Register
Forgot your password?

Left main coronary artery stenosis: cardiologist view

Authors: O.L. Barbarash 1, O.M. Polikutina 1, E.V. Tavlueva 1, N.A. Barbarash 2

Company: 1 Research Institute for Complex Issues of Cardiovascular Diseases, Siberian Branch of the Russian Academy of Sciences; Sosnovyy bul’var, 6, Kemerovo, 650002, Russian Federation;
2Kemerovo State Medical Academy of Ministry of Health of the Russian Federation; ulitsa Voroshilova, 22a, Kemerovo, 650029, Russian Federation

Type:  Stable ischemic heart disease


DOI: https://doi.org/10.15275/kreatkard.2015.02.01

For citation: O.L. Barbarash, O.M. Polikutina, E.V. Tavlueva, N.A. BarbarashLeft main coronary artery stenosis: cardiologist viewCreative Cardiology. 2015; 2: 5-15

Keywords: stenosis of the left coronary artery myocardial revascularization fractional flow reserve multivessel coronary disease

Download
Full text:  

 

Abstract

The degree of damage of the left main coronary artery (LM) is one of the main factors determining survival in patients with coronary artery disease (CAD). Both anatomy and atherosclerotic lesions of LM are described in the article. The LM stenosis of more than 50% allows to refer the patients to the category of a high risk of a sudden death. The review presents a detailed description of the clinical and functional characteristics of a patient with LM stenosis. Currently there are number of studies revealing the complexity of invasive coronary angiography in assessment the degree of LM lesion. From that point of view “the gold standard” of invasive assessment of myocardial ischemia in patients with LM stenosis is measuring of fractional flow reserve. Intravascular ultrasound significantly helps to assess a degree of arteries stenosis, a nature of plaque, a proper diameter of the vessel and an adequacy of stenting. The review presents the management options in patients with LM stenosis. It is considered that survival rate different enormously in patients with medical or surgical strategy. According to the latest European guidelines, choosing the revascularization technique requires a Heart Team discussion to define the best revascularization strategy in relation of efficiency and safety.

