolated left main coronary ostial stenosis is a very rare condition. In the majority of cases there are coexisting diseases in multiple coronary vessels. Here, a case of isolated left main coronary ostial stenosis due to an acute angle take-off, with clockwise rotation of the coronary sinus, confirmed by cardiac MRI is presented. A 44-year old female patient presented with an exertional and stabbing anterior chest pain. The patient had no premedical history. A coronary angiogram showed an isolated left main coronary ostial stenosis due to an acute take-off of the left main coronary artery. A cardiac MRI showed an acute angle take-off of the left main coronary artery, with clockwise rotation of the coronary sinus. The patient underwent surgical angioplasty of the coronary ostia, with a patch of autologous pericardium. This acute angle take-off may be due to rotation of the coronary sinus. (Korean Circulation J 2003;33 (5):435-438)

Does Acute Normovolemic Hemodilution Work in Cardiac Surgery?

University Hospital of Geneva, Switzerland. denis.morel@hcuge.chIn Reply:—We appreciate the interest of Moskowitz et al . regarding our article. 1They hypothesize that too restrictive inclusion criteria and excessive fluid replacement in the acute normovolemic hemodilution (ANH) group could explain the absence of beneficial effects of ANH.First, for obvious ethical reasons, we selected patients to undergo preoperative ANH based on the recommendations of the British Committee for Standards in Blood Transfusion, which take into account the potential risks and benefits of blood salvage techniques. Therefore, due to the risk of myocardial ischemia, stroke, or heart failure, we did not perform ANH in patients with severe coronary artery disease (recent myocardial infarction, unstable angina, left main coronary stenosis), severe aortic stenosis, poor left ventricular function, carotid stenosis, and/or preoperative anemia. According to these stringent exclusion criteria, we included only 57% of all consecutive patients undergoing elective coronary revascularization or valvular surgery. Nevertheless, a high risk of bleeding was considered in more than 50% of these surgical candidates (preoperative anticoagulant and/or aspirin therapy, repeat or combined operation) in whom the blood-sparing benefits of ANH could be anticipated.Second, perioperative fluid hydration was similar in both groups, except for compensation of the removed blood by colloids in the ANH group: the volumes of infused crystalloids (94.6 ml · kg−1· 24 h−1and 88.8 ml · kg−1· 24 h−1in the control and ANH groups, respectively) and colloids (16.5 ml · kg−1· 24 h−1and 26.2 ml · kg−1· 24 h−1in the control and ANH groups, respectively) were in the range of the values commonly reported 2and included any solution administered intravenously and through the cardiopulmonary bypass (e.g. , cardioplegia, priming). To achieve similar cardiac preload conditions, larger than expected volume of colloids were given in the ANH group (hypervolemic compensation), which resulted in ANH-induced vasodilatation and reduced blood viscosity. 3Since ANH is known to be associated with poor tolerance to acute blood loss and impaired adrenergic response, 4,5we closely guided fluid administration using transesophageal echocardiography and central venous pressure monitoring in order to avoid hypovolemia and to detect myocardial ischemia.Finally, as suggested by Dr. Moskowitz and others, 6we agree that the implementation of a standardized, multidisciplinary approach, including definition of transfusion criteria, administration of antifibrinolytic drugs, use of cell saver devices, and external heating, is most helpful to reduce transfusion of allogenic blood products in patients undergoing cardiac surgery. However, evidence supporting the addition of ANH as a blood-sparing technique is still lacking, although a consensus is based on data from observational studies and prospective, unblinded, randomized trials. 7

Should follow-up angiography be routine in asymptomatic patients after stenting of unprotected left main coronary stenosis?

Should follow-up angiography be routine in asymptomatic patients after stenting of unprotected left main coronary stenosis?

Resultados de la cirugía de revascularización coronaria aislada y combinada en pacientes mayores de 75 años

Increase in life expectancy is causing an increase of surgical myocardial revascularization procedures in the elderly. We evaluate the evolution of this type of interventions in people older than 75 years, taking into account the risk factors, results and survival. Between July 1988 and May 2001, 237 isolated or combined myocardial revascularization procedures were carried out in patients older than 75 years (Group I), while 1177 were performed in younger patients (Group II). We retrospectively analyzed the mortality risk factors, surgical procedures, postoperative complications and survival in Group I patients. Preoperatively, Group I patients showed a more frequent left ventricular dysfunction, left main coronary stenosis, emergency surgery and combined procedures, while Group II patients displayed more common preoperative myocardial infarction and dyslipemia. Mortality in Group I was 20.7% vs 9.09% in Group II. Mortality was higher for mixed procedures (27.1%) than for isolated myocardial revascularization (13.8%). Postoperative complications were present in 48.5% patients. Significant preoperative risk factors of mortality in Group I were: female sex, high-risk ergometry, III-IV NYHA functional class, and atrial arrhythmia. The preoperative NYHA functional class was also a morbidity risk factor. Survival at 1, 3 and 5 years was present in 98.4%, 92.1% and 81% patients, respectively, NYHA functional class I-II being present in 94.18% patients. Myocardial revascularization surgery in people older than 75 years leads to an increase of morbimortality. Anyway, long-term survivors' quality of life makes us think of surgery as a valid treatment alternative.

Should we still perform angioplasty and stenting of an unprotected left main coronary artery stenosis in heart transplant patients? two new cases and a review of the literature

Coronary balloon angioplasty with stent implantation has emerged as a possible alternative to bypass grafting or repeat transplantation in left main coronary stenosis in heart transplant patients. We report 2 new cases of stent implantation for unprotected and isolated left main stenosis in heart transplant patients. Despite an initially successful procedure, restenosis prompted the performance of bypass surgery in both patients. The relative advantages and disadvantages of available techniques of revascularization are discussed in the context of the literature.