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Twin ostial openings in the left posterior aortic sinus: a pictorial overview of coronary revascularisation and aortic valve replacement in a patient with absent left main artery Nasir Hussain, 1,2,3 Atiq Rehman, 3,4 Faisal H Cheema 5 1 Hartford Hospital, University of Connecticut, Hartford, Connecticut, USA 2 Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA 3 Department of Cardiothoracic Surgery, College of Physicians and Surgeons of Columbia University, New York Presbyterian Hospital, New York, New York, USA 4 Sarasota Memorial Hospital, Sarasota, Florida, USA 5 Department of Cardiothoracic Surgery, University of Maryland Medical Centre, Baltimore, Maryland, USA Correspondence to Dr Nasir Hussain, [email protected] Accepted 1 March 2014 To cite: Hussain N, Rehman A, Cheema FH. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2014-204043 DESCRIPTION Congenital absence of the left main (LM) with left anterior descending (LAD) and left circumflex (LCX) arteries arising directly from the left sinus of Valsalva with their separate ostia is an extremely rare anomaly with an estimated incidence rate of around 0.4% of the cardiac catheterisations per- formed. 1 A 73-year-old man presented with a 8-month history of exertional dyspnoea. Preoperative diagnostic workup demonstrated severe aortic stenosis on transthoracic echocardiog- raphy, while the coronary catheterisation depicted separate ostia with critical ostial stenosis for the LAD and LCX arteries ( figure 1A–D). The patient underwent coronary artery bypass graft with left internal mammary artery anastomosis to the LAD and a reverse saphenous vein graft anastomosis to the obtuse marginal branch of LCX. A concomitant aortic valve replacement (AVR) was also performed and separate ostia were clearly identified and pre- served while seating the new prosthesis ( figure 2A, B). Thus, the presentation of an absent LM artery may affect the clinical management, especially in cases of AVR. Injection of the contrast dye into the left posterior aortic sinus during the caudal left anterior oblique or lateral projections of the coron- ary angiography helps in making a diagnosis for this anomaly. 1 Operator should ensure that selective decannulation and catheter-related vasospasm, by careful monitoring of pressure tracing during cardiac catheterisation, is differentiated from true absence of LM. 2 Figure 1 Images from the cardiac catheterisation laboratory. (A and B) Images taken in left anterior oblique (LAO) caudal view and depict separate ostial origins with critical ostial stenosis for left anterior descending (LAD) and left circumflex (LCX). (C and D) Images taken in LAO cranial view and demonstrate absent left main. Hussain N, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204043 1 Images in … on 14 June 2020 by guest. Protected by copyright. http://casereports.bmj.com/ BMJ Case Reports: first published as 10.1136/bcr-2014-204043 on 28 March 2014. Downloaded from
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Twin ostial openings in the left posterior aortic sinus:a pictorial overview of coronary revascularisation andaortic valve replacement in a patient with absent leftmain arteryNasir Hussain,1,2,3 Atiq Rehman,3,4 Faisal H Cheema5
1Hartford Hospital, Universityof Connecticut, Hartford,Connecticut, USA2Department of InternalMedicine, Saint JosephHospital, Chicago, Illinois, USA3Department of CardiothoracicSurgery, College of Physiciansand Surgeons of ColumbiaUniversity, New YorkPresbyterian Hospital,New York, New York, USA4Sarasota Memorial Hospital,Sarasota, Florida, USA5Department of CardiothoracicSurgery, University of MarylandMedical Centre, Baltimore,Maryland, USA
Correspondence toDr Nasir Hussain,[email protected]
Accepted 1 March 2014
To cite: Hussain N,Rehman A, Cheema FH.BMJ Case Rep Publishedonline: [please include DayMonth Year] doi:10.1136/bcr-2014-204043
DESCRIPTIONCongenital absence of the left main (LM) with leftanterior descending (LAD) and left circumflex(LCX) arteries arising directly from the left sinus ofValsalva with their separate ostia is an extremelyrare anomaly with an estimated incidence rate ofaround 0.4% of the cardiac catheterisations per-formed.1 A 73-year-old man presented with a8-month history of exertional dyspnoea.Preoperative diagnostic workup demonstratedsevere aortic stenosis on transthoracic echocardiog-raphy, while the coronary catheterisation depictedseparate ostia with critical ostial stenosis for theLAD and LCX arteries (figure 1A–D). The patientunderwent coronary artery bypass graft with leftinternal mammary artery anastomosis to the LAD
and a reverse saphenous vein graft anastomosis tothe obtuse marginal branch of LCX. A concomitantaortic valve replacement (AVR) was also performedand separate ostia were clearly identified and pre-served while seating the new prosthesis (figure 2A,B). Thus, the presentation of an absent LM arterymay affect the clinical management, especially incases of AVR. Injection of the contrast dye into theleft posterior aortic sinus during the caudal leftanterior oblique or lateral projections of the coron-ary angiography helps in making a diagnosis forthis anomaly.1 Operator should ensure that selectivedecannulation and catheter-related vasospasm, bycareful monitoring of pressure tracing duringcardiac catheterisation, is differentiated from trueabsence of LM.2
Figure 1 Images from the cardiac catheterisation laboratory. (A and B) Images taken in left anterior oblique (LAO)caudal view and depict separate ostial origins with critical ostial stenosis for left anterior descending (LAD) and leftcircumflex (LCX). (C and D) Images taken in LAO cranial view and demonstrate absent left main.
Hussain N, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204043 1
Images in…
on 14 June 2020 by guest. Protected by copyright.
http://casereports.bmj.com
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ase Reports: first published as 10.1136/bcr-2014-204043 on 28 M
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Contributors NH and FHC were involved in writing and preparation of themanuscript. AR contributed to preparation of the manuscript and was directlyinvolved in the patient care and performed the surgery on the patient.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES1 Topaz O, DiSciasscio G, Cowley MH, et al. Absent left main coronary artery:
angiographic findings in 83 patients with separate ostia of the left anteriordescending and circumflex arteries at the left aortic sinus. Am Heart J1991;122:447–52.
2 Longenecker CG, Reemtsma K, Creech O Jr. Surgical implication ofsingle coronary artery: a review and two case reports. Am Heart J1961;61:383–6.
Learning points
▸ It is particularly important for the physicians to be aware aboutthe true congenital absence of the left main and be able todifferentiate the origins of separate ostia for left anteriordescending and left circumflex on coronary angiograms.
▸ Clear identification of the ostia during an aortic valvereplacement (AVR) is essential since the anomalous origin ofthe separate ostia could be from the same or different sinusesof Valsalva; therefore, extra caution should be taken in seatingthe prosthetic valve during AVR lest the struts or the sewingring of the valve inadvertently compromises one of the ostia.
▸ In addition, separate ostial identification is also important incases of AVR for aortic insufficiency for direct ostial infusionof cardioplegia (if a retrograde coronary sinus cardioplegiacatheter is not used).
Figure 2 Images from the operating room. (A and B) Intraoperative images that depict separate ostial origins of the left anterior descending (LAD)and left circumflex (LCX) from the left sinus of Valsalva.
2 Hussain N, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204043
Images in…
on 14 June 2020 by guest. Protected by copyright.
http://casereports.bmj.com
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MJ C
ase Reports: first published as 10.1136/bcr-2014-204043 on 28 M
arch 2014. Dow
nloaded from
