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Ann Thorac Surg 2006;81:828-834
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Long-Term Outcome After Surgical Left Main Coronary Angioplasty

Cornelis J. Botman, MD a , * , Wilbert Arnoudse, MD a , Olaf Penn, MD, PhD b , Nico Pijls, MD, PhD a

a Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
b Department of Thoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands

Accepted for publication September 22, 2005.

* Address correspondence to Dr Botman, Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5602 ZA, Eindhoven, the Netherlands (Email: carcbn{at}catharina-ziekenhuis.nl).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Direct surgical angioplasty of the left main coronary artery is aimed to restore a more physiologic flow of the left coronary artery compared with conventional coronary artery bypass graft surgery and allows subsequent percutaneous coronary interventions of more distal coronary lesions if necessary. Relatively little data are known about long-term outcome in these patients.

METHODS: In 1996 and 1997, in 31 patients in our hospital, surgical angioplasty of the left main coronary artery was attempted. The left main coronary artery was approached in the anterior way. Follow-up was performed during 8 years and concluded by invasive anatomic and functional evaluation of the left main coronary artery.

RESULTS: In 4 of these patients, the procedure was converted to conventional coronary artery bypass graft surgery owing to calcification of the left main coronary artery. Of the remaining 27 patients, 3 patients died in the perioperative period and 4 other patients died during follow-up. In 18 of the 20 survivors, coronary angiography was performed after 8 years, and the left main coronary artery was also evaluated by intravascular ultrasound and coronary pressure–based fractional flow reserve measurement. At angiography and intravascular ultrasound, a dilated funnel-shaped left main coronary artery was seen in all of these patients. In 1 patient, a hemodynamically significant left main coronary artery stenosis was present (fractional flow reserve < 0.75), and in this patient coronary artery bypass graft surgery was performed.

CONCLUSIONS: Although the total mortality of 23% was somewhat disappointing, the majority of the survivors had an excellent anatomic and physiologic result after direct surgical angioplasty of the left main coronary artery. Therefore, this technique deserves a place in the surgical armamentarium.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Direct surgical angioplasty of the left main coronary artery (LMDSA) has been advocated for years with the perspective to restore physiologic flow in the left main coronary artery (LMCA) [1]. Endarterectomy of proximal coronary arteries was first reported by Bailey and Lemmon in 1957 [2]. The first cases of LMCA reconstruction were described by Effer and coworkers in 1965 [3]. Both approaches were abandoned because the operative mortality was unacceptably high compared with that of conventional coronary artery bypass grafting [3–5] and exceeded 45%. With the introduction of better myocardial protection techniques and new surgical techniques to enlarge the LMCA, renewed interest for LMDSA arose. Using venous graft material or pericardial patches for interposition or reconstruction of the LMCA, the technique was advocated as an alternative for classic coronary artery bypass graft surgery in patients with isolated LMCA disease, without contraindications such as calcifications, involvement of the distal bifurcation, or older age [6]. Although venous material was normally used in performing LMCA angioplasty, an alternative method used a segment of the proximal right internal mammary artery as an onlay patch for surgical angioplasty [7].

Follow-up of LMDSA is limited to a number of small studies evaluating the short-term results by coronary angiography, magnetic resonance imaging, intravascular ultrasound (IVUS), spiral computed tomography, or transesophageal echocardiography [8–11].

In the present study we report the long-term outcome (8 years) of 31 patients who underwent LMDSA in our hospital between 1996 and 1997, and in whom coronary angiography, IVUS, and fractional flow reserve (FFR) measurements of the LMCA were performed to obtain the best possible anatomic and physiologic information about the LMCA 8 years after surgery.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Between January 1996 and December 1997, 31 patients underwent LMDSA and all of them were included in the present study.

The patients were selected for the surgical procedure on the basis of isolated LMCA stenosis, isolated LMCA stenosis and valvular disease, or LMCA stenosis and right coronary artery stenosis. Visible calcification of the LMCA on the coronary angiogram and extension of the disease including the LMCA bifurcation were exclusion criteria for LMDSA.

