ST-Segment–Elevation Myocardial Infarction Attributable to Left Main Coronary Artery Compression
2016; Lippincott Williams & Wilkins; Volume: 133; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.115.021102
ISSN1524-4539
AutoresRui Plácido, Susana Martins, Pedro Canas da Silva, Eduardo Infante de Oliveira, Paula Peixoto Campos, Ana G. Almeida, Fausto J. Pinto,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoHomeCirculationVol. 133, No. 18ST-Segment–Elevation Myocardial Infarction Attributable to Left Main Coronary Artery Compression Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBST-Segment–Elevation Myocardial Infarction Attributable to Left Main Coronary Artery Compression Rui Plácido, MD, Susana Robalo Martins, MD, Pedro Canas da Silva, MD, Eduardo Infante de Oliveira, MD, Paula Campos, MD, Ana G. Almeida, MD, PhD and Fausto J. Pinto, MD, PhD Rui PlácidoRui Plácido From Santa Maria Hospital, Cardiology Department, Lisbon Academic Medical Centre, CCUL, Portugal and University of Lisbon, Portugal (R.P., S.R.M., P.C.d.S., E.I.d.O., A.G.A., F.J.P.); and Santa Maria Hospital, Radiology Department, Lisbon, Portugal (P.C.). , Susana Robalo MartinsSusana Robalo Martins From Santa Maria Hospital, Cardiology Department, Lisbon Academic Medical Centre, CCUL, Portugal and University of Lisbon, Portugal (R.P., S.R.M., P.C.d.S., E.I.d.O., A.G.A., F.J.P.); and Santa Maria Hospital, Radiology Department, Lisbon, Portugal (P.C.). , Pedro Canas da SilvaPedro Canas da Silva From Santa Maria Hospital, Cardiology Department, Lisbon Academic Medical Centre, CCUL, Portugal and University of Lisbon, Portugal (R.P., S.R.M., P.C.d.S., E.I.d.O., A.G.A., F.J.P.); and Santa Maria Hospital, Radiology Department, Lisbon, Portugal (P.C.). , Eduardo Infante de OliveiraEduardo Infante de Oliveira From Santa Maria Hospital, Cardiology Department, Lisbon Academic Medical Centre, CCUL, Portugal and University of Lisbon, Portugal (R.P., S.R.M., P.C.d.S., E.I.d.O., A.G.A., F.J.P.); and Santa Maria Hospital, Radiology Department, Lisbon, Portugal (P.C.). , Paula CamposPaula Campos From Santa Maria Hospital, Cardiology Department, Lisbon Academic Medical Centre, CCUL, Portugal and University of Lisbon, Portugal (R.P., S.R.M., P.C.d.S., E.I.d.O., A.G.A., F.J.P.); and Santa Maria Hospital, Radiology Department, Lisbon, Portugal (P.C.). , Ana G. AlmeidaAna G. Almeida From Santa Maria Hospital, Cardiology Department, Lisbon Academic Medical Centre, CCUL, Portugal and University of Lisbon, Portugal (R.P., S.R.M., P.C.d.S., E.I.d.O., A.G.A., F.J.P.); and Santa Maria Hospital, Radiology Department, Lisbon, Portugal (P.C.). and Fausto J. PintoFausto J. Pinto From Santa Maria Hospital, Cardiology Department, Lisbon Academic Medical Centre, CCUL, Portugal and University of Lisbon, Portugal (R.P., S.R.M., P.C.d.S., E.I.d.O., A.G.A., F.J.P.); and Santa Maria Hospital, Radiology Department, Lisbon, Portugal (P.C.). Originally published3 May 2016https://doi.org/10.1161/CIRCULATIONAHA.115.021102Circulation. 2016;133:1828–1829IntroductionA 44-year-old man with Eisenmenger syndrome in the setting of a subaortic ventricular septal defect under treatment with bosentan presented with angina at rest for 12 hours. He reported effort chest pain and worsened dyspnea in the previous weeks.The ECG at admission showed transient ST elevation in aVR and V1 coupled with ST depression in the other leads (Figure A), suggesting ischemia attributable to left main coronary artery (LMCA) obstruction, given the clinical context.Download figureDownload PowerPointFigure. A, Standard 12-lead ECG showing transient ST elevation in aVR and V1 coupled with ST depression in the other leads. B, Cardiac volume rendered computed tomography (CT) showing the spatial relationship between the enlarged pulmonary artery and the left main coronary artery (LMCA). C and D, Cardiac CT in axial and oblique coronal views, respectively, depicting the high-grade ostial and proximal LMCA stenosis secondary to extrinsic compression by a massively enlarged main pulmonary artery (yellow arrows). E, Selective left