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Asian Cardiovasc Thorac Ann 1999;7:147-149
© 1999 Asia Publishing EXchange Pte Ltd

CASE STUDY

Left Main Coronary Reconstruction for Ostial Stenosis With Patent Ductus Arteriosus

Gao Chang Qing, MD, Zhu Lang Biao, MD, Li Bo Jun, MD, Xiao Cang Song, MD

Department of Cardiovascular Surgery
PLA General Hospital
Beijing, People's Republic of China
For reprint information contact: Gao Chang Qing, MD Tel: 86 10 6818 2255 ext. 3281 Fax: 86 10 6816 5185 Department of Cardiovascular Surgery, PLA General Hospital, 28 Fuxing Road, Beijing 100853, People's Republic of China.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A case of congenital ostial stenosis of the left main coronary artery with a large short patent ductus arteriosus is described. Revascularization was performed by autologous pericardial patch angioplasty and the ductus was closed simultaneously with a fabric patch.


   Introduction
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 Abstract
 Introduction
Case Report
 Discussion
 References
 
Critical coronary ostial stenosis is currently treated by a conventional bypass operation. However, this invariably leads to definitive occlusion of the coronary ostium, restores only retrograde perfusion to an often extensive myocardial area, and consumes bypass material. For young patients, graft attrition is an especially serious problem. This unusual case provided an opportunity to reconsider these issues.


   Case Report
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 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 20-year-old male was admitted to our institute because of recurrent exertional chest pain. He had occasional associated diaphoresis and dyspnea. Coronary angiography disclosed severe left coronary ostial stenosis (Figure 1Go). The narrowing persisted after nitroglycerin and nifedipine administration. The remaining right and left coronary arteries were otherwise normal and a left ventriculogram demonstrated left ventricular enlargement. Cardiac catheterization showed a patent ductus arteriosus (PDA), pulmonary artery hypertension (systolic pressure, 99 mm Hg), and a high pulmonary vascular resistance (7.5 Wood units). His electrocardiogram revealed biventricular hypertrophy.



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  		Figure 1. Preoperative angiogram showing severe left coronary ostial stenosis.

 
At surgery, the heart was exposed through a median sternotomy. There was chamber enlargement and unusual pulmonary artery widening. Routine cardiopulmonary bypass with aortic and cavoatrial cannulation was instituted. The left ventricle was vented through the right superior pulmonary vein and a retrograde cannula was placed via the coronary sinus. Moderate systemic hypothermia (25°C) and hemodilution were employed. A large short PDA (2 cm in diameter) was found, which was difficult to ligate, therefore, cardiopulmonary bypass was initiated. During cooling, the ductus was occluded by finger pressure on the pulmonary artery. It was exposed via an incision in the pulmonary artery. Using low flow, the ductus was first plugged with a Foley catheter and then closed on the pulmonary artery side with a Dacron patch. The ascending aorta was dissected free from the main pulmonary artery and the right pulmonary artery. Retraction of the main pulmonary artery and anterior rolling of the aorta provided exposure for dissection of the left main coronary artery (LMCA) and the area between the ascending aorta and pulmonary artery was dissected cleanly with cautery. The LMCA was dissected out along its entire length, from its aortic origin to the bifurcation. The aorta was cross-clamped and cardioplegic solution was injected into the aortic root with topical cooling for myocardial protection. Retrograde cardioplegia was used during the next stage of the procedure. The aorta was incised 1.5 cm transversely anteriorly and the ostium of the LMCA was identified and probed. The incision was then extended across the stenosis and along the superior wall of the LMCA up to the bifurcation. An oblong fresh autologous pericardial patch was attached to the LMCA with a running suture of 7/0 polypropylene and a continuous suture of 4/0 polypropylene. The suture was started from inside out, at the distal end of the arteriotomy incision, and continued proximally. To test the angioplasty for leaks, crystalloid cardioplegia solution was injected under pressure into the ascending aorta before the cross-clamp was released after de-airing. A scheme of the surgical technique is given in Figure 2Go.




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  		Figure 2. Operative technique. (A) Exposure and incision of the left main coronary artery and main pulmonary artery for closure of the patent ductus arteriosus. (B) After suturing the ductus, the main pulmonary artery, and the onlay patch on the left main coronary artery. AO = aorta, LMCA = left main coronary artery, LPA = left pulmonary artery, MPA = main pulmonary artery, RCA = right coronary artery, RPA = right pulmonary artery.

 
The patient was weaned from cardiopulmonary bypass without difficulty and his hemodynamics were good. His postoperative course was uneventful. A postoperative aortic root angiogram (Figure 3Go) showed a widely patent LMCA with excellent runoff and the PDA had disappeared. He was asymptomatic postoperatively.



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  		Figure 3. Postoperative angiogram showing a widely patent left main coronary artery with excellent runoff.

 

   Discussion
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 Abstract
 Introduction
 Case Report
 Discussion
References
 
Coronary ostial reconstruction for isolated LMCA disease is not new. Historically, it was associated with high mortality but its efficacy has been demonstrated in recent years.1–3 However, it remains a rare operation and LMCA reconstruction with simultaneous closure of a PDA has not been reported so far. Because anatomic exposure of the LMCA is rarely performed except for technical problems, we report this case to illustrate this helpful technique. The anterior approach offered a more frontal view and although it was technically demanding, it was easier for us than the posterior approach.4,5 Division of the pulmonary artery to facilitate exposure of the LMCA was not considered necessary in this case. A fresh autologous pericardial patch was preferred to a saphenous vein patch because of superior long-term durability. We found it useful to leave a surplus length of pericardium attached to facilitate handling of the patch. Retrograde cardioplegia was essential for myocardial protection in this operation because of the left ventricular enlargement and biventricular hypertrophy. Although we did not biopsy the stenotic region, the young age of the patient and lack of evidence of atheromatous alterations suggests that the stenosis was congenital in origin. The additional procedure of PDA closure was conveniently performed con-comitantly. Our favorable experience with this angioplasty technique leads us to conclude that it is a promising alternative to coronary artery bypass grafting in isolated LMCA disease. For young patients, this technique is an especially reasonable surgical choice.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Favaloro RG, Effler DB, Groves LK, Sheldon WC, Shirey EK, Sones FM. Severe segmental obstruction of the left main coronary artery and its divisions: surgical treatment by the saphenous vein graft technique. J Thorac Cardiovasc Surg 1970;60:469–82.[Medline]

  2. Hitchcock JF, de Medina R, Jambroes G. Angioplasty of the left main coronary artery for isolated left main coronary artery disease. J Thorac Cardiovasc Surg 1983;85:880–4.[Abstract]

  3. Dion R, Verhelst R, Matta A, Rousseau M, Goenen M, Chalant C. Surgical angioplasty of the left main coronary artery. J Thorac Cardiovasc Surg 1990;99:241–50.[Abstract]

  4. Sullivan JA, Murphy DA. Surgical repair of stenotic ostial lesions of the left main coronary artery. J Thorac Cardiovasc Surg 1989;98:33–6.[Abstract]

  5. Ridley PD, Wisheart JD. Coronary ostial reconstruction. Ann Thorac Surg 1996;62:293–5.[Abstract/Free Full Text]





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