21 April 1973 S.A. MEDICAL JOURNAL 641
Obstruction of the Left Main Coronary
Artery The Artery of Sudden Death *
M. S. GOTSMAN, M.D. UNIV. CAPE TOWN, M.R.C.P. LOND., B. S. LEWlS, M.B. B.CH. UNIV. RAND AND
A. BAKST, M.B. B.CH. UNIV. RA 'D, Cardiothoracic Unit, Wentll'orth Hospital and University of
SUMMARY AT REST
A 54-year-old patient with severe obstruction of the main
left coronary artery and of the proximal portion of the
anterior descending left coronary artery, is described.
Both lesions can cause sudden death from irreversible
2 3 R L F
The lesion can only be detected by coronary arterio-
graphy. Once the diagnosis is made, revascularization' of
the 'myocardium should be undertaken as soon as possible.
S. Afr. Med. l., 47, 641 (1973).
The patiern of coronary arterial obstruction varies, but
patients who have severe obstruction of the proximal
main left coronary artery may die suddenly. This is a
well-known clinical observation among those who under-
take coronary angiography, but the importance of this
lesion has not been emphasized in the published Iitera-
This article describes a patient with this form of ob-
struction to emphasize its importance and the need to
undertake urgent coronary artery bypass surgery.
CASE REPORT Fig. 1. Electrocardiogram at rest and after exercise. The
resting electrocardiogram shows a flat T wave in lead 1
and important ischaemic changes occur in leads 1 and "3-
A 54-year-old White male, a police captain, first developed 6 after exercise.
angina pectoris in December 1971. The pain initially was
substernal and radiated to the right arm; it was brought
on by severe exertion and relieved by TNT, and lasted Bicycle ergometry demonstrated that angina pectoris
1 - 2 minutes. His exercise tolerance decreased for a month developed after 2 minutes of sitting exercise at 25 Watts.
before admission to hospital and angina was precipitated Cardiac catheterization and dne coronary angiography
by climbing a few stairs. He needed 3 - 4 TNT tablets per were performed. The left ventricular pressure was 121/9-
day. 14 with a peak dp/dt of I 902 mmHg/sec.
Family history and systemic interrogation were non-
contributory. The left ventriculogram was also normal, contraction
was good and the ejection fraction was 77%. There was a
Physical examination was normal. Blood pressure was
small dyskinetic segment in the middle of the antero-
160/90. A soft fourth heart sound was present at the
lateral wall in late systole. Selective coronary arteriography
showed a 95 % obstruction of the main left coronary
The resting electrocardiogram was normal, but the effort
artery, immediately proximal to its bifurcation, and there
test showed pathological ST segment depression in the
was also narrowing of the left anterior descending artery
anterolateral leads (Fig. 1).
(60%), proximal to its first septal branch. The circumflex
Special investigations were within the range of normal: artery was narrowed by 80% at the origin of its antero-
haemoglobin 14,9 g/lOO ml; serum cholesterol 372 mg/ lateral marginal branch. Both the di tal left anterior
100 ml and serum triglycerides 83 mgjlOO m!. descending and circumflex arteries were normal (Figs 2
and 3). The right coronary artery was the eat of several
·Date received: 6 ovember 1972.
areas of atheroma producing 40 - 50% obstruction of the
Reprint requests to: Professor ~1. S. Gotsman, Wentworth Hospital,
P.B. Jacobs, 'ata1.
lumen. It was the dominant artery, supplying the cru of
642 S.-A. MEDIESE TYDSKRIF 21 April 1973
the heart and continuing as the posterior interventricular relieved by TNT. He was scheduled for coronary artery
artery. bypass surgery.
Course: The patient was well following investigation. Five days after catheterization, he developed angina
In the succeeding few days he had several episodes of pectoris at 1800 hours. This was relieved immediately by
angina at. rest or while shaving: these were immediately 2 sublingual TNT tablets (0,5 mg). He received visitors
at 1900 hours and the angina recurred at 2000 hours.
