Collateral beauty: left main stem atresia
Sara Ranchordás, Adriana Vazão, Francisco Soares, Marta Marques
Abstract
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Taxonomy
TopicsCoronary Artery Anomalies · Congenital Heart Disease Studies · Vascular anomalies and interventions
Case description
A 53-year-old man with arterial hypertension and diabetes underwent exams for an elective cholecystectomy. The patient reported only nonspecific complaints of body numbness. He had undergone amputation of both legs due to electrocution over 20 years before. He underwent Holter monitoring, which showed dynamic ventricular repolarization changes. Invasive coronary angiography (Figure 1A) followed by computed tomography coronary angiography (Figure 1B–F) showed left main stem (LMS) atresia with collaterals from the right coronary artery (RCA) supplying retrogradely the left coronary circulation. The echocardiogram showed good biventricular function, with no regional wall motion abnormalities. Cardiac magnetic resonance myocardial perfusion imaging showed no ischaemia. During the 18-month follow-up period, the patient remained asymptomatic for ischaemic events, and therefore, no intervention was deemed necessary. He continued his usual medication, including clopidogrel.
(A) Invasive coronary angiography. Right coronary catheterization showing left main stem atresia with collaterals from the right coronary artery supplying retrogradely the left coronary circulation. (B–F) Computed tomography coronary angiography. (B and C) 3D reconstruction showing collaterals between left anterior descending and right coronary artery and left main stem atresia. (D) 2D axial plane showing left main stem atresia. (E) 3D reconstruction showing left main stem atresia. (F) 3D reconstruction of the coronary tree showing collaterals between left anterior descending artery and right coronary artery and left main stem atresia. Cx, circumflex artery; LAD, left anterior descending artery; LMS, left main stem; RCA, right coronary artery.
Left main stem atresia is an exceedingly rare coronary artery anomaly characterized by the absence of the LMS, resulting in the proximal blind ending of the left anterior descending and circumflex arteries, which are supplied by collateral circulation from the RCA, unlike the differential diagnosis single coronary artery malformation. When there is a single coronary blood supply, direction is antegrade, flowing from the single coronary to its branches.^1,2^
The diagnosis is generally made early in life, if there are symptoms, such as angina, syncope, or sudden cardiac death. However, in rare cases, it is only diagnosed in adulthood, frequently as an incidental finding, due to the development of sufficient collateral circulation.^1^
When symptomatic, coronary artery bypass surgery or surgical coronary repair is recommended. However, in asymptomatic adult patients with no evidence of inducible myocardial ischaemia, conservative management with optimal medical therapy is reasonable.^3^
The reference list from the paper itself. Each links out to its DOI / PubMed record.
- 1Talanas G , Corda G, Parodi G, Portoghese M. Incidental finding and conservative management of left main coronary atresia in an adult patient: a case report. Eur Heart J Case Rep 2021;5:ytab 052.33738422 10.1093/ehjcr/ytab 052PMC 7954245 · doi ↗ · pubmed ↗
- 2Jiang X , Ye W, Xiao Y, Han L, Ding W, Li W, et al Clinical characteristics of congenital atresia of the left main coronary artery in 12 children. Front Pediatr 2022;10:866010.35573961 10.3389/fped.2022.866010 PMC 9100423 · doi ↗ · pubmed ↗
- 3Alsalehi M , Jeewa A, Wan A, Contreras J, Yoo SJ, Laks JA. A case series of left main coronary artery ostial atresia and a review of the literature. Congenit Heart Dis 2019;14:901–923.31532081 10.1111/chd.12842 · doi ↗ · pubmed ↗