References

  1. Windecker S., Kolh Ph., Alfonso F., Collet J., Cremer J., Falk V. 2014 ESC/EACTS Guidelines on myocardial revascularization The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur. Heart J. DOI: 10.1093/eurheartj/ehu278. 
  2. Herric J. Clinical features of sudden obstruction of the coronary arteries. JAMA. 1912; 59: 2015-22.
  3. DeMots H., Bonchek L.I., Rosch J., Anderson R.P., Starr A., Rahimtoola S.H. Left main coronary artery disease. Risks of angiography, importance of coexisting disease of other coronary arteries and effects of revascularization. Am. J. Cardiol. 1975; 36: 136–41. 
  4. Fajadet J., Chieffo A. Current management of left main coronary artery disease. Eur. Heart J. 2012; 33 (1): 36–50. 
  5. Baroldi G., Mantero O., Scomazzoni G. The collaterals of the coronary arteries in normal and pathologic hearts. Circ. Res. 1956; 4: 223–9. 
  6. Chikwe J., Kim M., Goldstone A.B., Fallahi A., Athanasiou T. Current diagnosis and management of left main coronary disease. Eur. J. Cardiothorac. Surg. 2010; 38: 420–30. 
  7. Dodge Jr. J.T., Brown B.G., Bolson E.L., Dodge H.T. Lumen diameter of normal human coronary arteries. Influence of age, sex, anatomic variation, and left ventricular hypertrophy or dilation. Circulation. 1992; 86: 232–46. 
  8. James T.N. Anatomy of coronary arteries. Circulation. 1965; 32: 1020–33.
  9. Johnson A.D., Detwiler J.H., Higgins C.B. Left coronary artery anatomy in patients with bicuspid aortic valves. Br. Heart J. 1978; 40: 489–93.
  10. Yamanaka O., Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet. Cardiovasc. Diagn. 1990; 21 (1): 28–40. 
  11. Bergelson B.A., Tommaso C.L. Left main coronary artery disease: assessment, diagnosis, and therapy. Am. Heart J. 1995; 129: 350–9. 
  12. Ku D.N., Giddens D.P., Zarins C.K., Glagov, S. Pulsatile flow and atherosclerosis in the human carotid bifurcation. Positive correlation between plaque location and low oscillating shear stress. Arterioscler. Thromb. Vasc. Biol. 1985; 5: 293–302.
  13. Heggtveit H.A. Syphilitic aortitis. A clinicopathologic autopsy study of 100 cases, 1950 to 1960. Circulation. 1964; 29: 346–55.
  14. Miller G.A., Honey M., el-Sayed H. Isolated coronary ostial stenosis. Cathet. Cardiovasc. Diagn. 1986; 12: 30–4.
  15. Atay Y., Yagdi T., Turkoglu C., Altintig A., Buket S. Spontaneous dissection of the left main coronary artery: a case report and review of the literature. J. Card. Surg. 1996; 11: 371–5.
  16. Dibie A., Philippe F., Temkine J., Larrazet F., Folliguet T., Czitrom D. et. Iatrogenic lesions of the left main coronary artery. Arch. Mal. Coeur Vaiss. 2002; 95: 781–6. 
  17. Акбашева М.Т., Закарян Н.В., Алекян Б.Г. Атеросклероз и его осложнения. Актуальные вопросы диагностики и лечения ишемической болезни сердца. Креативная кардиология. 2009; 2: 68–79.
  18. Рабкин И.Х., Ткаченко В.М., Абугов А.М. Стеноз основного ствола левой коронарной артерии: клинические, коронарографические, гемо- динамические параллели и сократительная функция левого желудочка. Азербайджанский медицинский журнал. 1984; 3: 39–44. 
  19. Кузнецов В.А., Бессонов И.С., Зырянов И.П., Самойлова Е.П., Горбатенко Е.А., Игнатов Д.И. Клинико-функциональная характеристика и лечение пациентов с поражением ствола левой коронарной артерии в реальной клинической практике. Кардиология. 2014; 1: 55–60. 
  20. Caracciolo E.A., Davis K.B., Sopko G., Kaiser G.C., Corley S.D., Schaff H. et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease long-term CASS experience. Circulation. 1995; 91: 2335–44. 
  21. Oviedo C., Maehara F., Mintz G.S., Araki H., Choi S.Y., Tsujita K. et al. Intravascular ultrasound classification of plaque distribution in left main coronary artery bifurcations where is the plaque really located? Circulation: Cardiovasc. Interv. 2010; 3 (2): 105–12.
  22. Fassa A.A., Wagatsuma K., Higano S.T., Mathew V., Barsness G.W. et al. Intravascular ultrasound-guided treatment for angiographically indeterminate left main coronary artery disease: a long-term follow-up study. J. Am. Coll. Cardiol. 2005; 45 (2): 204–11.
  23. Andersen K., Vik-Mo H., Omvik P. Can left main or proximal left anterior descending coronary artery disease be assessed by non-invasive means? Acta Med. Scand. 1982; 212 (6): 361–5.
