Concomitant aortic valve replacement and surgical angioplasty of left main coronary ostium

Successful surgical osteoplasty of the left main coronary artery with concomitant mitral valve replacement and tricuspid annuloplasty

A 50-year-old woman with rheumatic heart disease, mitral stenosis, and critical isolated left main ostial stenosis was successfully treated by mitral valve replacement, tricuspid annuloplasty, and surgery of left main osteoplasty and is reported for its rarity. Notable clinical findings included an intermittently irregular pulse, blood pressure of 100/70 mmHg, cardiomegaly, a diastolic precordial thrill, a mid-diastolic murmur without presystolic accentuation that was loudest at the mitral area. Chest radiograph revealed cardiomegaly with a cardiothoracic ratio of 0.7 due to enlarged right atrium, right ventricle with a straightened left heart border and evidence of pulmonary hypertension. The investigation shows that surgical reconstruction of the left main coronary artery is safe and effective for the treatment.

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.