Short left main (LM) not well seen on catheter angiography - for evaluation

This 53-years old man with unstable angina had a catheter angiogram done (Figs. 1, 2). The left main (LM) was short and there was a suspicion of a LM stenosis.

A cardiac CT was performed only to evaluate the LM. The LM on the CT was very short, but absolutely normal.

Sometimes, in short LMs, it may be difficult to engage the LM properly and to conclusively rule out disease. In such situations, a cardiac CT would be the ideal way of evaluating the LM.

Comments

[Dr Shantanu Deshpande]

I think CT images show spared ostium but there is a significant pinching of LM around 2-3 mm after the ostium. Selective angiography in such situation results in catheter going beyond the lesion and pressure dampening , this may happen when there is cath and artery size mismatch also resulting in pseudo dampening. Yes, CT angio is good modality in such situation but most physiological assessment is by the pressure wire.As here patient is going to be labelled either of two ends that is normal angio vs LM disease we all have to be very careful in such situations. Significant LM disease carries a high moratalty and warrants urgent revascularisation.