External compression by metastatic squamous cell carcinoma: a rare cause of left main coronary artery narrowing

Noninfiltrating Adenocarcinoma of the Lung Causing ST-Segment Elevation

ST-segment-elevation myocardial infarction is a leading cause of cardiovascular morbidity and death. We describe the case of a 51-year-old woman with advanced adenocarcinoma of the lung who presented with ST-segment elevation in the presence of an extracardiac lung mass but no objective evidence of myocardial ischemia or pericardial involvement. After the patient died of hypoxic respiratory failure, autopsy findings confirmed normal-appearing pericardium and myocardium, and mild-to-moderate atherosclerosis in the coronary arteries. A 4.5 × 4-cm extracardiac left hilar lung mass was confirmed to be poorly differentiated adenocarcinoma of the lung adjacent to the myocardium. The persistent current of injury that had been detected electrocardiographically was thought to occur from direct myocardial compression. ST-segment elevations secondary to direct mass contact on the myocardium should be considered in patients who have a malignancy and ST-segment elevation.

Differential diagnosis of non-atherosclerotic left main coronary artery stenosis

A left main coronary artery (LMCA) stenosis without any atherosclerotic changes elsewhere in the coronary artery tree is a rare finding, and some uncommon reasons for luminal narrowing should be considered. An unusual case of non-atherosclerotic LMCA stenosis is reported.A middle-aged patient presented with acute myocardial infarction. An immediate coronary angiography was ordered and revealed a subtotal mid LMCA stenosis. A drug-eluting stent was successfully implanted in the LMCA.Operative revascularisation was recommended. Routine surgery was performed and surprisingly revealed an extended mass of a mediastinal tumour surrounding the aortic root. Histopathological examination of the tumour revealed a poorly differentiated squamous cell carcinoma.Postoperatively, the patient was treated with chemotherapy (carboplatin and docetaxel). Five years after the first admission to our hospital, the patient died as a result of ventricular fibrillation.The differential diagnosis of non-atherosclerotic LMCA stenoses is discussed.

Management of coronary artery compression caused by recurrent aortic root abscess

Extrinsic coronary artery compression is a rare cause of coronary ischemia. We report the case of a 61-year-old male who developed a recurrent aortic root abscess causing extrinsic coronary artery compression. This complication occurred one year after undergoing aortic valve replacement and pericardial patch exclusion of an aortic root abscess. Surgical correction required debridement of the abscess and replacement of the aortic root with a homograft resulting in resolution of coronary compression.

Postoperative asystole in a vasculopathic man

We present a case of postoperative cardiac arrest caused by extrinsic occlusion of the right coronary artery by an aortic pseudoaneurysm. Extrinsic impingement upon the coronary arteries may result from several etiologies and lead to cardiac symptoms identical to those caused by intrinsic coronary disease. Extrinsic compression may be amenable to treatment with angioplasty or a combination of angioplasty and surgery.

Acute myocardial infarction caused by coronary tumor thromboembolism: a rare primary manifestation of malignant tumor disease

Myocardial infarction in the context of malignant tumor disease is rare but well documented and can occur through various pathophysiological mechanisms. We report an unusual case of a patient with recurrent myocardial infarction due to coronary tumor thromboembolism as the first clinical manifestation of a previously unknown squamous cell carcinoma of the lung. The possible pitfalls leading to a wrong preliminary diagnosis in our case as well as the literature on myocardial infarction in patients with cancer were discussed.

Myocardial infarction due to saphenous vein graft compression by an extracardiac mass

We present an unusual case of a patient with an inferior infarct caused by saphenous vein graft compression by an extracardiac malignant spindle cell tumour, a mechanism of myocardial ischaemia rarely described. This case also illustrates how chest X-ray and angiography can be useful for making an early diagnosis of a cardiac mass.

HeartPatch implanted direct cardiac compression: effect on coronary flow and flow patterns in acute heart failure sheep

A novel HeartPatch direct cardiac compression (DCC) device has been shown to effectively restore circulatory parameters in sheep with acute heart failure (HF). Its effect on the coronary circulation and myocardial perfusion, however, remains uncertain. The effect of DCC assist on coronary artery blood flow (CABF) and its patterns in acute HF sheep were examined in this study. Ten sheep (51 +/- 6 kg) were implanted with a heart patch on each of the left ventricular and right ventricular free walls 1 week before study. Stable HF [cardiac output (CO) at 51 +/- 8% of baseline] induced by intravenous esmolol resulted in CABF decreasing to 53 +/- 16% of baseline (p < 0.001). DCC device activation did not alter CABF (54 +/- 15% of baseline, N.S.) but was accompanied by increases in both peak antegrade and retrograde flow velocity (161 +/- 75%, p < 0.001 and 413 +/- 377%, p < 0.001). A shift in the proportion of flow occurring in diastole (%DF) also was observed: baseline, 81 +/- 9%; HF, 82 +/- 6%; DCC assist, 121 +/- 16% (p < 0.001). Despite significant changes in coronary artery flow pattern resulting from DCC of the failing heart, total antegrade coronary flow was maintained. These findings suggest that myocardial perfusion is not compromised by DCC.

