Pinhole-Like Left Main Ostium: Managing a High-Risk Anatomical Substrate With a Novel Percutaneous Strategy.

BACKGROUND: Coronary artery anomalies, increasingly recognized as a cause of angina because of higher use of noninvasive imaging, can lead to debilitating symptoms and increased risk of sudden death. CASE SUMMARY: A 49-year-old woman presented with years of daily exertional chest pain/dyspnea. Coronary computed tomography angiography revealed a left main coronary artery with a pinhole-like ostium, an inferior takeoff between the noncoronary and left coronary cusps, and poststenotic dilatation. The patient declined surgery and underwent successful intravascular ultrasound-guided percutaneous coronary intervention (PCI) with symptom resolution. DISCUSSION: This is a successful case report of PCI to correct a pinhole-like ostium of the left main coronary artery. Given the patient's progressive symptoms, the benefit of preventing a life-threatening arrhythmia and improving her function outweighed the procedural risks. TAKE-HOME MESSAGES: This case demonstrates that PCI is a safe and feasible approach to treat critical pinhole-like left main stenosis in select patients, to prevent life-threatening ischemia-induced arrhythmias and improve functional capacity. Careful longitudinal surveillance will be essential to monitor continued stent patency and freedom from symptoms.