Case Study
Chronic total occlusion of left main coronary artery in a young man
Asian Cardiovascular & Thoracic Annals 21(4) 453–455 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312455022 aan.sagepub.com
Moaath M Alsmady1, Mahmood A Abu Abeeleh1, Suhail S Saleh1, Eman T Al-Antary2 and Akram M Saleh2
Abstract Chronic total occlusion of the left main coronary artery is rarely encountered in coronary angiography. Patients are at high risk of death because of its intimate association with massive anterior myocardial infarction. A 29-year-old man with no cardiac risk factors, presented with myocardial infarction and severe mitral regurgitation. Coronary angiography revealed chronic total occlusion of the left main coronary artery. He underwent coronary artery bypass grafting and mitral valve repair.
Keywords Coronary angiography, coronary artery bypass, coronary occlusion, mitral valve insufficiency, myocardial infarction
Introduction Ischemic heart disease (IHD) is a major cause of death and disability in developed countries Although IHD mortality rates have declined over the past 4 decades in the United States and elsewhere, IHD remains responsible for about one-third of all deaths in individuals over age 35 years.1 However, chronic total occlusion of the left main coronary artery (LMCA) is rarely encountered in coronary angiography, with a prevalence of 0.025%–0.4%.2 We describe the case of young man with no cardiovascular risk factors who presented with myocardial infarction (MI) and severe mitral regurgitation.
Case report A 29-year-old man, a nonsmoker with no medical history, presented with chest pain, orthopnea, and easy fatigability (non-ST segment elevation MI) for 1 month. He had no cardiovascular risk factors. Although he mentioned that his father had died at the age of 51 years due to a cerebrovascular accident, there was no documented family history of premature IHD. Coronary angiography revealed chronic total occlusion of the LMCA (Figure 1) with retrograde perfusion via a normal dominant right coronary artery (Figure 2). Echocardiography showed a left ventricular ejection fraction less than 25% and grade IV (severe)
mitral regurgitation. A carotid Doppler study was normal with no evidence of stenosis. However, the left vertebral artery appeared ectatic with multiple areas of narrowing on neck magnetic resonance imaging with contrast. The patient underwent urgent coronary artery bypass graft surgery with distal anastomosis of the left internal mammary artery to the left anterior descending artery and an autologous saphenous vein graft bypassing the first obtuse marginal artery, in addition to mitral valve repair and intraaortic balloon pumping to augment native coronary perfusion. He was weaned from the intraaortic balloon pump and extubated 1 day later. Postoperative echocardiography showed a left ventricular ejection fraction of 30% and mild mitral regurgitation.
Discussion Isolated total occlusion of the LMCA is rare in patients with IHD, and defined as the complete absence of 1 Department of General Surgery, Cardiothoracic Surgery, University of Jordan, Amman, Jordan 2 Department of Internal Medicine, University of Jordan, Amman, Jordan
Corresponding author: Moaath Alsmady, MD, Department of Cardiothoracic Surgery, University of Jordan, PO Box 2086, Aljbiha, Amman 11942, Jordan. Email: [email protected]
454
Figure 1. Transfemoral coronary angiogram (left injection) demonstrating chronic total occlusion of the left main coronary artery (arrow A).
antegrade flow of contrast beyond the bifurcation of the LMCA.3 Total occlusion can be acute and usually presents as MI, pulmonary edema, cardiogenic shock, sudden death, or an abrupt change in angina severity. Chronic total occlusion manifests more insidiously, usually over a period of more than 3 months, and patients are often asymptomatic.4 Moreover, a patient with LMCA occlusion below the age of 30 years is rarely seen among candidates for coronary artery bypass grafting. Kawasaki disease and familial hypercholesterolemia may cause coronary occlusive disease in young patients.5,6 However, the preoperative examination in this 29-year-old man did not suggest any systemic disease that might have caused his coronary artery disease. A congenital anomaly or absence of the orifice of the LMCA might be responsible for such a case, but in this patient, the collateral pathway from the right coronary artery system seemed to be too small to suggest occlusion of the LMCA from birth. Left ventricular function was abnormal in the majority of reported cases, usually because of hypokinesis or akinesis of the anterior apical segment and septum. This case is unusual because the patient was not documented with any risk factor for IHD or previous attacks of angina. Furthermore, his coronary angiography showed isolated LMCA total occlusion with severe mitral regurgitation, which is a rare finding. Surgery is the treatment of choice for chronic total occlusion because crossing the occlusion with a wire has a limited success rate of 40%–80% and a high restenosis rate.7 A percutaneous coronary intervention is generally considered for acute lesions or patients deemed surgically unfit for coronary artery bypass
Asian Cardiovascular & Thoracic Annals 21(4)
Figure 2. Transfemoral coronary angiogram (right injection) demonstrating retrograde filling of the distal circumflex arteries (arrow B) from collaterals arising from a patent dominant right coronary artery.
grafting, and remains a potential therapeutic option if the patient has good collaterals and incomplete occlusion. However, patients undergoing percutaneous coronary interventions are more likely to require future repeat revascularization. Bare metal stenting for LMCA occlusion has a 1-year mortality of 3%–28% and a restenosis rate of 20%, the latter decreasing to 10% with use of drug-eluting stents.8 An isolated LMCA lesion is a rare presentation of IHD. Further study and reports are needed to determine the proper patient-tailored approach to avoid early mortality or late morbidity. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest None declared.