Three minutes later he developed sudden ventricular
fibrillation. Three doctors were available within the ward
precinct. External cardiac massage and prompt resuscita-
tion were applied, but the cardiac output. fell imme-
diately and although ventricular fibrillation was termi-
nated successfully on 3 occasions, the arrhythmias soon
recurred and external countershock was then successful.
The blood pressure was unrecordable from the onset
of the first episode of ventricular fibrillation and re-
suscitation was abandoned after 1 hour.
Postmortem: The external appearances were normal.
The abdominal organs were normal and the lungs
showed severe pulmonary oedema. There was minor
atheroma of the cerebral arteries, the thoracic aorta and
lower abdominal aorta.
The heart was normal in size and weighed 300 grams.
There was no evidence of recent myocardial infarction.
The ostium of the left coronary artery was normal, but
0,5 cm beyond its origin, it was narrowed by a circum-
ferential fibrous stricture, a consequence of pre-existent
atheroma. This narrowed its lumen to about 5°~ or less
of normal (95% obstruction). The anterior descending
artery was calcified; 2 cm from its origin there was a 60%
obstruction by a large plaque of hard atheroma (Fig. 4).
Fig. 2. Selective left coronary arteriogram; left anterior
oblique projection. This shows 95% obstruction of the There were a few other small plaques of atheroma in
main stem left coronary artery and a 60% narrowing of the anterior descending artery but more distaIIy the lumen
the left anterior descending artery proximal to its first
was of normal calibre. The circumflex branch had an area
of severe narrowing at the origin of its anterolateral margi-
nal branch. The distal vessel was normal (Fig. 5). The
right coronary artery had 4 important plaques of athero-
ma which produced about 40% narrowing of its lumen.
There was no fresh thrombus in any of the coronary
arteries. The heart muscle was normal.
It is well known that obstruction of the main left coronary
artery, or of the proximal anterior descending branch
before its first septal perforating artery, may cause sud-
den death. There is no way of identifying patients who
have this lesion before coronary angiography is under-
taken. They have good myocardial function and the heart
is too good to die.
This patient had an obstruction of the left main artery
and of the proximal anterior descending vessel. The pre-
cipitating factor for the final episode in this patient is
unknown, but it is possible that emotional stress increased
the work load of the ventricle, rendering it hypoxaemic and
Fig. 3. Selective left coronary arteriogram, right anterior setting up an irreversible vicious cycle. It is interesting to
oblique position. This shows the severe obstruction of the record that this event happened suddenly, with medical
main stem left coronary artery and of the proximal staff in attendance, in a hospital in which emergency
anterior descending branch. There is also an 80% narrow-
ing of the circumflex artery at the origin of its antero- open-heart cardiac surgery is immediately available. Hypo-
lateral marginal branch. tension was instantaneous and death inevitable. We pre-
21 April 1973 S.A. MEDICAL JOURNAL 643
Fig. 4. Postmortem specimen showing aortic root and the anterior descending and circumflex branches of the left coro-
nary artery. A 95% stricture of the main stem left coronary artery is shown as well as a 60% obstruction of the anterior
Fig. S. Autopsy specimen of left coronary artery. This shows the obstruction to the main stem and proximal anterior
descending vessels. The artery has been opened. This distorts the anatomy. It was not possible to pass a fine probe
through the main stem obstruction. An important plaque of atheroma is shown in the circumflex artery at the origin
of its anterolateral marginal branch.
sume that the blood flow through the artery became in- terior descending branch, are candidates for immediate
adequate, and that there was immediate loss of pump elective surgery while they are well. When obstruction
function of at least two-thirds of the left ventricular occurs, a large part of the left ventricle becomes ischaemic
myocardium. and the final outcome is so swift that there is insufficient
We believe that patients with obstruction of the main time to mobilize the facilities for immediate open heart
left coronary artery, or the proximal portion of the an- surgery. Under ideal circumstances, this takes t - 1 hour.
