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The angiocardiographic and clinical findings in 218 patients with significant obstruction confined to the left anterior descending coronary artery were reviewed to study the influence of the site of obstruction and of the collateral circulation on clinical presentation and prognosis. One hundred and fifty-six patients had been managed medically, 51 had had aortocoronary bypass operations, and 11 had had left ventricular aneurysms excised. The artery was divided into three segments: left anterior descending 1 (LAD1) from its origin to the first septal branch, left anterior descending 2 (LAD2) from the first septal to the first diagonal branch, and left anterior descending 3 (LAD3) the remaining distal vessel. Cardiogenic shock occurred only in patients with LAD1 lesions, but apart from this the clinical presentation bore no consistent relation to the site of disease. Patients with proximal lesions were more likely to have a "positive" exercise test, had more severely impaired left ventricular function, and had a worse prognosis than those with more distal disease. Non-visualisation of collateral vessels in patients with left anterior descending occlusion was associated with extensive infarction, and patients who presented with infarction had more severely impaired ventricular function than those who presented with angina and subsequently had an infarction. Left ventricular function was poor at the time of angiography in 11 of 12 of those who subsequently died; it is therefore unlikely that the prognosis of patients with isolated left anterior descending obstruction could be improved by expanding the indication for aortocoronary bypass from that of severe angina.

We report the clinical features and the results of investigation and surgery in 20 patients with significant left main coronary artery stenosis. All had moderate to severe angina; 8 had pain at rest. Three had dyspnoea as a major symptom. The electrocardiogram was abnormal in 17, with evidence of previous myocardial infarction in 10. Of the 11 patients exercised, 8 developed chest pain. Nine patients had a normal left ventriculogram. At coronary angiography all patients had major disease elsewhere in addition to the left main coronary artery stenosis. There were no deaths or major complications associated with this investigation. One patient was unsuitable for surgery because of diffuse left ventricular hypokinesia, one had a fatal myocardial infarction while awaiting operation, and there was one preoperative death. Sixteen of the 17 surgical survivors are free from angina. There has been a significant improvement in the maximum exercise capacity in the 10 patients who had pre- and postoperative exercise tests.

We have examined 5 patients with typical angina pectoris and found them to have left coronary ostial stenosis without evidence of any other coronary arterial disease and without evidence of aortic disease (Takayasu aortitis, syphilitic aortitis, or familial hypercholesterolaemia). All five patients were female aged between 38 and 53 years, a striking difference from the normal 7:1 male:female ratio for atherosclerotic coronary artery disease. It may be that these patients represent a rare but distinct syndrome. The angiographic diagnosis can be difficult but a pressure drop as the catheter tip engages the ostium and lack of spill-over of contrast into the sinus of Valsalva are findings that should lead the angiographer to suspect ostial stenosis.

A young man with Takayasu's disease had severe right and left coronary ostial stenoses. Severe angina was relieved by operation at which the right coronary ostium was enlarged by a pericardial patch extending across the stenosis from aorta to coronary artery; the aortic end of a vein graft to the left coronary artery was attached to this patch. This technique may reduce the risk of recurrence of ostial stenosis or of stenosis at graft origins.

The article relates the author's observation of the accomplishment of aortocoronary bypass surgery after a decade. The author suggests to assess its place in the management of coronary disease in the U.S. Over the years, one has witnessed that the aortocoronary bypass effectively relieves angina in individuals where symptoms are poorly controlled by optimum medical treatment like beta-adrenergic blocking drug.