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Ann Thorac Surg 1996;62:550-552
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Surgical Angioplasty of the Left Main Coronary Artery: Follow-up With Magnetic Resonance Imaging

Surgical Unit and Department of Radiology, Papworth Hospital, Cambridge, England

Accepted for publication April 8, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Ostial stenosis of the left main coronary artery is a serious condition with a dismal prognosis. The treatment is surgical, with the two viable options being coronary artery bypass grafting and surgical angioplasty of the left main coronary artery.

Methods. We describe the use of surgical angioplasty to treat 3 patients (2 women and 1 man) with left main ostial stenosis using the posterior approach. Patency of the angioplasty was demonstrated subsequently with magnetic resonance imaging.

Results. All 3 patients were free of angina 12, 18, and 24 months after operation. Magnetic resonance imaging scans in all 3 patients demonstrated the widely patent left main coronary artery.

Conclusions. Surgical angioplasty is an effective alternative to coronary artery bypass grafting in patients with left main ostial stenosis. Magnetic resonance imaging is an excellent noninvasive method for monitoring the patency of the left main coronary artery.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The ostium of the left main coronary artery may be narrowed by atheroma or fibromuscular dysplasia and, more rarely, by syphilis [1] or Takayasu arteritis [2]. In the absence of coronary disease elsewhere, isolated left main coronary ostial stenosis appears to be a distinct clinical entity affecting a younger, mostly female [3] group of patients. Any left main stenosis carries a dismal prognosis with medical therapy, with 4and 6-year survival rates of 65% and 44% [4, 5], respectively. The treatment is therefore surgical, traditionally by coronary artery bypass grafting to the major branches of the left main coronary artery. Other procedures, including endarterectomy and percutaneous angioplasty, have been abandoned because of a high mortality rate. When the only lesion is stenosis of the left main ostium, a possible alternative is surgical angioplasty of the ostium.

We present 3 consecutive patients with left coronary ostial stenosis who were treated successfully with surgical angioplasty. In the postoperative period, the patency of the angioplasty was clearly demonstrated by magnetic resonance imaging.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
During a 2-year period, 3 patients with left main coronary ostial stenosis were identified as suitable for the operation of left main coronary angioplasty.

PATIENT 1.
A 41-year-old woman with multiple risk factors for ischemic heart disease-obesity, smoking, and hypercholesterolemia-presented with a cardiac arrest due to ventricular fibrillation. She was treated successfully with amiodarone. Subsequent echocardiography revealed a dilated left ventricle with an end-diastolic diameter of 6.1 cm. Treadmill exercise test was negative, and coronary angiography showed a left main coronary ostial stenosis with otherwise normal coronary arteries (Fig 1). At operation, a pinpoint left coronary ostium was found, and she underwent left main coronary artery angioplasty with an autologous vein patch. She was discharged on the sixth postoperative day taking aspirin and amiodarone. Subsequent electrophysiologic testing after discontinuation of amiodarone showed that ventricular arrhythmias could not be induced.

View larger version (53K): [in this window] [in a new window]   Fig 1. . Left anterior oblique projection of left coronary artery angiogram demonstrating a short, tight stenosis of the proximal left main stem (arrowheads).

PATIENT 3.
A 48-year-old housewife presented with angina pectoris on mild to moderate exertion. She smoked 10 to 15 cigarettes a day. Treadmill exercise test was positive, with chest tightness and 4 mm of inferolateral ST depression after 7 minutes of the Bruce protocol. Coronary angiography revealed left main coronary ostial stenosis with normal epicardial arteries. She underwent left main coronary artery angioplasty with an autologous vein patch and made an uncomplicated postoperative recovery.

The Operation
In all 3 patients, the operation of left main coronary artery angioplasty was carried out using full cardiopulmonary bypass, aortic cross clamping, and crystalloid cardioplegia for myocardial preservation.

We used the posterior approach as described by Hitchcock and colleagues [6]. The aorta was opened obliquely as for an aortic valve replacement. The right side of the aortotomy, however, was extended into the left main coronary artery across the stenosis and not into the noncoronary sinus. The aortotomy was then closed with autologous saphenous vein on the right side, thus enlarging the left main coronary artery. Alternative materials for completion of the angioplasty included a piece of left internal mammary artery or a pericardial patch.

A possible second approach to the left main coronary artery was the anterior approach [7]. This involved retraction of the main pulmonary artery to the left with dissection of the left main coronary artery. The aorta was opened anteriorly and the incision was extended to the left onto the anterior aspect of the left main coronary artery, thus crossing the stenosis. The aortotomy was then closed in a similar fashion using autologous vein or pericardium.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All 3 patients were free of angina 12, 18, and 24 months after the operation. All underwent magnetic resonance imaging, which clearly demonstrated the widely patent, typically funnel-shaped neoostium (Fig 2).