    24. 24. Aoki J., Hoye A., Staferov A.V., Alekyan B.G., Serruys P.W. Sirolimus-eluting stent implantation for chronic total occlusion of the left main coronary artery. J. Interv. Cardiol. 2005; 18 (1): 65–9. 
  24. Dacosta A., Tardy B., Favre J.P., Guy J.M., Rachet F., Lamaud M. et al. Left main coronary artery disease. Arch. Mal. Coeur Vaiss. 1994; 87 (9): 1225–32. 
  25. Sianos G., More M., Kappetein A.P., Morice M., Colombo A., Dawkin K. The SYNTAX Score: an angiographic tool grading the complexity of coronary artery disease. EuroInterv. 2005; 1: 219–27.
  26. Favaloro R.G., Effler D.B., Groves L.K., Sheldon W.C., Shirey E.K., Sones F.M., Jr. Severe segmental obstruction of the left main coronary artery and its divisions. Surgical treatment by the saphenous vein graft technique. J. Thorac. Cardiovasc. Surg. 1970; 60: 469–82.
  27. Cohen V., Gorlin R. Main left coronary artery disease. Clinical experience from 1964–1974. Circulation. 1975; 52: 275–85.
  28. Gotsman M.S., Lewis B.S., Bakst A. Obstruction of the left main coronary artery – the artery of sudden death. S. Afr. Med. J. 1973; 47 (15): 641–4. 
  29. Mehta J., Hamby R.I., Hoffman I., Hartstein M.L., Wisoff B.G. Medical-surgical aspects of left main coronary artery disease. J. Thorac. Cardiovasc. Surg. 1976; 1 (1): 137–41. 
  30. Pryor D.B., Shaw L., Harrell F.E., Jr, Lee K.L., Hlatky M.A., Mark D.B. et al. Estimating the likelihood of severe coronary artery disease. Am. J. Med. 1991; 90: 553–62. 
  31. Kallikazaros I., Tsioufis C., Sideris S., Stefanadis C., Toutouzas P. Carotid artery disease as a marker for the presence of severe coronary artery disease in patients evaluated for chest pain. Stroke. 1999; 30: 1002–7. 
  32. Montalescot G., Sechtem U., Achenbach S., Andreotti F., Arden C., Budaj A. et al. ESC guidelines on the management of stable coronary artery disease. Eur. Heart J. 2013; 34: 949–3003. DOI: 10.1093/eurheartj/eht296. 
  33. Сыркин А.Л. (ред.) Нагрузочные ЭКГ-тесты: 10 шагов к практике: Учебное пособие. М.: МЕДпресс-информ; 2013. 
  34. Jong G.P., Ma T., Chou P., Shyu M.Y., Tseng W.K., Chang T.C. Reciprocal changes in 12-lead electrocardiography can predict left main coronary artery lesion in patients with acute myocardial infarction. Int. Heart J. 2006; 47 (1): 13–20.
  35. Wong C.K., Gao W., Stewart R.A., French J.K., Aylward P.E., White H.D. The prognostic meaning of the full spectrum of aVR ST-segment changes in acute myocardial infarction. Eur. Heart J. 2012; 33 (3): 384–92. 
  36. Praudfit W.L., Bruschke A.V., Sones F.M., Jr. Natural history of obstructive coronary artery disease: ten-year study of 601 nonsurgical cases. Prog. Cardiovasc. Dis. 1978; 21 (1): 53–78.
  37. Ragosta M. The complexity involved in assessment of left main coronary artery disease. JACC Cardiovasc. Interv. 2012; 5 (10): 1026–8. 
  38. Topol E.J., Nissen S.E. Our preoccupation with coronary luminology. The dissociation between clinical and angiographic findings in ischemic heart disease. Circulation. 1995; 92 (8): 2333–42. 
  39. Arnett E.N., Isner J.M., Redwood D.R., Kent K.M., Baker W.P., Ackerstein H. et al. Coronary artery narrowing in coronary heart disease: comparison of cineangiographic and necropsy findings. Ann. Intern. Med. 1979; 91 (3): 350–6. 
  40. Botman C.J., Schonberger J., Koolen S., Penn O., Botman H., Dib N. et al. Does stenosis severity of native vessels influence bypass graft patency? A prospective fractional flow reserve-guided study. Ann. Thorac. Surg. 2007; 83 (6): 2093–7.
  41. Kroncke G.M., Kosolcharoen P., Clayman J.A., Peduzzi P.N., Detre K., Takaro T. Five-year changes in coronary arteries of medical and surgical patients of the Veterans Administration Randomized Study of Bypass Surgery. Circulation. 1988; 78 (3, Pt 2): I144–50. 
  42. Wang P., Chen T., Ecabert O., Prummer S., Ostermeier M., Comaniciu D. Image-based device tracking for the co-registration of angiography and intravascular ultrasound images. Med. Image Comput. Comput. Assist. Interv. 2011; 14 (Pt 1): 161–8. 
  43. Lindstaedt M., Spiecker M., Perings C., Lawo T., Yazar A., Holland-Letz T. et al. How good are experienced interventional cardiologists at predicting the functional significance of intermediate or equivocal left main coronary artery stenoses? Int. J. Cardiol. 2007; 120 (2): 254–61.
