Percutaneous Coronary Intervention in Left Main Coronary Artery Disease - A Case Report

Abstract

Left main coronary artery (LMCA) atherosclerosis bears extra importance because of the large territory of myocardium supplied by the vessel. By convention, significant LMCA stenosis is treated by coronary artery bypass graft (CABG) surgery, and this type of lesion has long been regarded as a contraindication for percutaneous coronary intervention (PCI). However, with the advancement in interventional tools, operators' expertise, pharmaceuticals and supportive measures, outlook regarding left main PCI is changing. Recent clinical trials tell about the feasibility of LMCA PCI. The three cases of significant left main lesion presented here, were treated successfully by percutaneous transluminal coronary angioplasty (PTCA) with stenting in National Institute of Cardiovascular Diseases (NICVD), Dhaka. In near future, PCI may be an equally effective alternative to surgical revascularization in judiciously selected cases of LMCA stenosis even in Bangladesh. Case 1:Mr. AB, a 43-year-old smoker, who was hypertensive but non-diabetic, was admitted into NICVD, Dhaka. Two weeks back, he was treated as a case of unstable angina in Chittagong Medical College Hospital (CMCH). Coronary angiography (CAG) done in Chittagong Medical College Hospital (CMCH) revealed severe left main coronary artery (LMCA) disease with 70-80% stenosis at its mid part, for which he was referred to NICVD for further management. His resting ECG showed ST depression in lead II, III, AVF, V 5 and V 6 ; echocardiography disclosed septal and inferior left ventricular wall hypokinesia with left ventricular ejection fraction (LVEF) 54%. Blood counts and biochemistry including sugar, creatinine and lipid profile were normal. Serological tests i.e. HBsAg, Anti-HCV, Anti-HIV, VDRL were negative. PTCA and stenting to LMCA was done uneventfully. The LMCA lesion was negotiated with floppy PTCA guidewire, and a 3.0x10 mm cobultchromium stent was deployed at the lesion at 14 atm pressure, preceded by dilatation with a 1.5x6 mm balloon at 8 atm. TIMI III flow was established (Fig. 1). Postprocedural period was uneventful. An anesthesiologist was constantly present in the cath lab and a full coronary artery bypass graft (CABG) team was kept ready for emergency revascularization surgery, if needed. Case 2:Mr. AK, a 38-year-old normotensive, nondiabetic but dyslipidaemic man, with a strong family history of coronary artery disease, presented to NICVD with compressive chest pain. He was haemodynamically stable with pulse 80 beats per minute, blood pressure 120/75 mm Hg, lung bases were clear and heart sounds were