Dr.S.Venkatesan MD

We frequently  hear  a comment  about  LCX angioplasty   being a  tricky intervention   . Even  many experienced cardiologists   do agree with this .

What could be the  apparent explanation for this seemingly important observation in cath lab ?

1. The first and foremost is the anatomical  uniqueness of  origin and course of LCX. LAD is direct continuation of  left-main  , while LCX always  originate  with a  considerable angle at  it’s origin   . Further downstream  it flexes circum-ferentially over the lateral free wall of left ventricle .This  ensures  the  catheters and stents  we   maneuver often  traverse a hair pin bend  .
2. The  endurance of  coronary stents are  put into biggest test during LCX angioplasty . While any mediocre metal stent can sit comfortably in LAD , LCX is different story altogether.(A flexible multi link  model  like that of Abbot Vision platform seems ideal . )
3. The LCX wire crossing and exchange  is vested  with  potential  threat  to  the much important LAD circulation . Time and again , we have observed  ,  prolonged procedures  inside    LCX  some how compromise    the LAD  flow.
4. Once the LCX is opened ( especially in  a CTO , ) there is a sort of   stealing  of LAD blood flow. We have witnessed this in  at least 2 patients , who developed  anterior  MI after opening up of LCX CTO. (Who  had a insignificant  LAD lesion )
5. LAD may be widow maker artery ,  but it remains a fact  LCX   has much  more important role in regulating  mitral valve  papillary  muscle  . Even transient  ischemia  in  LCX territory can result in  lung congestion or even  flash pulmonary edema .This  is  fairly frequent during complex LCX angioplasty .
6. The antero-lateral pap muscle is located in a critical location especially so in post infarct remodeled left ventricle  even minor degrees of ischemia can  create  a havoc .This is what   occurs during  flash  pulmonary edemas in LCX angioplasties.
7. Spillover of thrombus from LCX to  LAD  can occur  during  aspiration  of   LCX  primary PCI
8. Finally,   ECG  changes   are often blind in LCX territory . It remains an  Irony ,  we  do not monitor  the heart  with 12 leads during   sensitive procedure like a PCI.(The monitor leads easily miss LCX ischemia .This is hardly surprising,   as we know   LCX territory  has blind spots even with 12 lead ECG !)

Final message

It is  true LCX angioplasties can not be taken casually . One can not afford to have a prolonged procedure  within LCX.Whether dominant or not   LCX  delivers  blood supply  to more vital areas  of myocardium  that typically  includes lateral free wall and  mitral valve function .It is possible septal ischemia is  relatively well tolerated while free wall ischemia triggers an early mechanical deterioration .