  44. Hamilos M., Muller O., Cuisset T., Ntalianis A., Chlouverakis G., Sarno G. et al. Long-term clinical outcome after fractional flow reserve-guided treatment in patients with angiographically equivocal left main coronary artery stenosis. Circulation. 2009; 120 (15): 1505–12.
  45. Chakrabarti A.K., Grau-Sepulveda M.V., O'Brien S., Abueg C., Ponirakis A., Delong E. et al. Angiographic validation of the American College of Cardiology Foundation-the Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies study. Circ. Cardiovasc. Interv. 2014; 7 (1): 11–8. 
  46. King S.B. Is it form or function? The “COURAGE” to ask. JACC Cardiovasc. Interv. 2014; 7 (2): 202–3. 
  47. Puri R., Kapadia S.R., Nicholls S.J., Harvey G.E., Kataoka T., Tuzcu E.M. Optimizing outcomes during left main percutaneous coronary intervention with intravascular ultrasound and fractional flow reserve the current state of evidence. J. Am. Coll. Cardiol. Intv. 2012; 5 (7): 697–707. 
  48. Park S.J., Ahn J.M., Kim Y.H. How to optimize left main percutaneous coronary intervention. JACC Cardiovasc. Interv. 2014; 7 (7): 731–2.
  49. Park S.J., Ahn J.M., Kang S.J. Unprotected left main percutaneous coronary intervention: integrated use of fractional flow reserve and intravascular ultrasound. J. Am. Heart Assoc. 2012; 1 (6): e004556.
  50. Daniels D.V., van't Veer M., Pijls N.H., van der Horst A., Yong A.S., De Bruyne B. et al. The impact of downstream coronary stenoses on fractional flow reserve assessment of intermediate left main disease. JACC Cardiovasc. Interv. 2012; 5 (10): 1026–8.
  51. Abizaid A.S., Mintz G.S., Abizaid A., Mehran R., Lansky A.J., Pichard A.D. et al. One-year follow-up after intravascular ultrasound assessment of moderate left main coronary artery disease in patients with ambiguous angiograms. J. Am. Coll. Cardiol. 1999; 34 (3): 707–15.
  52. Park S.J., Kim Y.H., Park D.W., Lee S.W., Kim W.J., Suh J. et al. Impact of intravascular ultrasound guidance on long-term mortality in stenting for unprotected left main coronary artery stenosis. Circ. Cardiovasc. Interv. 2009; 2 (3): 167–77. 
  53. De la Torre Hernandez J.M., Baz Alonso J.A., G_mez Hospital J.A., Alfonso Manterola F., Garcia Camarero T., Gimeno de Carlos F. et al. Clinical impact of intravascular ultrasound guidance in drug-eluting stent implantation for unprotected left main coronary disease: pooled analysis at the patient-level of 4 registries. JACC Cardiovasc. Interv. 2014; 7 (3): 244–54. 
  54. Stone G.W. Revascularization decisions in coronary artery disease: hitting a moving target. JACC Cardiovasc. Interv. 2014; 7 (5): 507–9. 
  55. Gyenes G.T., Ghali W.A. Should all patients with asymptomatic but significant (>50%) left main coronary artery stenosis undergo surgical revascularization? Circulation. 2008; 118 (4): 422–5.
  56. Amanullah A.M., Heo J., Acio E., Narula J., Iskandrian A.E. Predictors of outcome of medically treated patients with left main/three-vessel coronary artery disease by coronary angiography. Am. J. Cardiol. 1999; 83 (3): 445–8.
  57. Iqbal J., Serruys P.W. Revascularization strategies for patients with stable coronary artery disease. J. Intern. Med. 2014; 276 (4): 336–51. 
  58. Prapas S.N., Tsakiridis K., Zarogoulidis P., Katsikogiannis N., Tsiouda T., Sakkas A. et al. Current options for treatment of chronic coronary artery disease. J. Thorac. Dis. 2014; 6 (1): 2–6.
  59. Migliorini A., Valenti R., Marcucci R., Parodi G., Giuliani G., Buonamici P. et al. High residual platelet reactivity after clopidogrel loading and long-term clinical outcome after drug-eluting stenting for unprotected left main coronary disease. Circulation. 2009; 20 (22): 2214–21.
  60. Puri R., Wolski K., Uno K., Kataoka Y., King K.L., Crowe T.D. et al. Left main coronary atherosclerosis progression, constrictive remodeling, and clinical events. JACC Cardiovasc. Interv. 2013; 6 (1): 29–35.

About Authors

  • Barbarash Ol’ga Leonidovna, MD, DM, Professor, Director of Research Institute for Complex Issues of Cardiovascular Diseases Siberian Branch of the Russian Academy of Sciences, Chief of Laboratory;
  • Polikutina Ol’ga Mikhaylovna, MD, PhD, Chief of Laboratory;
  • Tavlueva Evgeniya Valer’evna, MD, DM, Leading Research Associate
  • Barbarash Nina Alekseevna, MD, DM, Professor

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery


Sort by