References 1. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Heart disease and stroke statistics—2010 update : a report from the American Heart Association. Circulation 2010; 121: 948–954. 2. Akhtar RP, Naqshband MS, Abid AR, Tufail Z, Waheed A and Khan JS. Surgery for chronic total occlusion of the left main stem: a 10-year experience. Asian Cardiovasc Thorac Ann 2009; 17: 472–476. 3. Trehan V, Mehta V, Mukhopadhyay S, Yusuf J and Arora R. Percutaneous stenting of chronic total Occlusion of unprotected left main coronary artery. Indian Heart J 2003; 55: 172–174.
Alsmady et al. 4. Azam AF, How LA, Nor A, Badmanaban B and Sachithanandan A. Surgery for isolated non-inflammatory chronic total occlusion of the left main coronary artery: a case report and literature review. Med J Malaysia 2011; 66: 374–375. 5. Kato H, Ichinose E and Kawasaki T. Myocardial infarction in Kawasaki disease: clinical analyses in 195 cases. J Pediatr 1986; 108: 923–927. 6. Slack J. Risks of ischaemic heart-disease in familial hyperlipoproteinaemic states. Lancet 1969; 2: 1380–1382.
455 7. Aoki J, Hoye A, Staferov AV, Alekyan BG and Serruys PW. Sirolimus-eluting stent implantation for chronic total occlusion of the left main coronary artery. J Interv Cardiol 2005; 18: 65–69. 8. Taggart DP, Kaul S, Boden WE, Ferguson Jr TB, Guyton RA, Mack MJ, et al. Revascularization for unprotected left main stem coronary artery stenosis. Stenting or surgery. J Am Coll Cardiol 2008; 51: 885–892.
Chronic total occlusion of left main coronary artery in a young man
Asian Cardiovascular & Thoracic Annals 21(4) 453–455 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312455022 aan.sagepub.com
Moaath M Alsmady1, Mahmood A Abu Abeeleh1, Suhail S Saleh1, Eman T Al-Antary2 and Akram M Saleh2
Abstract Chronic total occlusion of the left main coronary artery is rarely encountered in coronary angiography. Patients are at high risk of death because of its intimate association with massive anterior myocardial infarction. A 29-year-old man with no cardiac risk factors, presented with myocardial infarction and severe mitral regurgitation. Coronary angiography revealed chronic total occlusion of the left main coronary artery. He underwent coronary artery bypass grafting and mitral valve repair.
Keywords Coronary angiography, coronary artery bypass, coronary occlusion, mitral valve insufficiency, myocardial infarction
Introduction Ischemic heart disease (IHD) is a major cause of death and disability in developed countries Although IHD mortality rates have declined over the past 4 decades in the United States and elsewhere, IHD remains responsible for about one-third of all deaths in individuals over age 35 years.1 However, chronic total occlusion of the left main coronary artery (LMCA) is rarely encountered in coronary angiography, with a prevalence of 0.025%–0.4%.2 We describe the case of young man with no cardiovascular risk factors who presented with myocardial infarction (MI) and severe mitral regurgitation.
Case report A 29-year-old man, a nonsmoker with no medical history, presented with chest pain, orthopnea, and easy fatigability (non-ST segment elevation MI) for 1 month. He had no cardiovascular risk factors. Although he mentioned that his father had died at the age of 51 years due to a cerebrovascular accident, there was no documented family history of premature IHD. Coronary angiography revealed chronic total occlusion of the LMCA (Figure 1) with retrograde perfusion via a normal dominant right coronary artery (Figure 2). Echocardiography showed a left ventricular ejection fraction less than 25% and grade IV (severe)
mitral regurgitation. A carotid Doppler study was normal with no evidence of stenosis. However, the left vertebral artery appeared ectatic with multiple areas of narrowing on neck magnetic resonance imaging with contrast. The patient underwent urgent coronary artery bypass graft surgery with distal anastomosis of the left internal mammary artery to the left anterior descending artery and an autologous saphenous vein graft bypassing the first obtuse marginal artery, in addition to mitral valve repair and intraaortic balloon pumping to augment native coronary perfusion. He was weaned from the intraaortic balloon pump and extubated 1 day later. Postoperative echocardiography showed a left ventricular ejection fraction of 30% and mild mitral regurgitation.
