Coronary artery disease remains the leading cause of mortality in industrialized countries. Treatment options for patients requiring revascularization are constantly re-evaluated by both cardiologists and cardiac surgeons to find an optimal strategy for affected patients. While coronary artery bypass grafting is typically considered first choice for the treatment of left main stenosis, there is a trend towards left main stenting due to a steadily aging population in western countries with a high operative risk and patients with single vessel coronary artery disease affecting the left main artery. Nevertheless left main stenting remains controversial, especially in patients with concomitant indications for open-heart surgery.
We want to present a case of a 78-year-old male patient with high-grade aortic stenosis who underwent surgical aortic valve replacement at our heart center due to anatomical contraindications for transcatheter aortic valve replacement. Stenting of the left main coronary artery was performed three years earlier due to single vessel coronary artery disease while moderate aortic valve stenosis was under surveillance at the time of the intervention. Intraoperatively we found the stent to be deformed in the left main coronary artery, covering nearly 25% of the left coronary ostium, consequently cardioplegia for myocardial protection was applied retrograde through the coronary sinus.
While left main stenting can be reasonable for a specific population of patients, it should be used cautiously in patients with concomitant indications for open-heart surgery in the near future and a low perioperative risk profile. Coronary artery bypass grafting remains the treatment option of choice for patients with left main stenosis especially in those with a low operative risk and other indications for heart surgery. Clear recommendations for patients with left main stenosis and coexisting moderate aortic valve stenosis are required in future guidelines to improve the long-term outcome for affected patients.