Reply

Evaluation of the etiology of proximal LAD subocclusive stenosis, including coronary artery vasospasm as a possible mechanism, is a very interesting issue in our case owing to the unexpected complete resolving of coronary pathology 8 years after left internal mammary artery–left anterior descending artery (LIMA-LAD) cardiac surgery [1]. This possible mechanism that may be responsible for the complete disappearance of coronary pathology seen in 2004 is nicely questioned in the letter by Tomislav Miljak, MD, MBA.

Coronary vasospasm as a cause of LAD stenosis was comprehensively evaluated by the heart team involved in the medical case. According to the heart team, the following events were decisive in supporting obstructive atherosclerotic (not vasospastic) characteristics of proximal LAD subocclusive stenosis:

  1. 1.

    During April 2004, 2 months before LIMA-LAD cardiac surgery, an ergometric stress test (EST) was performed. The EST was stopped at 8 MET because of both retrosternal pain and significant ECG changes suggestive of myocardial ischemia (ST depression of more than −  2 mm in five contiguous leads).

  2. 2.

    During coronary arteriography, the catheter was placed in the LM ostium, not further in the LM tree, close to the LAD branch. In this case it was not necessary to perform another angiogram after nitroglycerine administration in order to exclude coronary vasospasm in the LAD artery.

  3. 3.

    After LIMA-LAD cardiac surgery, a new EST was performed in December 2004. There were no symptoms or signs of myocardial ischemia during this EST, with 14 MET reached, which was a markedly improved finding compared with the previous one 6 months earlier. Three years later, in 2007, the EST results were again negative regarding the presence of myocardial ischemia.

  4. 4.

    On the basis of our conviction of obstructive characteristics of an LAD lesion (not vasospasm), optical coherence tomography (OCT) or intravascular ultrasound (IVUS) were not performed during coronary angiography in 2012.