Images in Clinical Medicine
A Life-Threatening Coronary-Artery Stenosis
N Engl J Med 2000; 343:403August 10, 2000
- Article
Figure 1 A 74-year-old man presented with a one-week history of exertional angina and dizziness. Treadmill testing showed deep, prolonged depression of the ST segment and hypotension at a low level of exercise. During urgent cardiac catheterization, the 6-French diagnostic catheter recorded severe pressure damping during cannulation of the ostium of the left coronary artery. A single anteroposterior angiogram was quickly obtained before the catheter was removed. The angiogram showed severe stenosis of the left main coronary artery (arrow) and a total absence of contrast reflux despite forceful injection by hand. Since the left coronary artery was dominant and provided a preponderance of the arterial blood supply, sudden occlusion could cause potentially lethal left ventricular ischemia. A small, nondominant right coronary artery was open. Resting left ventricular function was normal. Myocardial ischemia developed and was stabilized with intraaortic balloon counterpulsation. The patient subsequently underwent coronary bypass surgery, in which the internal thoracic artery was anastomosed to the left anterior descending artery and separate saphenous-vein grafts were placed in three marginal vessels. The patient had a full recovery. A follow-up treadmill test showed no evidence of ischemia.
Chester M. Boltwood, Jr., M.D.
Valley Heart Associates Medical Group, Modesto, CA 95350Terril Spitze, M.D.
Sierra Internal Medicine, Sonora, CA 95370