These patients were followed clinically for a period of 8 years, and at the end of that period, the LMCA was evaluated by coronary angiography, IVUS, and FFR.

The study was approved by the institutional review board, and written informed consent was obtained from all patients before the follow-up investigations.

The baseline characteristics of the study population are given in Table 1.


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  		Table 1. Baseline Characteristics (n = 31)
 
Surgical Technique
The LMCA was approached anteriorly. The incision was started on the anterior aspect of the aortic root and was extended across the left lateral wall toward the LMCA. The main pulmonary artery was usually retracted to the left to facilitate exposure. The anterior aspect of the LMCA was incised across the stenosis. A venous onlay patch was used to enlarge not only the LMCA but also the adjacent 2 cm of the aortic incision to give the LMCA ostium a funnel shape, which was assumed to favor laminar blood flow [1]. Using a venous patch was the preference of the performing surgeon (Fig 1).


Figure 1
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  		Fig 1. Anterior approach to left main coronary artery (LMCA) surgical view. The main pulmonary artery (MPA) is retracted away from the aorta (Ao). A generous exposure of the left main coronary artery and of its distal bifurcation between the circumflex artery (CX) and left anterior descending artery (LAD) is obtained. The transverse aortotomy should stay away from the commissure between the left coronary cusp (LCC) and the right coronary cusp (RCC). The onlay patch is enlarging not only the left main coronary artery but also a part of the aortotomy so as to obtain a funnel shape. (LPA = left pulmonary artery; RPA = right pulmonary artery.)

 
Invasive Follow-Up: Coronary Angiography, Fractional Flow Reserve Measurements, and Intravascular Ultrasound
Patients were seen at the outpatient clinic on a 1-year basis. In those patients alive after 8 years, invasive anatomic and physiologic evaluation of the LMDSA was performed and documented as follows. After administration of 5,000 U of heparin, a left coronary guiding catheter was advanced in the left coronary ostium, 200 µg of intracoronary nitroglycerin was administered, and angiograms were performed in at least two orthogonal views for offline quantitative coronary analysis. Thereafter, a 0.014-inch sensor-tipped pressure guidewire (Pressure Wire; Radi Medical Systems, Uppsala, Sweden) was advanced to the tip of the guiding catheter, and after equal pressures were confirmed at that location, the wire was advanced across the LMCA. Intravenous adenosine 140 µg · kg–1 · min–1 was administered through the femoral vein to induce maximum coronary hyperemia [12]. Fractional flow reserve was calculated by the ratio Pd/Pa at steady-state maximum hyperemia, where Pd equals mean coronary pressure distal of the LMCA (recorded by the pressure wire) and Pa is mean aortic pressure (recorded by the guiding catheter) as described before [12, 13]. All measurements were performed twice with the pressure wire once in the left anterior descending artery and once in the left circumflex artery. After the second measurement a pullback curve was performed at sustained hyperemia for precise localization of a pressure gradient if present. At present, FFR is considered the gold standard for physiologic assessment of the coronary artery [13].

Thereafter, IVUS was performed (Galaxy IVUS Imaging System; Boston Scientific, Natick, MA) using the pressure wire as a guidewire for advancing the IVUS catheter across the LMCA, and an automatic pullback of the IVUS catheter was performed at 0.5 mm/s. Intravascular ultrasound is considered to be the gold standard for anatomic assessment of the coronary artery.

Analysis of Data
All quantitative coronary analysis data, FFR, and IVUS measurements were stored digitally, on paper, and on videotape and analyzed offline by an independent experienced reviewer. Because of the funnel shape of the LMCA after LMDSA, as a matter of course no reference diameter for quantitative coronary analysis and IVUS were available, and therefore the results of these methods are expressed as minimal lumen diameter and minimal square area. Fractional flow reserve is expressed as usual by a number between 0 and 1, expressing the achieved maximum blood flow as a fraction of the normal maximum blood flow if no LMCA disease were present at all. All data are expressed as mean ± standard deviation, and the range is added between brackets.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Procedural Results
A total of 31 patients were scheduled for MLDSA, 23 patients were male and 8 female, and the mean age was 62 years with a range from 44 to 79 years. Twenty-two patients were planned for isolated surgical angioplasty without concomitant surgery, 4 patients for additional grafting of the right coronary artery, and 5 patients for additional mitral valve surgery.

