Asian Cardiovasc Thorac Ann 2006;14:445
© 2006 Asia Publishing EXchange Ltd
LEFT MAIN CORONARY STENOSIS OR LEFT CORONARY ARTERY FROM PULMONARY ARTERY?
Shiv K Choudhary, MCh,
Sachin Talwar, MCh,
Anita Saxena, DM,
Balram Airan, MCh
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi -110029, India., Tel: 91 11 2658 8500, Fax: 91 11 2658 8663, Email: shivchoudhary{at}hotmail.com
Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
We read with interest the article by Murala et al on anomalous origin of the left coronary artery from the pulmonary artery in adults (
Asian Cardiovasc Thorac Ann 2006;14:38–42[Abstract/Free Full Text]
) and would like to share our experience with one such case in a 56-year old woman who is much older than their oldest patient aged 37 years. Only a few patients who achieved more than 50 years of age have been described in the English medical literature. 1–3 A 56-year old woman, presented with a 3 months history of angina on exertion of NYHA class III severity. Besides this she complained of dyspnoea since last 4 years which had gradually progressed to Class III severity. Her significant past history consisted of an episode of chest pain resembling acute myocardial infarction 4 years ago, but no detailed records were available. Besides this she had hypertension and diabetes mellitus well controlled on oral hypoglycemics. The clinical examination, chest radiographs and electrocardiogram were unremarkable. Her echocardiograms revealed normal chamber dimensions and a left ventricular ejection fraction of 45% with mild mitral regurgitation and focal areas of calcification in the papillary muscles. She underwent coronary arteriography (CART) at another centre which revealed a grossly dilated right coronary artery filling up the left coronary system. The left main coronary artery ostium was not visualized. The patient was diagnosed to be suffering from coronary artery disease (probably left main disease) and was referred to us for coronary artery bypass grafting (CABG). However, the atypical angiographic picture suggested otherwise to us; hence a CT angiogram was performed which clearly demonstrated the anomalous origin of the left coronary artery from the pulmonary artery with normal bifurcation into the left anterior descending (LAD) coronary and the left circumflex (LCx) arteries. The right coronary artery was seen to be grossly dilated and feeding collaterals to the left coronary system. The findings were confirmed at operation and the patient underwent uneventful CABG with reversed saphenous vein grafts to the LAD and LCx along with closure of the ostium of the anomalous coronary from within the pulmonary artery. Internal mammary artery was not used as it was damaged during harvesting.
Untreated, more than 80% of the patients with ALCAPA die in infancy and childhood and it is extremely rare to encounter elderly patients with this anomaly.1–3 When observed in this population, the clinical presentation is usually non-specific with syncope, cardiac arrhythmias, exertional fatigue, dyspnoea and rarely angina pectoris. However, stress testing almost always demonstrates chronic ischemia which can be improved with surgery. Although coronary angiogram should be diagnostic in the majority of patients, the condition should be suspected if the left main origin is not visualized or there appears to be "ostial left main disease" in the presence of a dilated and tortuous right coronary artery. CT angiography is diagnostic in doubtful cases and helps to plan the correct treatment which as pointed out by Murala et al should consist of an attempt at the establishment of a two coronary system rather than simple ligation of the ALCAPA.
REFERENCES
- Fierens C, Budts W, Denef B, Van De Werf F. A 72 year old woman with ALCAPA. Heart 2000; 83: E2.[Medline]
- Alexi-Meskishvili V, Berger F, Weng Y, Lange PE, Hetzer R. Anomalous origin of the left coronary artery from the pulmonary artery in adults. J Card Surg 1995;10:309–15.[Medline]
- Selzman CH, Zimmerman MA, Campbell DN. ALCAPA in an adult with preserved left ventricular function. J Card Surg 2003;18:25–28.[Medline]
