Coronary ostial stenosis: surgical considerations

Surgical patch angioplasty of the left main coronary artery

Isolated ostial stenosis of the left main coronary artery (LMCA) is rare, occurring in <1% of the patients undergoing coronary angiography. Surgical patch angioplasty (SPA) offers an alternative to conventional coronary artery bypass grafting (CABG) in such cases and is advantageous in restoring more physiological myocardial perfusion, maintaining ostial patency and preserving conduit material. However, a number of early technical failures and high perioperative mortality have limited the generalized uptake of this procedure, and only recently have advances in myocardial protection and novel surgical approaches to the LMCA resulted in a resurgence of the technique. A systematic literature search identified 45 studies incorporating 478 patients undergoing SPA. A variety of patch materials were used, including the pericardium, saphenous vein and internal mammary and pulmonary arteries. Patients were followed up for a mean of 54.4 months. The 30-day mortality was 1.7% and cardiac specific mortality 3.3% at last follow-up. Encouragingly, 92.4% of reported cases (n = 182) showed complete angiographic patency at last follow-up. Our results indicate that SPA may be a viable alternative to CABG in the surgical management of isolated ostial LMCA stenosis. However, no randomized trials have been performed, and it is clear that careful patient selection is essential in minimizing morbidity and mortality in the short- and long-term. Further research is required to allow a direct comparison of SPA to techniques with a more substantial evidence base such as CABG and percutaneous coronary intervention, and to define the optimal patch graft material, elucidating that any beneficial effects arterial patches may have on long-term patency.

Diffuse myocardial infarction caused by isolated bilateral coronary ostial stenoses in a young woman: report of a case

A young Japanese woman who appeared to be free from any coronary risk factors was admitted to a local hospital with chest pain. Serological tests showed no evidence of inflammation; however, an electrocardiogram revealed diffuse myocardial ischemia and a coronary angiogram demonstrated isolated bilateral coronary ostial stenoses. Moreover, her serum creatine phosphokinase level was high. On the day following admission, the patient developed severe cardiogenic shock, and she was transferred to our hospital where emergency coronary artery bypass grafting with the saphenous veins was performed using retrograde tepid blood cardioplegia. Recovery of cardiac function was immediate and her postoperative course was uneventful. We suspect that fibromuscular dysplasia was the most likely cause of the ostial stenoses in this patient.

Isolated bilateral ostial coronary artery stenoses

Isolated coronary ostial narrowing is rare and most often attributed to atherosclerotic disease of the aorta. A man with isolated, bilateral stenoses of the coronary ostia is presented, who also had severe peripheral vascular disease. A review of previous reports concerning coronary ostial disease is presented.