In 4 patients the primary operation was converted to conventional coronary artery bypass graft surgery because of severe calcification of the LMCA. The patients who underwent LMDSA with or without concomitant grafting of the RCA were treated with aspirin; patients with concomitant valve surgery were treated with coumadin.

Three patients died shortly after surgery. One patient with previous myocardial infarction and severe mitral valve regurgitation died as a result of left ventricular failure after 1 day. A second patient died as a result of extensive myocardial infarction after acute closure of the LMCA 2 days after surgery. The myocardial infarction occurred after a period of hypotension in the intensive care unit. The third patient died after 14 days as a result of mediastinitis (Table 2).


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  		Table 2. Outcome and Adverse Events Related to Direct Surgical Angioplasty of the Left Main Coronary Artery During Hospital Stay and Follow-Up
 
Clinical Follow-Up
During a follow-up of 8 years in the remaining 24 patients, another 4 patients died, of whom 3 were as a result of progression of coronary artery disease, and 1 was because of pulmonary disease.

Of the remaining 20 patients alive at the end of the 8-year follow-up period, 18 were in class I according to the Canadian Cardiovascular Society (CCS) and 2 were in class II. No additional percutaneous interventions or repeated surgery had been necessary in any of the surviving patients up to the moment of the follow-up invasive investigations.

Invasive Follow-Up: Coronary Angiography, Fractional Flow Reserve, and Intravascular Ultrasound
In 18 of the 20 patients alive after 8 years of follow-up, invasive evaluation of the LMCA was performed. Also, IVUS and FFR measurements were successfully performed in all these patients. Two patients refused the invasive follow-up.

At angiography, a wide-open funnel-shaped LMCA was seen in all 18 patients. At quantitative coronary analysis, the minimal lumen diameter was 3.1 ± 0.77 mm. In 1 patient, an intermediate stenosis in the LMCA bifurcation was present (Fig 2), and in another patient a severe stenosis in the left anterior descending artery distal to the first diagonal branch was noted (Fig 3).


Figure 2
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  		Fig 2. An insignificant lesion of the distal left main coronary artery is shown both with angiography (A) and intravascular ultrasound (B). Although this lesion was anatomically not significant, it proved to be significant with fractional flow reserve measurement. This patient underwent reoperation.

 

Figure 3
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  		Fig 3. A significant lesion is shown in the mid part of the left anterior descending coronary artery artery with angiography (A) and intravascular ultrasound (B). It also proved to be significant with fractional flow reserve measurement. This patient underwent a percutaneous coronary intervention of this lesion.

 
The angiographic findings corresponded well with the IVUS measurements. The LMCA was wide open in all patients; 1 patient had plaque and calcification on the LMCA bifurcation, and in another patient the left descending artery was diffusely diseased with a severe stenosis as described before (Fig 3). The cross-sectional area was 12.1 ± 1.3 mm2.

At coronary artery pressure measurement, FFR was 0.93 ± 0.09 (range, 0.66 to 1.00). In 2 patients FFR was less than 0.75, considered as the threshold for a significant stenosis [14, 15], and in these 2 patients repeated coronary artery bypass graft surgery or percutaneous coronary intervention was performed. The clinical follow-up and anatomic and physiologic data are presented in Table 3.


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  		Table 3. Clinical Angiographic, Intravascular Ultrasound, and Physiologic Data 8 Years After Direct Surgical Angioplasty of the Left Main Coronary Artery (n = 18)
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Long-term outcome after surgical angioplasty of the LMCA in our clinic resulted in a mortality of 23% after 8 years, which seems somewhat disappointing, if compared with mortality after conventional coronary artery bypass graft surgery or even with percutaneous coronary intervention of the LMCA after long-term follow-up [16]. However, in those patients alive after 8 years, invasive evaluation by coronary angiography and IVUS and FFR measurements showed good results of LMDSA in all but 2 patients. Also the functional class in these survivors was excellent.

