Response to Letter by Kern Regarding Article “Primary Stenting of an Anomalous Left Main Coronary Artery With an Interarterial Course During Cardiac Arrest: Imaging With CT Angiography”

Abstract

We thank Dr Kern for his thoughtful comments regarding the evaluation and treatment of this patient. We performed primary stenting of a critical narrowing in the midsegment of a left main coronary artery with an anomalous origin from the right coronary sinus and an interarterial course in a patient with cardiac arrest. Follow-up computed tomographic angiography and intravascular ultrasound demonstrated patency of the stent but a slit-like orifice of the artery with a cross-sectional area of 6.3 mm 2 . The patient underwent bypass surgery and has been well for 1 year since then.The decision to refer the patient to surgery was made primarily because of uncertainty regarding possible future mechanical compression of the stented midsegment as it coursed between the aorta and pulmonary artery. We agree that the stenosis of the ostial segment may not have been physiologically significant. However slitlike ostial morphology has been associated with adverse outcome in subjects with this anomaly regardless of the measured crosssectional area. 1 The utility of fractional flow reserve in guiding therapy in this case is unclear because left main lesions were excluded from the FAME study, which is the primary source of outcome data for this technology. 2 We are aware of the risk of graft failure in vessels with non-flow-limiting stenosis; however, our surgical colleagues preferred not to occlude the left main artery at the time of surgery. DisclosuresNone. Ronen