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Ann Thorac Surg 1997;64:282-283
© 1997 The Society of Thoracic Surgeons

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Update

Left Coronary Ostial Stenosis: Comparison With Left Main Coronary Artery Stenosis

As Originally Published in 1989:

Updated in 1997 by Hendrick B. Barner, MD, and Andrew C. Fiore, MD

Divisions of Cardiothoracic Surgery, Washington University and Christian Hospital Northeast, and St. Louis University and St. Mary's Health Center, St. Louis, Missouri

The intent of our previous publication [1] was to present clinical differences and their potential influence on outcome in two groups of patients with left main or left ostial stenosis. Our only comment on management was to indicate that we did not use ostialplasty but only coronary bypass with saphenous vein and internal thoracic artery because of the frequent association of coronary artery disease that requires bypass grafting. Since that report our choice of conduits has evolved and herein that change is updated.

We later reported on use of bilateral internal thoracic artery grafts as the only left-sided conduits for left main/ostial stenosis [2]. Concern over hypoperfusion by arterial conduits in this demanding situation was not recognized by us or by others [3]. With regard to the potential for hypoperfusion by arterial conduits, these reports were eclipsed by introduction of the T graft, which seemingly represents the maximum in demand for flow with only a single inflow source to supply the left ventricular myocardium [4]. Although initially skeptical of this approach to myocardial revascularization [5], we were later able to achieve this configuration but chose to substitute the radial artery for the free right internal thoracic artery in patients with a negative Allen test [6]. Hypoperfusion has not been a problem (<1%) with this modification of the T graft in patients with triple-vessel disease or left main/ostial stenosis.

Direct ostialplasty/angioplasty with a vein or pericardial patch [7] is appropriate if there is no disease at the left main bifurcation, which we believe is best managed with coronary bypass grafting. The presence of significant intimal disease has required unplanned endarterectomy and bypass grafting [7], which is better treated by preoperative recognition and planned bypass with arterial conduits. Inappropriate use of left main patching has resulted in proximal postoperative stenosis of one or both of its branches. Only 2.7% of patients with left main stenosis and 16.3% of those with left ostial stenosis did not have significant (greater than 50% stenosis) disease of the left coronary arteries at the time of operation, and they were usually younger than 50 years [1]. The prevalence of left main disease in patients having coronary bypass is about 9% [8], but the occurrence of ostial disease is less well characterized. In our experience it was 2.9%, which is probably higher than in the experience of others without a specific interest in this problem in view of the angiographic incidence of 0.25% to 1.3% [9].

Footnotes

Address reprint requests to Dr Barner, 11125 Dunn Rd, Suite 211, St. Louis, MO 63136.

References

1. Barner HB, Reese J, Standeven J, et al. Left coronary ostial stenosis: comparison with left main coronary artery stenosis. Ann Thorac Surg 1989;47:293–6.[Abstract]
2. Barner HB, Naunheim KS, Willman VL, Fiore AC. Revascular-ization with bilateral internal thoracic artery grafts in patients with left main coronary stenosis. Eur J Cardiothorac Surg 1992;6:66–71.
3. Paolini G, Zuccari M, Di Credico G, et al. Myocardial revascularization with bilateral internal thoracic artery in patients with left main disease: an incremental risk? Eur J Cardiothorac Surg 1994;8:576–9.[Abstract]
4. Tector AJ, Amundsen S, Schmal TM, Cress DC, Peter M. Total revascularization with T grafts. Ann Thorac Surg 1994;57:33–9.[Abstract]
5. Barner HB. Use of the internal thoracic artery: simple, complex, or with a backup? Ann Thorac Surg 1994;57:8–9.[Medline]
6. Barner HB. Defining the role of the radial artery. Semin Thorac Cardiovasc Surg 1996;8:3–9.[Medline]
7. Dion R, Verhelst R, Matta A, Rousseau M, Goenen M, Chalant C. Surgical angioplasty of the left main coronary. J Thorac Cardiovasc Surg 1990;99:241–50.[Abstract]
8. Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: The Society of Thoracic Surgeons national database experience. Ann Thorac Surg 1994;57:12–9.[Abstract]
9. Barner HB, Naunheim KS, Kanter KR, et al. Coronary ostial stenosis. Eur J Cardiothorac Surg 1988;2:106–12.[Abstract]

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This Article 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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Search for Related Content PubMed PubMed Citation