The most common cause of LMCA stenosis is arteriosclerosis and accounts for the majority of the LMCA stenosis affecting particularly the mid-part and distal bifurcation, often associated with two-vessel or three-vessel disease. Left main coronary artery stenosis is present in 9% of patients undergoing coronary artery bypass graft surgery. Isolated stenosis of the ostium and first third of the LMCA has a prevalence of only 1% [17]. Coronary artery bypass graft surgery is an excellent treatment of LMCA stenosis but with some potential limitations, such as complete graft-dependent perfusion because of progressive occlusion of the LMCA and the risk of arteriosclerotic changes of the graft or occlusion of the grafts [18, 19]. It has also been suggested that perfusion of a large area of the myocardium retrograde would be suboptimal [6].

Direct surgical angioplasty of the LMCA was suggested as a good alternative by restoring native antegrade flow and allowing percutaneous coronary intervention of peripheral lesions as coronary artery disease progresses [6, 20]. The patients in the present study were selected because of isolated LMCA disease not including the bifurcation and without visual calcification on coronary angiography. Concomitant right coronary artery disease and valve surgery were not exclusion criteria. There was no specific lack of conduits. In our opinion LMDSA can be used also in the case of reoperation for aortic stenosis with other conduits intact. Also this technique can be used for isolated LMCA stenosis or as a hybrid procedure when concomitant right coronary artery disease is present, LMDSA followed by percutaneous coronary intervention of the right coronary artery, when there is a lack of conduits.

Technically, two principal methods have been described on how to get access to the LMCA, the posterior and the anterior approach [1, 6, 20, 21]. Postoperative angiography shows a slight difference in angiographic appearance between both techniques, with a larger neo-ostium when using the posterior approach. The significance of this finding is not known [7]. Restenosis of the LMCA is reported in both approaches [1, 3, 11]. In the present study the anterior approach was used.

In most studies either a pericardial or saphenous vein onlay patch was used. However, it is well documented that the internal mammary artery has a higher patency compared to venous material when used in bypass surgery [22–25]. The internal mammary artery resembles coronary arteries with respect to histologic properties more closely than autologous pericardium or the saphenous vein. To reduce restenosis and acute thrombosis, the internal mammary artery was also used as an onlay patch, and excellent results with this technique have been reported [7]. A disadvantage in using the internal mammary artery as an onlay patch is that it cannot be used as a bypass graft if reoperation is necessary.

To evaluate the results of surgical angioplasty of the LMCA different methods have been used, but not on a regular basis or systematically in follow-up studies. Most reports concern one or just a few patients [8, 10, 11, 26]. Dion and colleagues [1] reported a larger series of 47 patients treated by LMDSA with a mortality of 19% after a mean clinical follow-up of 6 years, but all other studies are too small or have a very short follow-up so that no conclusions can be drawn [26–28].

The techniques used for invasive evaluation of LMDSA in our present study were coronary angiography and IVUS and FFR measurements to obtain complete anatomic and physiologic information. Such combined morphologic and physiologic assessments has not been reported.

Feasibility of IVUS alone was already shown in previous reports [2]. Also with magnetic resonance imaging and angiography, the typical funnel-shaped LMCA was shown after surgical angioplasty, as we saw in this present study [1, 10, 27]. In our opinion, IVUS is suboptimal for evaluating the LMCA after surgical angioplasty because of the wide funnel shape because often the IVUS catheter cannot be positioned centrally in the LMCA, and no reference diameter is present.

So far no information was available about the hemodynamic properties of the LMCA after surgical angioplasty. An average FFR of 0.93 ± 0.06 indicates that also in this respect, a good functional operative result was present in the majority of the patients alive after 8 years. Only in 1 patient was a significant pressure drop present in the distal LMCA, and that patient underwent repeat coronary artery bypass graft surgery. Another patient had a significant stenosis in the left anterior descending coronary artery and was treated with percutaneous coronary intervention. These 2 patients had an FFR well under 0.75. All the 16 remaining patients showed a FFR greater than 0.90, indicating that there was no significant hyperemic pressure drop in the LMCA after surgical angioplasty even after 8 years, ruling out any significant flow obstruction in the LMCA regardless of its funnel-shaped morphology.

