DISCUSSION
Only five adult cases of congenital LMS atresia have been reported
previously in the literature, and interestingly, one case was only
diagnosed on autopsy1 2. This handful of adult cases
have confirmed that strong collateralization of the arterial tree let
them skip a turn up at an early
age.3, 4The range of symptoms vary from being completely asymptomatic to overt
heart failure.5 Important differential diagnoses also
include origin of the LMS from the pulmonary artery and endomyocardial
fibrosis.3,6
Our case report depicts the chain of investigations which are required
for diagnosis of coronary atresia and determination of the culprit
lesions jeopardizing heart muscle function. Kate et.al emphasized the
limited role of invasive coronary angiography in this important
diagnosis. Cardiac MR angiography and multi-slice computed tomography
(MSCT) gives a 3d visualization and are potentially more powerful
modalities to identify this diagnosis. 7
In the present case report, directed investigations played an essential
role in committing to the correct treatment. Whereas gated CT
angiography provided the actual coronary anatomy, stress
echocardiography determined the true origin of ischemia and guided
subsequent therapy. This suggests that, in the case of demonstrable
myocardial compromise, prompt revascularization is the optimal therapy
for patients with LMS atresia.1