Summary:We report a patient with acute occlusion of left main coronary artery with only a small increase of cardiac enzymes but without electrocardiographic signs of acute myocardial infarction. Normal global and regional left ventricular function could be documented angiographically. Damage of myocardium was prevented by extensive collateral circulation from a large dominant right comnary artery. Key words: acute occlusion of left main coronary artery Case ReportA 42-year-old female was admitted because of sudden onset of thoracic pain. Risk factors for coronary heart disease were hypertension and elevated serum cholesterol. Admission electrocardiogram (ECG) showed 2 mm STsegment depression in precordial leads V3-V5. Maximal documented rise of creatine kinase MB (CKMB) fraction was 38 U/L (normal range up to 10 U/L). Because of the small infarct size and the minor ECG changes the patient was recommended to conservative therapy and thrombolysis was not done. Postinfarct angina and a pathologic exercise stress test required coronary angiography 10 days after admission. The ostium of the left main coronary artery was cannulated using a 8 Fr Judkins coronary catheter and revealed a short, totally occluded left main stem. Only few millimeters of the occluded left main stem were opacified by contrast material. The right coronary artery was a smooth dominant large vessel. Collateral circulation to the left anterior descending artery could be documented via septa1 collaterals from the posterior descending artery and via ventricular branches of the right coronary artery. Additional filling of the left anterior descending artery was seen by a conus artery from the proximal right coronary artery. Circumflex artery was filled antegrade from the origin of the left anterior descending artery (Figs. I , 2). No additional stenoses were visible in the remaining coronary artery system. Surprisingly, biplane left ventriculography (RAO 30" and LAO 60") showed normal left ventricular volumes and normal global ejection fraction (72%). Also, regional left ventricular function was completely normal (Figs. 3 , 4). Although no vascular filling defect of left ventricular myocardium was present, additional contrast injection in the aorta ascending was done to rule out protection of left myocardium by aberrant vessels. The patient underwent elective bypass operation and was diagnosed in good condition. DiscussionSurvival of acute total occlusion of the left main core)-nary artery is extremely rare. 1 . 3 . 9 . 1 1 The majority of these patients suffer extensive myocardial infarction followed by rapid onset of cardiogenic shock or other lethal complications. In a few cases, myocardium is protected by well-developed collaterals and patients have survivcd. However, in most such cases, extensive myocardial infarction followed by a decrease of global and regional left ventricular function is seen. A recent article summarized the literature on acute occlusion of left main coronary artery,' where only four cases were cited showing normal global b...

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The catheter tips of 152 patients, who were haemodynamically supervised by pulmonary artery monitoring or continuous cardiac output determination, were bacteriologically examined. 106 cultures remained sterile, 21 cultures revealed a growth of non pathogenic organisms. Staphylococcus aureus was cultured 15 times, pseudomonas aeruginosa 4 times, Citrobacter as well as Escherichia coli twice, and Klebsiella and Enterobacter once each. There was no statistically significant connection between dwelling period and contamination. Also diabetes mellitus or corticoid medication in high dosage had no significant influence on contamination rate.

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Nocturnal angina occurred in a 43-year-old man. Biplane left-ventricular angiography demonstrated normal left ventricular function (ejection fraction of 75%) with mild apical hypokinesia. The right coronary artery had a normal origin, was dominant and its lumen smooth. The left coronary artery also originated from the right coronary cusp, the left main stem coursing between the pulmonary artery and aorta within the aortic wall. It had a long, 40% stenosis. During atrial stimulation (130 beats/min) angiography demonstrated a 60% increase in luminal narrowing. Because of the symptoms caused by the stenosis in the anomalous coronary artery a mammary artery implant into the anterior interventricular branch and a vein graft to the circumflex artery were performed. The patient has since been free of symptoms. In relatively young persons the presence of coronary artery anomalies should be considered in the differential diagnosis even of atypical chest pain; indications for cardiac catheterization with angiography should be broad.