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Eur J Cardiothorac Surg 2003;23:585-588
© 2003 Elsevier Science NL

Transesophageal echocardiography evaluation and follow-up of left main coronary artery patch angioplasty

Erez Sharonia, Eldad Ereza, Yaron Shapirab, Bernardo A. Vidnea*, Alexander Sagieb

a Department of Cardiothoracic Surgery, Rabin Medical Center,1, Beilinson Campus, Petach Tikva 49100, Israel
b Echocardiography Unit, Cardiology Department, Rabin Medical Center,1, Beilinson Campus, Petach Tikva 49100, Israel

Received 13 July 2002; received in revised form 9 November 2002; accepted 27 November 2002.

* Corresponding author. Tel.: +972-3-937-6701; fax: +972-3-924-0762
e-mail: bvidne{at}clalit.org.il


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: Isolated ostial stenosis of the left main coronary artery is a rare but serious condition. The treatment is surgical with two options: coronary artery bypass grafting or surgical angioplasty of the left main coronary artery. Assessing surgical results as well as follow-up were traditionally done by angiography. Methods: We describe the use of transesophageal echocardiography (TEE) for evaluating and follow the surgical left main coronary artery (LMCA) angioplasty results in eight patients with isolated ostial left main stenosis. Results: All patients were alive and free of ischemic events 8 months to 7 years post-surgery. TEE demonstrated a widely opened left main coronary artery with a good flow. Conclusions: Surgical angioplasty is an alternative option for treating ostial LMCA stenosis. TEE is an additional excellent non-invasive technique for assessing left main anatomy pre- and postoperatively, as well as being on of the quality control tools for evaluating new surgical techniques.

Key Words: Left main coronary artery • Patch angioplasty


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
The ostium of the left main coronary artery (LMCA) may be narrowed by atheroma or fibromuscular dysplasia and rarely by syphilis [1] or Takayasu aortitis [2]. The prevalence of isolated ostial left main coronary artery stenosis is 0.7% [3], and appears to be a distinct clinical entity affecting younger, mostly female patients [4]. Surgical treatment is unanimously recognized as the treatment of choice for this condition [5,6].

Surgical patch angioplasty of the LMCA was first reported by Effler and colleagues [7] in 1965, but this technique was soon abandoned due to its high perioperative risk [7,8]. Advances in myocardial protection, together with stricter clinical and operative criteria, made the revival of this technique possible and in 1983, Hitchcock and colleagues [9] reported encouraging results in their series of surgical patch angioplasty. In 1997, Dion and coworkers [10] reported their results in 49 such procedures in 47 patients; leading them to conclude that this technique appears to be a valuable therapeutic method in the treatment of isolated LMCA stenosis.

Traditionally, surgical results and graft patency were assessed by angiography, although the use of magnetic resonance imaging [11] or spiral computed tomography [12] have been reported. Transesophageal echocardiography (TEE) is an established excellent technique for imaging the proximal left and right coronary system especially the proximal left main. However, the assessment of surgical patch angioplasty of the left main by TEE has never been studied. In this series, we report our clinical experience with this procedure, with particular emphasis on the use of TEE in the assessment and follow-up of our patients.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Between January 1993 and September 2000, 5555 patients were operated for surgical coronary revascularization; eight patients (0.14%) were subjected to surgical angioplasty of the LMCA and were included in this study. Preoperative data are summarized in Table 1.


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  		Table 1. Preoperative data

 
All patients had been catheterized prior to surgery and were found to have isolated ostial LMCA stenosis without peripheral coronary disease. One patient underwent TEE investigation prior to surgery, which showed a narrowed Isolated ostial left main coronary artery (Fig. 1) . Seven patients had good ventricular function and one patient had severely depressed LV function with an ejection fraction of 15%.



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  		Fig. 1. TEE showing aorta with left main coronary artery stenosis, preoperatively.

 
2.1. Operative procedure
Surgery was performed using standard balanced fentanyl anesthesia. Prior to aortic cannulation, the ascending aorta was mobilized and dissected extensively from the pulmonary artery. Myocardial preservation includes hypothermic (28 °C) cardiopulmonary bypass and cardiac arrest which was induced by cold intermittent cardioplegia, in the first patient; and cold blood intermittent cardioplegia antegradely and retrogradely in the last seven patients. The left ventricle was vented through the right superior pulmonary vein.

The anterior approach and technique described by Dion and associates [13] was used in all patients. A saphenous vein on-lay patch was used in the first patient and fresh autologous pericard in the last seven patients. The aortotomy was closed with 5-0 prolene.

Evaluation of the surgical angioplasty in the operating room after weaning from cardiopulmonary bypass was performed in one patient using TEE, which showed a widely open left main with good flow (Fig. 2) .



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  		Fig. 2. TEE showing aorta with neo-ostium of the left main coronary artery, postoperatively.

 
Within a period of 3 weeks during October 2000, all patients were contacted for follow-up. Informed consent was obtained from all patients to undergo patency assessment with TEE.

