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Asian Cardiovasc Thorac Ann 1999;7:313-315
© 1999 Asia Publishing EXchange Pte Ltd

CASE STUDY

Total Occlusion of Left Main Coronary Artery Trunk in a Young Man

Akihiro Nabuchi, MD,1, Li Qing He, MD, Zhu Zhan Lai, MD

Department of Cardiac Surgery Tianjin Chest Hospital Tianjin, People's Republic of China
1 Department of Cardiac Surgery Yamato Seiwa Hospital Kanagawa, Japan
For reprint information contact: Akihiro Nabuchi, MD Tel: 81 462 64 3911 Fax: 81 462 78 5787 email: nabuchi{at}swan.syscom.ne.jp Department of Cardiac Surgery, Yamato Seiwa Hospital, 9-8-2 Minami Rinkan, Yamato, Kanagawa 242-0006, Japan.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A 28-year-old male with total occlusion of the main trunk of the left coronary artery underwent successful coronary artery bypass surgery with bilateral internal mammary arteries. He did not have hypercholesterolemia and the ascending aorta, bilateral internal mammary arteries, and peripheral part of the left coronary artery were normal in character and size, which indicated that no systemic or inflammatory diseases caused the lesion. Smoking was the only risk factor identified.


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
A surgeon rarely encounters a young patient with total occlusion of the left main trunk (LMT) of the coronary artery, with normal left ventricular function, and without any accompanying disease that may account for it.1–4


   Case Report
TOP
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 28-year-old male who had intermittent precordialgia on effort for one year was admitted to Tianjin Chest Hospital. Chest radiography and electrocardiography did not disclose any abnormality (Figures 1 and 2GoGo). A coronary angiogram showed total occlusion of the left main coronary artery (Figure 3Go) and no disease in the right coronary artery. The peripheral part of the left coronary artery system was visible because of collateral flow from the right coronary artery (Figure 4Go). A two-dimensional echocardiogram showed normal ventricular function without any valvular dysfunction. The patient has been smoking for 10 years. His levels of total cholesterol (1.91 g•L–1), blood sugar, and uric acid were normal and he had no family history of early atherosclerosis. His height was 169 cm and his weight was 63.5 kg. No vascular bruit was audible and the arteries in all four extremities were easily palpable.



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  		Figure 1. Chest radiograph on admission.

 


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  		Figure 2. Electrocardiogram on admission.

 


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  		Figure 3. Angiogram of the left coronary artery showing total occlusion of the left main trunk.

 


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  		Figure 4. Angiogram of the right coronary artery showing collateral blood supply to the left anterior descending coronary artery. The left circumflex coronary artery is not visible in this view.

 
The patient underwent coronary artery bypass grafting through a median sternotomy. Bilateral internal mammary arteries were harvested and they appeared to be completely normal. During cannulation for cardiopulmonary bypass, the ascending aorta was found to be of normal pliability and no atherosclerotic plaque was palpable. After cross-clamping the aorta, complete cardiac arrest was achieved with standard antegrade intermittent crystalloid cardio-plegia. The left anterior descending coronary artery and a relatively large branch of the circumflex coronary artery were identified easily and noted to be of normal color and pliability. No degenerative tissue or scar formation suggestive of inflammatory activity was detected and no congenital anomaly was observed in the coronary arteries. The right internal mammary artery was anastomosed to the left anterior descending coronary artery and the left internal mammary artery was anastomosed to the circumflex artery in standard fashion. Prompt recovery of cardiac function was observed after removal of the aortic crossclamp and the entire surgical procedure was completed within 3.5 hours. No complication was encountered postoperatively.


   Discussion
TOP
 Abstract
 Introduction
 Case Report
 Discussion
References
 
Asymptomatic onset of total occlusion of the LMT is uncommon.1 Moreover, a patient with LMT 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 28-year-old man did not suggest any systemic disease that might have caused his coronary artery disease.6–8 Congenital anomaly or absence of the orifice of the LMT 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 LMT from birth. Idiopathic thromboembolism might have caused an occlusion of the coronary artery without a luminal lesion. However, that would usually result in catastrophic symptoms or sudden death. Left ventricular function was preserved and normal in this patient, which suggests that the occlusion had developed gradually.


   References
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 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Sugishita K, Shimizu T, Kinugawa K, Harada K, Ikenouchi H, Matsui O. Chronic total occlusion of the left main coronary artery. Intern Med 1997;36:471–8.[Medline]

  2. Goldberg S, Grossman W, Markis JE, Cohen MV, Baltaxe HA, Levin DC. Total occlusion of the left main coronary artery: a clinical, hemodynamic and angiographic profile. Am J Med 1978;64:3–12.[Medline]

  3. Valle M, Virtanen K, Hekali P, Frick MH. Survival with total occlusion of the left main coronary artery. Significance of the collateral circulation. Cathet Cardiovasc Diagn 1979;5:269–71.[Medline]

  4. Charitos CE, Nanas JN, Tsoukas A, Anastasiou-Nana M, Lolas CT. Total occlusion of the left main coronary artery with preserved left ventricular function. Int J Cardiol 1997;61:193–6.[Medline]

  5. Kato H, Ichinose K, Kawasaki T. Myocardial infarction in Kawasaki disease: clinical analysis in 195 cases. J Pediatr 1986;108:923–7.[Medline]

  6. Slack J. Risks of ischaemic heart disease in familial hyperlipoproteinemic states. Lancet 1969;2:1380–1.[Medline]

  7. AHA Committee report. Risk factors and coronary disease: a statement for physicians. Circulation 1980;62:449–51.[Abstract/Free Full Text]

  8. O'Brien T, Nguyen TT, Zimmerman BR. Hyperlipidemia and diabetes mellitus. Mayo Clin Proc 1998;73:969–76.[Abstract]





This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
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Right arrow Email this article to a friend
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Right arrow Author home page(s):
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Qing He Li
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Right arrow Articles by Nabuchi, A.
Right arrow Articles by Zhu, Z. L.
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Right arrow Articles by Nabuchi, A.
Right arrow Articles by Zhu, Z. L.

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