Percutaneous Transluminal Coronary Angioplasty for Postoperative Left Coronary Artery Stenosis Following Surgical Reconstruction of Congenital Atresia of the Left Main Coronary Artery

Abstract

ongenital atresia of the left main coronary ostium (LMCA) is a rare condition in which there is no left coronary ostium and the proximal main trunk ends blindly. [1][2][3] Among the different surgical approaches, including various forms of coronary artery bypass (eg, using the saphenous vein or internal mammary artery), reconstruction is the current technique of choice. However, postoperative coronary artery stenosis is a major complication. Although percutaneous transluminal coronary angioplasty (PTCA) is an acceptable treatment for adult patients with coronary artery stenosis, experience with postoperative coronary stenosis in pediatric patients remains limited. [4][5][6] We report the mid-term result of PTCA in a 3-year-old boy with postoperative left coronary artery stenosis following surgical reconstruction of the LMCA. Case ReportA boy was referred to hospital at 2.5 years of age for assessment of heart murmur. On physical examination, a grade 3 systolic murmur and a 3 rd heart sound were heard in the mitral area. Chest X-ray showed cardiomegaly with left atrial enlargement. Resting ECG demonstrated left atrial enlargement, but there were no ST-T changes. Echocardiography demonstrated a dilated left ventricle and atrium, with severe mitral regurgitation (MR). Myocardial thallium (Tl) scan concomitant with 123 I-BMIPP showed diffuse dissociation between perfusion and lipid metabolism, consistent with ischemia of the left main coronary artery perfusion area. At cardiac catheterization, left ventricular angiography showed a normal ejection fraction of 71% and dilation of the end-diastolic volume was 387% of normal, with grade 4 MR. On selective right coronary angiography, the right coronary artery was dilated with retrograde filling of the left coronary artery via collaterals, but there was no passage of contrast media from the left coronary artery to the main CASE REPORT

Left Main Coronary Atresia

“…Various surgical interventions have been described, with coronary artery bypass grafting using the internal mammary artery as the treatment of choice. Alternatively, coronary bypass with saphenous vein grafts anastomosed to the LAD/LCx or direct surgical reimplantation or reconstruction of the left main coronary artery using azygos vein have also been described . The hypoplastic left coronary system appears to grow in diameter once sufficient flow is established and collateral arteries tend to disappear .…”

A rare case of Left Main Coronary Artery Atresia presenting as Dilated Cardiomyopathy and misdiagnosed as ALCAPA

“…Alternative to bypass grafting, direct surgical reimplantation or reconstruction of the left main coronary artery using azygos vein have been described to provide the shortest and most efficient way for blood to the myocardium. [6,12,13]. The advantages they offer relative to bypass grafting are prevention of the occlusion of main trunk, provision of the antegrade flow and avoidance of competitive flow.…”

Redo coronary bypass grafting for congenital left main coronary atresia: a case report

“…Although early development of coronary artery stenosis 8 months after reconstruction of the left main trunk with an azygos vein patch has been reported in a patient with LMCA [5], occlusion of the coronary artery CABG to LMCA was not reported in the long-term follow-up. One possible reason was anastomotic technical difficulties with the heels of the anastomoses because of likely small size of coronary arteries in a 6 year old child.…”