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

Abstract

BackgroundCongenital left main coronary atresia is an extremely rare coronary anomaly. Long-term surgical outcomes and the optimal management strategies for recurrence of ischemia remain uncertain. Herein, we present a case involving successful redo coronary artery bypass grafting for unstable angina 27 years after the initial coronary artery bypass grafting for congenital left main coronary atresia.Case presentationA 33-year-old woman was referred to our department with unstable angina. At the age of 6, she had undergone coronary artery bypass grafting of the second diagonal branch using the left internal thoracic artery and the obtuse marginal branch using saphenous vein grafting for left main coronary atresia. Although a coronary angiogram showed a patent left internal thoracic artery graft to the second diagonal branch and a patent saphenous vein graft to the obtuse marginal branch, the left anterior descending artery was not being perfused by the grafts because of a disruption of blood flow to the left anterior descending artery from the left internal thoracic artery. Therefore, we performed a redo coronary artery bypass grafting using the in situ right internal thoracic artery to the first diagonal branch, which was to be connected to the left anterior descending artery, resulting in amelioration of the ischemia of the left anterior wall. The patient was discharged 10 days after the operation and has been in good health for over 3 years without recurrence of chest symptoms.ConclusionsCoronary revascularization using a saphenous vein and left internal thoracic artery grafts is effective in achieving an adequate blood supply to the distal coronary arteries, and this effect can last for decades. However, careful follow-up is necessary because recurrent myocardial ischemia due to the development of a coronary artery occlusion may occur in adulthood.

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

“…Catastrophic situations like sudden cardiac arrest, low cardiac output, and cardiomyopathy, as seen in our case, can also be the first symptoms of infants with LMCAA. [5,6] Since these symptoms are not specific to LMCAA, the clinical diagnosis might be neglected. Thus, other coronary anomalies should be excluded to reach a correct diagnosis.…”

Occlusion of left main coronary artery presenting with ventricular fibrillation in teenagers: an unrecognised cause of sudden death?

“…An anomalous coronary artery origin from the opposite sinus with an intra-mural or an inter-arterial course is well described as a cause of sudden death, 2 but occlusion of the left main coronary artery has not, presumably due to its rarity. 3 Left main coronary artery atresia differs from an intramural or inter-arterial course of an anomalous coronary artery, as the blood flows retrograde from smaller calibre collateral arteries to larger calibre left-sided vessels. 4 Musiani et al hypothesise the collateral vessels are inadequate to meet the myocardial demand which leads to cardiac and coronary insufficiency.…”

“…4,7 A review of literature reveals numerous other case studies with delayed diagnosis of left main coronary artery atresia. [3][4][5][6] Amaral et al described two paediatric cases confirmed via coronary angiography or direct inspection in the operating room, despite normal coronaries on echocardiogram. Shah et al described a paediatric case with recurrent exertional syncopal episodes, an echocardiogram with prominent right coronary artery (otherwise normal), normal exercise testing and diagnosis confirmed by cardiac catheterisation.…”

“…An occluded or atretic left main coronary artery is extremely rare with only 60 cases described in the literature prior to 2017 and few recent publications. 3 Imaging modalities such as echocardiography and CT angiography can identify coronary artery anomalies; however, they may also provide false reassurance of normal coronary anatomy. [4][5][6] Early diagnosis and surgical intervention lead to improved outcomes.…”

Congenital atresia of the left main coronary artery: Imaging feature in children

“…It has been reported the incidence of coronary artery anomalies is approximately 0.6%–1.3% in an angiographic series and 0.3% in an autopsy series . Congenital left main coronary atresia (LMCA) is an extremely rare anomaly when the left main coronary ostium ends blindly and the left coronary artery (LCA) is perfused via collateral flow from the right coronary artery (RCA) .…”