644 S.-A. MEDIESE TYDSKRIF 21 April 1973
It is conceivable that a cardiac assist device or extra- These patients are candidates for sudden death, the
corporeal venovenous perfusion may maintain cerebral event is unpredictable and the underlying pathology can
blood flow while the bypass procedure is started, and only be identified by good coronary angiography.
that the myocardium may survive an ischaemic period of
I - 2 hours, until revascularization is achieved. Aortic per- 1. Favaloro, R. G., Effler, D. B., Groves, L. K., Shirey, E. K. and
fusion is inadequate to perfuse the myocardium in the Sones, F. M. jnr (1970): J. Thorac. Cardiovasc. Surg., 60, 469.
2. Cohen, M. V., Cohn, P. E., Herman, M. V. and Gorlin, R. (1972):
presence of such a significant coronary arterial obstruction. Circulation, 45, suppl. I, p. 57.
Carcinoma in a Hamman -Rich Lung *
A CASE REPORT
DENYS SCHORN, M.B. CH.B. UNIV. PRET. AND1. J. DE KOCK, M.B. CH.B. UNIV. PRET., Department of Internal
Medicine, H. F. Verwoerd Hospital, Pretoria
SUMMARY CASE REPORT
The case history of a patient with diffuse pulmonary A 72-year-old White female had a 12-month history of
interstitial fibrosis is presented. In the course of the spontaneous, progressive dyspnoea first noted on exertion,
disease carcinoma cells were repeatedly isolated from but that was present at rest 9 months later. She also
sputum. The pathogenesis of malignant change in lung developed a non-productive cough 5 months before ad-
fibrosis is incompletely understood. The tumors are usually mission. There was no history of bronchial asthma or
small, peripherally situated and do not often matastasize. other allergic reactions. She had suffered a myocardial
Because of the better prognosis as a result of modern infarction 5 years previously.
therapy, malignant change should be sought in all patients There was peripheral cyanosis, but no finger clubbing.
with fibrotic lung disease. The pulse rate was 90/ minute and the blood pressure
140/90 mmHg. The respiration rate was 4O/minute, the
S. Atr. Med. J., 47, 644 (1973). chest showed an increased anterior-posterior diameter,
and moved very little with the respiratory efforts. There
Hamman and Rich' described the syndrome of rapid, was vesicular breathing with diffuse, bilateral, fine crepi-
progressive dyspnoea, cyanosis and right-sided heart tations. The heart sounds were normal, with no murmurs,
failure as 'acute diffuse interstitial fibrosis of the lungs' and no signs of cardiac failure. There were no clinical
(Hamman-Rich syndrome). They also noted a metaplasia signs of systemic sclerosis (scleroderma), or rheumatoid
of the bronchial epithelium and alveolar lining. Inter- arthritis. X-ray examination of the chest showed an
stitial lung fibrosis can occur in a number of systemic elevated right diaphragm, that moved on fluoroscopy,
diseases, e.g. scleroderma, rheumatoid arthritis and tube- and a diffuse mottling, consistent with interstitial fibrosis
rous sclerosis,'" but in many other cases the aetiology throughout both lung fields (Fig. 1).
remains obscure.' The majority have chronic rather than A barium swallow and meal, and electrocardiogram,
acute disease and cases have been followed-up for longer were normal. The lung function tests showed a restrictive
than 6 years. Lung cancers have been reported in patients lesion without bronchial obstruction (Table I).
with scleroderma, and, more rarely, in interstitial fibrosis The white cell count was 11800/mm', haemoglobin
as a result of other diseases, including the Hamman-Rich 12,9 g/l00 ml, antinuclear and rheumatoid factors nega-
syndrome (the first report appears to have been in 1952).' tive, and the erythrocyte sedimentation rate was 22 mm
This is not a common combination and the pathogenesis in the first hour (Westergren method).
is incompletely understood. In this case malignant cells
were demonstrated in a patient suffering from sclerosing Carcinoma cells were present in repeated fresh sputum
alveolitis tlIamman-Rich syndrome). examinations (Figs. 2 and 3).
Lung biopsy showed an interstitial fibrosis with obli-
"Date received: 10 November 1972. teration of many alveoli, picture consistent with sclerosing