Although the invasive follow-up showed favorable results in the survivors, the present study also shows a relatively high mortality after long-term follow-up, especially when taking into account the relatively young age and preserved left ventricular function of the patients at the time of the initial procedure. On the other hand, 5 patients had concomitant valve surgery of which 2 patients died in the postoperative period; these deaths had no direct relation with LMDSA. Furthermore, the amount of calcification in the LMCA was not evaluated preoperatively, accounting for the four conversions to classic coronary artery bypass graft surgery. To rule out abundant calcification of the LMCA, IVUS or other imaging techniques could play a role in preoperative assessment of the feasibility of LMDSA [29–31].

Although the total mortality of 23% was disappointing, in the majority of the survivors an excellent anatomic and physiologic result of LMDSA was observed after 8 years of follow-up. Provided there is a good preoperative assessment of the LMCA with respect to calcification and other contraindications such as involvement of the LMCA bifurcation and older age are ruled out, LMDSA deserves a place in the array of surgical techniques.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Dion R, Verhelst R, Matta A, et al. Surgical angioplasty of the left main coronary artery J Thorac Cardiovasc Surg 1990;99:241-250.[Abstract]
  2. Bailey CP, Lemmon WN. Survival after coronary endarterectomy JAMA 1957;164:641-646.[Medline]
  3. Effer DB, Sones FM, Favaloro R, et al. Endarterectomy with patch graft reconstructionclinical experience with 34 cases. Ann Surg 1965;162:590-601.[Medline]
  4. Bortototti U, Milano A, Balbarini A, et al. Surgical angioplasty for isolated coronary ostial stenosis Tex Heart Inst J 1997;24:366-371.[Medline]
  5. Favaloro RG, Effler DB, Groves LK, et al. Severe segmental obstruction of the left main coronary and its divisionsurgical treatment by the saphenous vein graft technique. J Thorac Cardiovasc Surg 1970;60:469-482.[Medline]
  6. Hitchcock JF, Robles de Medina EO, Jambroes G. Angioplasty of the left main coronary artery for isolated left main coronary artery disease J Thorac Cardiovasc Surg 1983;85:880-884.[Abstract]
  7. Liska J, Jonsson A, Lockowandt U, et al. Arterial patch angioplasty for reconstruction of proximal coronary artery stenosis Ann Thorac Surg 1999;68:2185-2190.[Abstract/Free Full Text]
  8. Sharoni E, Erez E, Shapira Y, et al. Transesophagal echocardiography evaluation and follow-up left main coronary artery patch angioplasty Eur J Cardiothorac Surg 2003;23:585-588.[Abstract/Free Full Text]
  9. Spencker S, Hetzer R, Kreps P, et al. Surgical angioplasty of the left main coronary artery. Evaluation and postoperative follow-up with intravascular ultrasound Z Kardiol 2002;91:846-852.[Medline]
  10. Briffa NP, Clarke S, Kugan G, et al. Surgical angioplasty of the left main coronary arteryfollow-up with magnetic resonance imaging. Ann Thorac Surg 1996;62:550-552.[Abstract/Free Full Text]
  11. Meseguer J, Hurle A, Fernandez-Latorre F, et al. Left main coronary artery angioplastymid term experience and follow-up with spiral computed tomography. Ann Thorac Surg 1998;65:1594-1598.[Abstract/Free Full Text]
  12. Pijls NHJ, Van Gelder B, Van Der Voort P, et al. Fractional flow reservea useful index to evaluate the influence of an epicardial coronary stenosis on myocardial blood flow. Circulation 1995;92:3183-3193.[Abstract/Free Full Text]
  13. Pijls NHJ, De Bruyne B, Peels K, et al. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenosis N Engl J Med 1996;334:1703-1708.[Abstract/Free Full Text]
