Complete Obstruction of the Left Main Coronary Artery Associated with Congenital Pulmonary Valvular Stenosis" R. D. Suthe rland, M.D., F.C.C .P.; Walter A llison, M .D .; W. A. Guynes, MD .; and H. E. Mart inez , M.D ., F.C.C.P.
The sur gical treatment of the completely obstructed left main coronary artery is aortocoronary sa phenous-vein bypass to the left coronary artery system. Without surgical int ervention, thi s lesion has an exceedingly poor prognosis. Thi s report describes a patient with atherosclerotic obstruction of the left main coronary artery and congenital pulmonary valvular stenosis, an unusual combination of lesions not pr eviou sly documented together. The pati ent remains asymptomatic 22 months after aortocoronary saphe nous-vein bypass and pulmonary valvotomy.
C
om ple te atheroscleroti c occlusion of th e lef t main coro na ry artery is a relativel y rare finding, while conge nital pulmon a ry val vul ar s te no sis is not rare. The au tho rs ca n find no previou s report of th ese two en ti ties bei ng prese nt in the sa m e patient. This report d escribe s the success fu l surgical tr eatment of a 56-year-old wom an with comple te ob struc tio n o f th e lef t main coro na ry artery and congeni ta l p ul m ona ry val vula r ste nosis . CASE R EPORT
A 56-year-old-white woma n was admitte d to SI. Anthony's Hospit al, Amarillo, Tex, for ca rdiac evaluatio n. Th e patient had a dec reased exercise tolerance for many years an d had been awa re of a heart murmur for 30 years. In th e six months pr ior to her admission , she had progressively developed exertional angina pectoris. Th e an gina pe ctoris was not relieved by admi nistration of isosorh ide d initrat e or nitr oglycerin. Ph ysical examina tion revealed a regul ar pul se at 84 heat s per min ute and a blood pressur e of 120/70 mm Hg. There were no rales heard in th e lun gs. Th e first heart sound was norm al; the second heart sound was pr omin ent wit h splitt ing during all phases of the respiratory cycle. T here was a grade 3/ 4 harsh systolic ejection murmur along th e le ft ste rnal border with rad iation int o the up per left side of the chest, hut not into the carotid arteries. An electroca rd iogram showed right ventricular hypertrophy. Hight and left hea rt cathe te riza tion wit h co ronary a ngiog raphy dem onst rat ed a large normal righ t coro na ry art ery with filling of th e entire left coronary art ery system th rough retro grad e collateral cir culation. Th e left main coro nary arter y was tota lly obstruc ted ( F ig 1 ). In addition, the pati en t had conge nital pu lmona ry valvu lar ste nosis. At rest , th ere was a gradi en t of 70 mm Hg across the pulmona ry valve. Several da ys lat er , th e pat ient underwent sur gery . A re°From the Amari llo Surgical Group ' a nd Department of Ca rdiovascular Sur gery, St Anth on y's Hospit al, Amari llo, Tex. Reprint requests: Dr. Sut herland , Six Medi cal D rive, Amarillo, Texas 79106
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The sur gical treatment of the completely obstructed left main coronary artery is aortocoronary sa phenous-vein bypass to the left coronary artery system. Without surgical int ervention, thi s lesion has an exceedingly poor prognosis. Thi s report describes a patient with atherosclerotic obstruction of the left main coronary artery and congenital pulmonary valvular stenosis, an unusual combination of lesions not pr eviou sly documented together. The pati ent remains asymptomatic 22 months after aortocoronary saphe nous-vein bypass and pulmonary valvotomy.
C
om ple te atheroscleroti c occlusion of th e lef t main coro na ry artery is a relativel y rare finding, while conge nital pulmon a ry val vul ar s te no sis is not rare. The au tho rs ca n find no previou s report of th ese two en ti ties bei ng prese nt in the sa m e patient. This report d escribe s the success fu l surgical tr eatment of a 56-year-old wom an with comple te ob struc tio n o f th e lef t main coro na ry artery and congeni ta l p ul m ona ry val vula r ste nosis . CASE R EPORT
A 56-year-old-white woma n was admitte d to SI. Anthony's Hospit al, Amarillo, Tex, for ca rdiac evaluatio n. Th e patient had a dec reased exercise tolerance for many years an d had been awa re of a heart murmur for 30 years. In th e six months pr ior to her admission , she had progressively developed exertional angina pectoris. Th e an gina pe ctoris was not relieved by admi nistration of isosorh ide d initrat e or nitr oglycerin. Ph ysical examina tion revealed a regul ar pul se at 84 heat s per min ute and a blood pressur e of 120/70 mm Hg. There were no rales heard in th e lun gs. Th e first heart sound was norm al; the second heart sound was pr omin ent wit h splitt ing during all phases of the respiratory cycle. T here was a grade 3/ 4 harsh systolic ejection murmur along th e le ft ste rnal border with rad iation int o the up per left side of the chest, hut not into the carotid arteries. An electroca rd iogram showed right ventricular hypertrophy. Hight and left hea rt cathe te riza tion wit h co ronary a ngiog raphy dem onst rat ed a large normal righ t coro na ry art ery with filling of th e entire left coronary art ery system th rough retro grad e collateral cir culation. Th e left main coro nary arter y was tota lly obstruc ted ( F ig 1 ). In addition, the pati en t had conge nital pu lmona ry valvu lar ste nosis. At rest , th ere was a gradi en t of 70 mm Hg across the pulmona ry valve. Several da ys lat er , th e pat ient underwent sur gery . A re°From the Amari llo Surgical Group ' a nd Department of Ca rdiovascular Sur gery, St Anth on y's Hospit al, Amari llo, Tex. Reprint requests: Dr. Sut herland , Six Medi cal D rive, Amarillo, Texas 79106
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