Discussion Isolated total occlusion of the LMCA is rare in patients with IHD, and defined as the complete absence of 1 Department of General Surgery, Cardiothoracic Surgery, University of Jordan, Amman, Jordan 2 Department of Internal Medicine, University of Jordan, Amman, Jordan
Corresponding author: Moaath Alsmady, MD, Department of Cardiothoracic Surgery, University of Jordan, PO Box 2086, Aljbiha, Amman 11942, Jordan. Email: [email protected]
454
Figure 1. Transfemoral coronary angiogram (left injection) demonstrating chronic total occlusion of the left main coronary artery (arrow A).
antegrade flow of contrast beyond the bifurcation of the LMCA.3 Total occlusion can be acute and usually presents as MI, pulmonary edema, cardiogenic shock, sudden death, or an abrupt change in angina severity. Chronic total occlusion manifests more insidiously, usually over a period of more than 3 months, and patients are often asymptomatic.4 Moreover, a patient with LMCA occlusion below the age of 30 years is rarely seen among candidates for coronary artery bypass grafting. Kawasaki disease and familial hypercholesterolemia may cause coronary occlusive disease in young patients.5,6 However, the preoperative examination in this 29-year-old man did not suggest any systemic disease that might have caused his coronary artery disease. A congenital anomaly or absence of the orifice of the LMCA might be responsible for such a case, but in this patient, the collateral pathway from the right coronary artery system seemed to be too small to suggest occlusion of the LMCA from birth. Left ventricular function was abnormal in the majority of reported cases, usually because of hypokinesis or akinesis of the anterior apical segment and septum. This case is unusual because the patient was not documented with any risk factor for IHD or previous attacks of angina. Furthermore, his coronary angiography showed isolated LMCA total occlusion with severe mitral regurgitation, which is a rare finding. Surgery is the treatment of choice for chronic total occlusion because crossing the occlusion with a wire has a limited success rate of 40%–80% and a high restenosis rate.7 A percutaneous coronary intervention is generally considered for acute lesions or patients deemed surgically unfit for coronary artery bypass
Asian Cardiovascular & Thoracic Annals 21(4)
Figure 2. Transfemoral coronary angiogram (right injection) demonstrating retrograde filling of the distal circumflex arteries (arrow B) from collaterals arising from a patent dominant right coronary artery.
grafting, and remains a potential therapeutic option if the patient has good collaterals and incomplete occlusion. However, patients undergoing percutaneous coronary interventions are more likely to require future repeat revascularization. Bare metal stenting for LMCA occlusion has a 1-year mortality of 3%–28% and a restenosis rate of 20%, the latter decreasing to 10% with use of drug-eluting stents.8 An isolated LMCA lesion is a rare presentation of IHD. Further study and reports are needed to determine the proper patient-tailored approach to avoid early mortality or late morbidity. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest None declared.
References 1. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Heart disease and stroke statistics—2010 update : a report from the American Heart Association. Circulation 2010; 121: 948–954. 2. Akhtar RP, Naqshband MS, Abid AR, Tufail Z, Waheed A and Khan JS. Surgery for chronic total occlusion of the left main stem: a 10-year experience. Asian Cardiovasc Thorac Ann 2009; 17: 472–476. 3. Trehan V, Mehta V, Mukhopadhyay S, Yusuf J and Arora R. Percutaneous stenting of chronic total Occlusion of unprotected left main coronary artery. Indian Heart J 2003; 55: 172–174.
Alsmady et al. 4. Azam AF, How LA, Nor A, Badmanaban B and Sachithanandan A. Surgery for isolated non-inflammatory chronic total occlusion of the left main coronary artery: a case report and literature review. Med J Malaysia 2011; 66: 374–375. 5. Kato H, Ichinose E and Kawasaki T. Myocardial infarction in Kawasaki disease: clinical analyses in 195 cases. J Pediatr 1986; 108: 923–927. 6. Slack J. Risks of ischaemic heart-disease in familial hyperlipoproteinaemic states. Lancet 1969; 2: 1380–1382.
455 7. Aoki J, Hoye A, Staferov AV, Alekyan BG and Serruys PW. Sirolimus-eluting stent implantation for chronic total occlusion of the left main coronary artery. J Interv Cardiol 2005; 18: 65–69. 8. Taggart DP, Kaul S, Boden WE, Ferguson Jr TB, Guyton RA, Mack MJ, et al. Revascularization for unprotected left main stem coronary artery stenosis. Stenting or surgery. J Am Coll Cardiol 2008; 51: 885–892.