  14. Leesar MA, Masden R, Jasti V. Physiological and intravascular ultrasound assessment of an ambiguous left main coronary artery stenosis Cathet Cardiovasc Interv 2004;62:349-357.[Medline]
  15. Jasti V, Ivan E, Yalamanchili V, et al. Correlations between fractional flow reserve and intravascular ultrasound in patients with an ambiguous left main coronary artery stenosis Circulation 2004;110:2831-2836.[Abstract/Free Full Text]
  16. Brener SJ, Lytle BW, Casserly IP, et al. Propensity analysis of long-term survival after surgical or percutaneous revascularization in patients with multivessel coronary artery disease and high-risk features Circulation 2004;109:2290-2295.[Abstract/Free Full Text]
  17. Edwards FH, Clark RE, Schwatz M. Coronary artery bypass graftingThe Society Of Thoracic Surgeons National Database experiency. Ann Thorac Surg 1994;57:12-19.[Abstract]
  18. Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main coronary artery disease Circulation 1995;91:2325-2334.[Abstract/Free Full Text]
  19. Gomberg J, Klein LW, Seelaus P, et al. Surgical revascularisation of left main coronary artery stenosisdeterments of preoperative and longterm-outcome in the 1980s. Am Heart J 1988;116:440-446.[Medline]
  20. Ridley PD, Wisheart JD. Coronary ostial reconstruction Ann Thorac Surg 1996;62:293-295.[Abstract/Free Full Text]
  21. Sullivan JA, Murphy DA. Surgical repair of stenotic ostial lesions of the left main coronary artery J Thorac Cardiovasc Surg 1989;98:33-36.[Abstract]
  22. Lytle BW, Loop FD, Cosgrove DM, et al. Long-term (5 to 12 years) serial studies of internal mammary artery and sapnenous vein coronary bypass grafts J Thorac Cardiovasc Surg 1985;89:248-258.[Abstract]
  23. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary artery graft on 10-year survival and other cardiac events N Engl J Med 1986;314:1-5.[Abstract]
  24. Lytle BW, Blackstone EH, Loop FD, et al. Two internal thoracic artery grafts are better than one J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
  25. Buxton BF, Komeda M, Fuller JA, et al. Bilateral internal thoracic artery grafting may improve outcome of coronary artery surgery Circulation 1998;98(Suppl):II-1-II-6.
  26. Shimakura T, Morishita A, Miyagishima M, et al. Surgical angioplasty of isolated left coronary ostial stenosis Kyuba Geka 2002;55:395-400.
  27. Dion R, Elias B, El Khoury G, et al. Surgical angioplasty of the left main coronary artery Eur J Cardiothorac Surg 1997;11:857-864.[Abstract]
  28. Malyshev M, Gladyshev I, Safuanov A, et al. Surgical angioplasty of the left main coronary artery and/or proximal segment of the right coronary artery by pulmonary autograft patch Eur J Cardiothorac Surg 2004;25:21-25.[Abstract/Free Full Text]
  29. Gussenhoven EJ, Essed CE, Frietman P, et al. Intravascular ultrasonic imaginghistologic and echographic correlation. Eur J Vasc Surg 1989;3:571-576.[Medline]
  30. Nishimura RA, Edwards WD, Warness CA, et al. Intravascular ultrasound imagingin vitro validation and pathologic correlation. J Am Coll Cardiol 1990;16:145-154.[Abstract]
  31. Nishimura RA, Higano ST, Holmes DR, et al. Use of intracoronary ultrasound imaging for assessing left main coronary artery disease Mayo Clin Proc 1993;68:134-140.[Medline]



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C. J. Botman, H. Post, O. Penn, and N. Pijls
Value of Magnetic Resonance Imaging, Angiography, and Fractional Flow Reserve to Evaluate the Left Main Coronary Artery After Direct Surgical Angioplasty
Ann. Thorac. Surg., February 1, 2007; 83(2): 490 - 494.
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