CTO of the LAD in a Young Adult After the Arterial Switch Operation

Patient History

A 19-year-old man had undergone the arterial switch operation with ventricular septal defect (VSD) repair in infancy but was lost to follow-up, returning to medical attention desiring clearance prior to becoming a forest ranger. He gives a history of profuse sweating and shortness of breath with mild chest discomfort associated with exercise, all of which resolve with rest. He denies palpitations, syncope, or cyanosis.

His resting electrocardiogram shows normal sinus rhythm and right bundle branch block without ST-T wave changes. His echocardiogram reveals moderate supravalvar pulmonary stenosis and a small residual VSD. No segmental wall motion abnormalities are noted. An exercise stress test does not show any significant ST-T wave changes at peak exercise, with no arrhythmias during stress or recovery.

A diagnostic cardiac catheterization reveals the origin of the left circumflex from the right coronary artery (RCA) and chronic total occlusion (CTO) of the ostium of the left anterior descending coronary artery (LAD), (Figure 1, Video 1). Subsequent stress myocardial perfusion scan shows ischemia in the distribution of the LAD.

The LAD is stented using a retrograde approach (Video 2, 3, 4; Figure 2). Two months after stenting, the patient reports resolution of profuse sweating and chest discomfort with exercise. An exercise perfusion scan performed a year later reveals normal exercise capacity and global left ventricular systolic function, albeit with mild hypokinesis in the area of a small, apical transmural scar. The previously seen ischemia in the distribution of the LAD is no longer seen (Video 5).

Figure 1

Figure 1

Selected angiographic frame of the RCA in a 40-degree right anterior oblique (RAO) projection. The LAD fills with contrast from retrograde RCA filling due to CTO of the LAD.

Figure 2

Figure 2

Selected angiographic frame of the LAD in a 30-degree anteroposterior caudal projection demonstrating antegrade flow through it after placement of a coronary stent in its proximal portion.

Video 1 Video 2 Video 3

Video 1

Aortic Root angiogram in anteroposterior, caudal projection demonstrating total ostial occlusion of the LAD. There is retrograde filling of the LAD from distal RCA collaterals. The left circumflex artery is seen arising from the RCA.

Video 2

Right coronary wire coursing through epicardial collaterals and the diagonal artery into the LAD.

Video 3

A wire through the RCA, coursing retrograde and externalized through the LAD.

Video 4 Video 5

Video 4

LAD ostium after stenting.

Video 5

RCA injection showing resolution of RCA to LAD collaterals.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, EP Basic Science, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD & Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Interventions, Interventions and Structural Heart Disease

Keywords: Cardiac Catheterization, Heart Defects, Congenital, Cicatrix, Coronary Vessels, Cyanosis, Dyspnea, Bundle-Branch Block, Electrocardiography, Exercise Test, Heart Septal Defects, Ventricular, Pulmonary Valve Stenosis, Stents, Syncope, Systole

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