All TEE investigations were carried out with 5 MHz multiplane TEE probe (HP, sonos 2000). Careful attention was paid when evaluating the LMCA to the bifurcation. Measurements of the left main diameter were made with and without color flow mapping.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
The operation was uneventful in all patients and they were easily weaned from cardiopulmonary bypass. Mean aortic cross-clamp time was 61 min (range 45–74 min), and mean cardiopulmonary bypass time was 88 min (range 62–106 min).

All patients had an uneventful postoperative course, with stable hemodynamics and without ischemic ECG changes. There were no neurological events, respiratory complications or renal complication. There were no hospital deaths.

During the follow-up period of 8 months to 7 years no patient suffered a cardiac event or required invasive treatment (i.e. cardiac catheterization, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting). There were no deaths during the follow-up period. Seven patients demonstrated good left ventricular function during the follow-up period. One patient who had a reduced ejection fraction (15%) prior to surgery improved after the operation to an ejection fraction of 35%.

All patients underwent TEE imaging which clearly demonstrated widely patent, typically funnel-shaped LMCA with a mean ostial diameter of 5 mm (range 3–7.5 mm), normal flow by PW Doppler and no aneurysmal dilation of the on-lay patch (Figs. 2 and 3)



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  		Fig. 3. TEE showing aorta with Doppler color flow in the neo-left main coronary artery, postoperatively.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Isolated ostial stenosis of the LMCA is a relatively rare feature accounting for less than 1% of all cases of coronary artery disease [3]. Coronary artery bypass grafting is an excellent and safe treatment for LMCA stenosis, but with some potential limitations, such as complete graft dependent perfusion due to progressive occlusion of the coronary ostium and the risk of developing graft atherosclerosis [14,15]. Direct surgical angioplasty of the LMCA, for patients with isolated ostial LMCA stenosis, offers a good alternative by restoring native antegrade flow and also by maintaining access to the distal coronary vessels allowing for future percutaneous coronary intervention of peripheral lesions.

Technically there have been two principal methods for accessing the LMCA: the posterior [9] and the anterior approach [10]. We prefer using the anterior approach, which provides excellent exposure of the LMCA, and by using an oblique incision we lessen the angle of the patch at the ostial junction, thus avoiding its main disadvantage. Dion [10], with the largest series of surgical left main angioplasty, also recommended the anterior approach because of its better exposure. Follow-up on his group was done by angiography, which showed excellent results with 87% patency rate. Heavily calcified left main and distal left main disease, found more in the older population, had been identified as risk factors for early failure [10]. Thus, precise identification of the candidates for this procedure can be done preoperatively by angiography and further evaluation would be complemented by intraoperative TEE.

In the present study mid- and long-term follow-up using clinical assessment and TEE revealed 100% freedom from cardiac events, enlarged anatomically sized left main and 100% patency of the proximal LMCA with no aneurysmal dilation of the on-lay patch.

At present, coronary angiography is the standard method of visualizing the coronary arteries including the LMCA. However, because it is not free of complications as well as its limited visualization of the left main compared to TEE, this invasive technique is not the optimal method for initial postoperative assessment of left main coronary artery patch angioplasty in the asymptomatic patients.

There have been some attempts to use non-invasive assessment and follow-up methods for graft patency, such as magnetic resonance imaging [11] with 90% accuracy [16] and spiral computed tomography, which failed to do so [13].

Several preliminary reports documented the feasibility of visualizing the proximal coronary artery by TEE [17–22]. Attempts to identify LMCA stenosis with this technique have been made and the detection rate has varied from 65% [17] to 100% [22].

In 1992, Samdrashi and colleagues [23] published their experience with a relatively large number of patients (111) and in 90% of them the LMCA could be completely visualized to its bifurcation; in particular, TEE made a correct diagnosis in all patients with ostial left main stenosis. Narrowing of the flow channel by Doppler color flow imaging was also found useful in detecting significant stenosis.

Based on these reports, we used TEE for the first time to evaluate early and late surgical results post LMCA patched angioplasty. We demonstrated that TEE can be used safely and LMCA anatomy and patency can be optimally delineated. TEE can be also used to select or exclude candidates for surgical angioplasty based on the findings of distal LM disease and/or LM calcifications. In our series, mid- and long-term follow-up after patched angioplasty did not show either restenosis nor excessive aneurysmal dilation of the proximal LMCA. Furthermore, we elected to use TEE as a quality control for evaluation of the surgical technique in our first surgical angioplasty cases; we do feel that new surgical procedures should be evaluated as part of the learning process, and TEE provides complete imaging of the left main and thus can be utilized as an excellent evaluation tool. Thus, TEE should be used routinely as part of the workup and follow-up in and out the operating room. Routine follow-up by TEE will successfully identify the asymptomatic patients with distal left main stenosis and allow for further and timely invasive evaluation and treatment.

In conclusion, surgical patch angioplasty is an effective treatment for LMCA ostial stenosis with good mid- and long-term patency, anatomy and without aneurysmal dilation as assessed by TEE. TEE is a useful semi-invasive tool to assess, follow and confirm surgical results after patch angioplasty of the LMCA.


   Footnotes
 
1 Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Israel. Back


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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