View larger version (32K): [in this window] [in a new window]   Fig 2. . Double oblique short-axis spin-echo image of the aortic root showing the wide funnel-shaped left coronary ostium (arrowheads) after operative angioplasty in the same patient as in Figure 1.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

There are several disadvantages to coronary artery bypass grafting. These include accelerated atheroma and occlusion of the left main coronary artery, competitive flow when two grafts are used, and the need for appreciable lengths of conduit material. A theoretic disadvantage is the drop in the pressure head with retrograde perfusion of an extensive myocardial area when one graft is used (the piezometer principle) [6]. Surgical angioplasty of the left main coronary artery avoids these problems and has the added advantage of allowing subsequent percutaneous angioplasty should new lesions develop [11]. As the diameter of the new ostium is quite large, it is hoped that restenosis of the new left main coronary artery is unlikely.

Patients with disease of the left main coronary artery that extends beyond the bifurcation do not do well with angioplasty.

Magnetic resonance imaging is a safe, noninvasive modality that can be used for direct visualization of coronary arteries, coronary artery bypass grafts, and the results of percutaneous transluminal coronary angioplasty. Spin-echo and gradient-echo techniques are now available on standard magnetic resonance imaging machines and provide information on graft patency with 90% accuracy [12]. We used this imaging technique to evaluate the results of surgical angioplasty of the left main coronary artery. The results clearly demonstrate that coronary angiography is not necessary in the postoperative assessment of these patients.

In conclusion, surgical angioplasty of the left main coronary artery using autologous vein is effective for the treatment of left main coronary artery ostial stenosis, and magnetic resonance imaging clearly demonstrates the results.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Nashef, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, England.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Cipriano PR, Silverman JF, Perlroth MG, Griepp RB, Wexler L. Coronary arterial narrowing in Takayasu's aortitis. Am J Cardiol 1977;39:744–50.[Medline]
2. Frater RWN, Jordan A. Syphilitic coronary ostial stenosis. Ann Thorac Surg 1968;6:463–7.[Free Full Text]
3. Thompson R. Isolated coronary ostial stenosis in women. J Am Coll Cardiol 1986;7:997–1003.[Medline]
4. De Mots H, Rosch J, McAnulty JH, Rahimtoola SH. Left main coronary artery disease. Cardiovasc Clin 1977;8:201–11.
5. DeMots H, Bonchek LI, Rosch J, Anderson RP, Starr A, Rahimtoola SH. Left main coronary artery disease. Risks of angiography, importance of coexisting disease of other coronary arteries and effects of revascularization. Am J Cardiol 1975;36:136–41.[Medline]
6. Hitchcock JF, Robles de Medina EO, Jambroes G. Angioplasty of the left main coronary artery for isolated left main coronary disease. J Thorac Cardiovasc Surg 1983;85:880–4.[Abstract]
7. Dion R, Verhelst R, Matta A, Rousseau M, Goenen M, Chalant C. Surgical angioplasty of the left main coronary artery. J Thorac Cardiovasc Surg 1990;99:241–50.[Abstract]
8. Bailey CP, Lemmon WN. Survival after coronary endarterectomy. JAMA 1957;164:641–6.
9. Effler DB, Sones FM, Favoloro R, Groves LK. Coronary endarterectomy with patch graft reconstruction: clinical experience with 34 cases. Ann Surg 1965;162:590–601.[Medline]
10. Sabiston DC, Ebert PA, Friesinger GC, Ross RS, Sinclair Smith B. Proximal endarterectomy: arterial reconstruction for coronary occlusion at aortic origin. Arch Surg 1965;91:758–64.[Medline]
11. Sullivan J, Murphy D. Surgical repair of stenotic ostial lesions of the left main coronary artery. J Thorac Cardiovasc Surg 1989;98:33–6.[Abstract]
12. Van Rossum AC, Galjee MA, Doesburg T, Hofman M, Valk J. The role of magnetic resonance in the evaluation of functional results after CABG/PTCA. Int J Cardiac Imag 1993;9(Suppl 1):59–69.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Norman P. Briffa John Wallwork Samer A. M. Nashef Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Briffa, N. P. Articles by Nashef, S. A. M. Search for Related Content PubMed PubMed Citation Articles by Briffa, N. P. Articles by Nashef, S. A. M.