Diagnosing Left Coronary Ostial Atresia: Sometimes the Old Ways Are Best
International Journal of Angiology
Noninvasive coronary artery imaging is an expanding subspecialty and has been suggested as an alternative to cardiac catheterization in the detection of coronary lesions. 1 We present a pediatric case in which cardiac computed tomography (CCT) and cardiac myocardial resonance (CMR) failed to demonstrate left main coronary artery (LMCA) ostial atresia. This was confirmed at cardiac catheterization. Clinical Report An otherwise well 12-year-old boy was referred for evaluation of "intermittent
... ope." Typical semiology included sudden loss of consciousness (less than 2 minutes), in the setting of exercise and preceded occasionally by presyncope or palpitations. There was no relevant family history. Physical examination, resting 12-lead electrocardiogram and Holter recordings were unremarkable. There were no inducible symptoms or arrhythmia on exercise stress testing (EST) but significant ST depression developed over the lateral chest leads at peak exercise. Echocardiography demonstrated a structurally and functionally normal heart. 2D echocardiography suggested both coronary arteries appeared to arise from the appropriate sinuses. However, antegrade color flow in the left coronary artery was difficult to elicit. CCT reported a mild focal dilata-tion of proximal left anterior descending artery with otherwise normal coronary anatomy (►Fig. 1). A CMR stress perfusion test identified no abnormality. In view of the history and EST result, despite reassurance from noninvasive modalities, cardiac catheterization was performed with selective coronary angiography. This identified LMCA ostial atresia with extensive collateral arterial supply from the right coronary arterial (RCA) system (►Fig. 2 a-c). The left coronary artery system is relatively well developed and there is Keywords ► coronary artery ► ostial atresia ► cardiac catheterization ► cardiac computed tomography Abstract A 12-year-old boy with intermittent syncope associated with exercise. Exercise stress testing suggested myocardial ischemia and 2D echocardiography failed to confirm antegrade flow in the left main stem. Advanced imaging techniques including cardiacgated computed tomography angiography and stress cardiac magnetic resonance imaging were falsely reassuring. Cardiac catheterization demonstrated left coronary artery ostial atresia with a good caliber left coronary system supplied by generous collaterals from the right coronary artery. The patient underwent successful coronary artery bypass grafting. Fig. 1 Cardiac computed tomography reported as both coronary arteries arising from appropriate sinuses.