Isolated significant left main coronary artery stenosis: Angiographic, hemodynamic, and clinical findings in 16 patients

doi:10.1016/0002-8703(91)90570-8

American Heart Journal

Volume 122, Issue 5, November 1991, Pages 1308-1314

https://doi.org/10.1016/0002-8703(91)90570-8 Get rights and content

Abstract

Among 21,545 adult patients who underwent consecutive coronary anglography, 16 (0.07%) were found during their coronary arteriography to have a significant isolated stenotic lesion (luminal diameter narrowing of 50% or more) located at the left main coronary artery. The remaining major epicardial coronary arteries and their branches were free of disease. A strong predilection for the isolated lesion to occur at the ostium of the left main artery was found (12 patients). The most common presenting symptom was angina of less than 4 weeks' duration, although one third of the group was asymptomatic. Resting electrocardiograms were normal in 12 patients, while three patients had T wave inversion and another had nonspecific ST-T changes. Eleven patients exhibited severe stenosis, with eight having 70% to 89% stenosis and three having 90% to 95% stenosis. Five patients had 50% to 69% stenosis. No significant differences were found between patients with angina and patients without angina with respect to age, left ventricular end-diastolic pressure, left ventricular ejection fraction, and mean percent stenosis of the obstructive lesion. Despite the severity and the crucial location of the obstructive lesion, most patients with an isolated, significant left main stenosis appear to have a preserved left ventricular ejection fraction, normal wall motion, and no significant alteration of the left ventricular end-diastolic pressure.