coronary angiography revealing a smooth tapered narrowing at the ostium of LMCA. E.1, Intravascular ultrasound (IVUS) cross-sectional image showing the proximal LMCA luminal reduction attributed to the extrinsic compression (green circle and green arrow). F, Final angiogram result after percutaneous coronary intervention. F.1, IVUS cross-sectional image demonstrating adequate and symmetrical stent expansion.Echocardiography depicted a large subaortic ventricular septal defect with predominant right-to-left shunt and depressed left ventricular ejection fraction attributable to global hypokinesia (Movie I in the online-only Data Supplement).Troponin I was markedly elevated (78.0 ng/mL; reference range, < 0.07 ng/mL). The patient was referred to urgent coronary angiography that revealed a smooth tapered narrowing at the ostium of the LMCA, without other coronary lesions.Coronary computed tomographic angiography (Figure B through D) was undertaken to provide optimal detail concerning the mechanism of obstruction. It depicted a significant slitlike narrowing of the ostium and proximal LMCA shaft, with a downward angulation of 30° relative to the left coronary sinus (yellow arrows), secondary to extrinsic compression by a massively enlarged main pulmonary artery (Movie II in the online-only Data Supplement). Moreover, there was no evidence of underlying atherosclerosis.According to the predictable high surgical risk imposed by severe pulmonary hypertension, a percutaneous coronary approach was attempted. Angiography (Figure E) and intravascular ultrasound (Figure E.1; Movie III in the online-only Data Supplement) confirmed the LMCA extrinsic compression (green arrow). A bare metal stent 4.5×12 mm (Omega, Boston Scientific Corporation, Marlborough, MA) was deployed with good angiographic result (Figure F), and was also assessed by adequate and symmetrical stent expansion by intravascular ultrasound (Figure F.1; Movie IV in the online-only Data Supplement).Specific pulmonary hypertension treatment intensification was provided to minimize the compression of adjacent structures by pulmonary artery trunk. At 4-month follow-up, the left ventricular ejection fraction had normalized, and the patient remained free of angina.Extrinsic compression of the LMCA by a dilated pulmonary artery is a rare condition usually associated with long-standing pulmonary hypertension.1 An integrated multimodality imaging approach provides incremental value in its diagnosis and management. Although debatable, percutaneous coronary intervention appears to be a feasible, safe, and effective therapeutic option, especially regarding the subgroup of patients with a high predictable surgical mortality.2DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.021102/-/DC1.Correspondence to Rui Plácido, MD, Hospital de Santa Maria, Serviço de Cardiologia I, Avenida Professor Egas Moniz, 1649-028 Lisbon, Portugal. E-mail [email protected]References1. Sakuma M, Demachi J, Suzuki J, Nawata J, Takahashi T, Shirato K.Proximal pulmonary artery aneurysms in patients with pulmonary artery hypertension: complicated cases.Intern Med. 2007; 46:1789–1793.CrossrefMedlineGoogle Scholar2. Salhab KF, Al Kindi AH, Ellis SG, Lad N, Svensson LG.Percutaneous coronary intervention of the left main coronary artery in a patient with extrinsic compression caused by massive pulmonary artery enlargement.J Thorac Cardiovasc Surg. 2012; 144:1517–1518. doi: 10.1016/j.jtcvs.2012.07.086.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Cabral D, Guimarães T, Almeida A, Campos P, Martins S, da Silva P, Pinto F and Plácido R (2022) Chest pain in a patient with pulmonary arterial hypertension, Revista Portuguesa de Cardiologia, 10.1016/j.repc.2020.05.021, 41:1, (73-80), Online publication date: 1-Jan-2022. May 3, 2016Vol 133, Issue 18 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.021102PMID: 27143552 Originally publishedMay 3, 2016 PDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsComputerized Tomography (CT)EchocardiographyStentUltrasound
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