Case report
A 66-year-old hypertensive female patient was investigated for attacks of unstable angina. Her cardiac examination was unremarkable, and her electrocardiogram showed signs of left ventricular strain pattern. An Echocardiogram demonstrated regional wall abnormalities in the anterior and the inferior segments of the heart. Left heart catheterization demonstrated significant right coronary artery stenosis, with super dominance in distribution pattern. The left main coronary artery had anomalous origin from the opposite right coronary cusp with separate ostium with significant luminal stenosis and small caliber left anterior descending (LAD) and Circumflex arteries. Coronary Computed Tomography (CT) for better assessment of the left main coronary anatomy was performed and showed an anomalous left main coronary artery arising from the opposite sinus and courses posterior to the aortic root with significant stenosis (Figure 1). The course also showed an interarterial passage between the pulmonary artery and the aorta with small and diseased branches (Figure 2). A heart team decision was made to offer this lady coronary artery bypass surgery as a valued option taking in consideration her left main coronary anomaly in addition to the atherosclerotic disease involving her coronary arteries.
Surgery was performed via median sternotomy incision using partial cardiopulmonary bypass utilizing left internal mammary artery (LIMA) and left great saphenous vein as conduits. myocardial protection was achieved using ante and retrograde routs of delivery for cardioplegic solutions. Vein grafts were used to bypass diseased RCA and the circumflex arteries while the LIMA was anastomosed to the left anterior descending artery. Intraoperative assessment of the grafts was performed using flowmeter and all the grafts showed excellent flow parameters. Patient did well and had uneventful recovery period and was dismissed from the hospital in fair condition.