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Citation Excerpt :
The majority of patients with significant LMCA stenosis have, in addition, significant narrowing of at least one of the other major coronary vessels. Isolated LMCA disease is an unusual clinical entity, and when seen, is predominantly at the ostium.13 Congenital anomalies for LMCA are infrequent, i.e. it may originate from the right coronary cusp or the noncoronary cusp.
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.
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2007, International Journal of Cardiology
Citation Excerpt :
The etiology, natural course and prognosis of this disorder remain uncertain as it was described only in a limited number of literatures in form of short case series or individual case reports. In some surgical series, yellow atheroma could be universally found in aortic wall encroaching on the left main artery ostium, but not found in the body of left main artery in two-third of patients [1]. Thus, the pathology of this disorder might be aortic in origin rather than coronary.
Idiopathic isolated ostial left main artery stenosis is a rare disease with uncertain etiology, clinical course and prognosis. We described a young woman with no cardiovascular risk factors, who developed the disease 3 years ago with a bare-metal stent implanted in the left main artery ostium. She presented again with severe angina of rapid onset. Coronary angiography revealed ostial left main artery in-stent restenosis. A drug-eluting stent was successfully deployed over the previous stent with good angiographic result. The etiology and management of this disorder were briefly discussed.
Main clinical and surgical determinants of in-hospital mortality after surgical revascularization of left main coronary artery stenosis: 2 Year retrospective study (1998-1999)
2004, Journal des Maladies Vasculaires
La sténose du tronc commun (TC) de l’artère coronaire gauche représente de 7 à 10 % de toutes les coronarographies. Deux méthodes de traitement sont couramment utilisées : la chirurgie et la pharmacothérapie. Tandis que la pharmacothérapie comporte une très haute mortalité, la revascularisation chirurgicale produit des résultats excellents et demeure la méthode standard. Par ailleurs, durant ces dernières années l’angioplastie coronaire est de plus en plus envisagée comme traitement alternatif.7
Déterminer la mortalité hospitalière des individus opérés pour une sténose du tronc commun du l’artère coronaire gauche dans notre « Kardiocentrum » et identifier les facteurs cliniques et opératoires associés à cette mortalité.
Analyse rétrospective des résultats postopératoires à courts termes des individus opérés de janvier 1998 à décembre 1999 (2 ans).
Au total 1 443 coronariens ont été opérés. Une sténose du TC était présente chez 330 individus (22,9 %) dont 276 hommes (83,6 %). L’âge moyen du groupe opéré était de 63 ± 8,6 ans ; 173 opérations (52,4 %) étaient programmées tandis que 157 (47,6 %) étaient des opérations en urgence, dont 3 effectuées sous choc cardiogénique. La mortalité hospitalière totale était de 4,2 % (14/330) ; la mortalité de la chirurgie en ugence était de 7 % (11/157) et celle de la chirurgie programmée de 1,7 % (3/173). Les facteurs prédictifs de la haute mortalité hospitalière étaient l’âge > 68 ans, la fraction d’éjection du ventricule gauche inférieure à 40 %, les antécédents d’infarctus du myocarde, le sexe féminin et le caractère non planifié des opérations (p < 0,05).
Le nombre de patients porteurs d’une sténose du TC traités dans notre service est assez large et nos résultats postopératoires à courts termes sont au niveau du standard européen. Bien que la revascularisation chirurgicale reste pour le moment la méthode de choix pour les patients ayant une sténose du TC, il est nécessaire d’envisager une angioplastie ou au mieux une revascularistion combinée pour les sujets à haut risque.
Stenosis of left main coronary artery (LMCA) is a common finding on coronary angiographies (7 to 10%). Mortality is very high for conservative therapy in comparison with surgery, which provides very good long-term outcome and is accepted as the standard therapy of this condition. Over the last few years, percutaneous coronary intervention (PCI) has become a new alternative in selected patients.
To assess in hospital mortality in subjects referred to our surgical unit for coronary artery bypass grafting (CABG) and to identify the main clinical and surgical determinants of in-hospital mortality.
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Among a group of 1443 patients operated for coronary heart disease, LMCA stenosis was found in 330 patients (22.9 %). The mean age was 63 ± 8.6 years. Elective surgery was done in 173 patients (52.4 %), and acute operation (i.e. urgent, emergent or desperate) in 157 patients (47.6 %). The total in-hospital mortality was 4.2 % (14/330). Elective surgery in-hospital mortality was 1.7 % (3/173) and urgent surgery in-hospital mortality was 7 % (11/157). The main risk factors of in-hospital mortality were age > 68 years, low ejection fraction (LVEF < 0.4), history of myocardial infarction, gender (female) and urgency of the operation.
The proportion of patients undergoing CABG for left main stenosis is relatively high in our center and their mortality is quite low especially for elective operations. As the mortality of patients treated by PCI for LMCA stenosis is similar to surgery in high-risk patients, we postulate that this approach can be a real alternative treatment for such patients. Because of its potential benefit, combined revascularisation is also an alternative that should be considered in some cases. Furthermore, as a new generation of coated stents has emerged in the treatment of restenosis after PCI, we hypothesize that this method can in the near future be accepted as equivalent to surgery. However several randomized clinical trials must first be conduced prove this point.
Intravascular ultrasound assessment of the stenoses location and morphology in the left main coronary artery in relation to anatomic left main length
2001, American Journal of Cardiology
Eighty-seven left main stenoses were evaluated by angiography and intravascular ultrasound. Intravascular ultrasound analysis included left main length (bifurcation to ostium), stenosis location, stenosis length, stenosis external elastic membrane, lumen, plaque & media cross-sectional area (CSA), plaque burden (plaque & media/external elastic membrane CSA), calcium arc, calcium length, eccentricity, and remodeling index (stenosis/reference external elastic membrane CSA). Long anatomic left main arteries (length ≥10 mm, n = 43) were compared with short anatomic left main arteries (length <10 mm, n = 44) regarding stenosis location. Ostial (proximal third of left main artery) (n = 32) and nonostial (midthird and distal third) stenoses (n = 55) were compared regarding stenosis morphology. Short anatomic left main arteries developed stenoses more frequently near the ostium (ostium 55%, bifurcation 38%). Conversely, long anatomic left main arteries developed stenoses more frequently near the bifurcation (ostium 18%, bifurcation 77%, p = 0.001). Ostial left main stenoses were more common in women (44% vs 20%, p = 0.02), had larger lumen area (6.2 ± 2.2 vs 4.6 ± 2.3 mm², p = 0.002), less plaque burden (62 ± 15% vs 80 ± 9%, p <0.0001), less calcification (arc = 78 ± 65° vs 195 ± 101°, p <0.0001), and more negative remodeling (remodeling index = 0.87 ± 0.19 vs 1.01 ± 0.21, p = 0.005) than nonostial left main stenoses. Most ostial left main stenoses were categorized as eccentric (97% vs 76%, p = 0.01). Short and long left main arteries develop stenoses at different locations. Stenosis morphology was significantly different in these 2 locations.

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Isolated significant left main coronary artery stenosis: Angiographic, hemodynamic, and clinical findings in 16 patients

Abstract

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Coronary anatomy and arteriography in patients with unstable angina pectoris

Am J Cardiol

Atherosclerotic and nonatherosclerotic factors in acute myocardial infarction

Atherosclerotic narrowing of the left main coronary artery: a necropsy analysis of 152 patients with fatal coronary heart disease and varying degrees of left main narrowing

Circulation

Grading of angina pectoris (Letter)

Circulation

External compression by metastatic squamous cell carcinoma: a rare cause of left main coronary artery narrowing

Clin Cardiol

Coronary ostial stenosis

J Thorac Cardiovasc Surg

Coronary ostial stenosis: a complication of aortic valve replacement

Circulation

Left main coronary artery ostial stenosis: clinical markers, angiographic recognition and distinction from left main disease

Cathet Cardiovasc Diagn

Incidence and etiology of isolated left main coronary artery stenosis [Abstract]

Chest