Extrinsic compression of the left main coronary artery by a dilated pulmonary artery: clinical, angiographic, and hemodynamic determinants

Extrinsic compression of the left main coronary artery (LMC) by the pulmonary artery (PA) is a very unusual and poorly understood entity, usually associated with the presence of adult congenital heart disease. We identified 12 patients (age range, 6 months to 55 years) with LMC stenosis (> or = 50%) presumably secondary to compression by a dilated main PA and related to various forms of heart disease (11 congenital, 1 pulmonary hypertension). In all cases, the main PA was dilated with the main PA/aortic root diameter increased (mean, 2.0; normal value, < or = 1.0), and in all but two, PA pressures were increased (> 30 mm Hg systolic). Left coronary trunk stenosis was usually visualized in only one angiographic view (best seen in 45 degrees left anterior oblique, 30 degrees cranial projection). The LMC also appeared to be inferiorly displaced and in close contact with the left aortic sinus (mean angle between sinus and LMC was 23 degrees +/- 13 degrees, a control group was 70 degrees +/- 15 degrees ). In one patient, surgical correction of the dilated PA was associated with a reduction in LMC stenosis from 85% to < 50% and less inferior left main displacement (from 25 degrees to 50 degrees ). Patients with a dilated main PA may exhibit extrinsic LMC compression leading to significant eccentric narrowing and downward displacement of the LMC. In the presence of significant dilatation of the main PA from any etiology, functional and/or anatomic studies should be performed to exclude significant LM obstruction.

Asymptomatic occlusion of the left main coronary artery by an aortic pseudoaneurysm

Extrinsic compression of the left main coronary artery is a rare cause of coronary ischemia. We describe a 35-year-old Asian woman with complete asymptomatic occlusion of the left main coronary artery by a large aortic pseudoaneurysm. She underwent repair of the pseudoaneurysm and coronary artery bypass grafting at the Mayo Clinic in Rochester, Minn. The differential diagnosis is discussed. Based on this patient's age and associated vascular lesions, we conclude that Takayasu arteritis was the most likely cause of her condition.

Total occlusion of the left main and proximal right coronary artery: case report and review of the literature

Chronic total left main coronary artery occlusion at angiography is very rare, and there are only four cases reported with concomitant total right coronary artery occlusion. We describe a case of total left main and proximal right coronary artery occlusion and review the clinical and angiographic characteristics of this condition which represents the most severe from of coronary artery disease compatible with life.

Neoplastic obstruction of the abdominal aorta

Obstruction of major arteries by neoplastic tissue is rare. A case of symptomatic obstruction of the distal abdominal aorta by metastatic carcinoma of the cervix, presenting 6 years after initial diagnosis, is described.

Radiation-induced coronary artery disease

Excessive unprotected radiation to the heart appears to lead to the development of CAD, even in the absence of significant cardiovascular risk factors. The coexistence of such factors may enhance the probability of CAD. The presence of hypercholesterolemia and concomitant or sequential use of chemotherapeutic agents (especially doxorubicin) could further increase this risk. Therapeutic decisions, as with any other manifestation of CAD, relate to the extent of myocardium at jeopardy and to the overall diffuseness of CAD. Management options possible are PTCA or coronary artery bypass surgery. The latter may be required in left main artery stenosis and complicated ostial lesions. Use of shielding should decrease the associated risk of radiation-induced CAD in future years. However, clinicians should continue to have a high degree of suspicion of CAD in patients treated with thoracic radiation without cardiac shielding.

Isolated significant left main coronary artery stenosis: angiographic, hemodynamic, and clinical findings in 16 patients

Among 21,545 adult patients who underwent consecutive coronary angiography, 16 (0.07%) were found during their coronary arteriography to have a significant isolated stenotic lesion (luminal diameter narrowing of 50% or more) located at the left main coronary artery. The remaining major epicardial coronary arteries and their branches were free of disease. A strong predilection for the isolated lesion to occur at the ostium of the left main artery was found (12 patients). The most common presenting symptom was angina of less than 4 weeks' duration, although one third of the group was asymptomatic. Resting electrocardiograms were normal in 12 patients, while three patients had T wave inversion and another had nonspecific ST-T changes. Eleven patients exhibited severe stenosis, with eight having 70% to 89% stenosis and three having 90% to 95% stenosis. Five patients had 50% to 69% stenosis. No significant differences were found between patients with angina and patients without angina with respect to age, left ventricular end-diastolic pressure, left ventricular ejection fraction, and mean percent stenosis of the obstructive lesion. Despite the severity and the crucial location of the obstructive lesion, most patients with an isolated, significant left main stenosis appear to have a preserved left ventricular ejection fraction, normal wall motion, and no significant alteration of the left ventricular end-diastolic pressure.

Complete left main coronary artery occlusion: angiographic evaluation of collateral vessel patterns and assessment of hemodynamic correlates

An angiographic study of eight patients with total occlusion of the left main coronary artery identified six patients with chronic occlusion and two with acute complete occlusion. In each of six patients, there were two to six different intercoronary collateral pathways. Altogether, a total of 13 specific collateral channels were recognized. One patient had evidence of unique homocollaterals represented by enlarged vasa vasorum, which created a vascular cuff that surrounded a totally obstructed left main artery. The ventricular function and hemodynamic parameters in these patients not only depend on the collateral vessels but may also be affected by the severity of coronary artery disease in the artery that supplies collaterals.