Angina pectoris due to left main coronary artery compression in Eisenmenger ductus arteriosus

Acute Myocardial Infarction due to External Compression of the Left Main Coronary Artery by a Large Pulmonary Artery Aneurysm

Background

Although rare, external compression of the left main coronary artery (LMCA) by a pulmonary arterial aneurysm (PAA) as a consequence of pulmonary arterial hypertension causing stable angina pectoris is well described. However, acute myocardial infarction is extremely rare, particularly with a full array of electrocardiographic, biochemical, and echocardiographic features, as in this scenario.

Case

In this case, a 62-year-old man with a past history of severe fibrotic lung disease was hospitalised with chest pain. The patient had dynamic anterolateral ischaemic changes on electrocardiography and serially elevated high-sensitivity troponin I. Transthoracic echocardiography revealed impaired left ventricular ejection fraction with anterolateral hypokinesis. Coronary angiography with intracoronary imaging revealed external compression of the LMCA. Computer tomography (CT) scans confirmed new PAA, compared to previous scans. The patient was successfully treated by percutaneous coronary stent implantation.

Conclusion

Progressive dilatation of the pulmonary artery due to pulmonary arterial hypertension can result in acute MI secondary to external compression of the LMCA. Clinicians should be mindful of acute coronary syndromes in patients with long-standing pulmonary hypertension presenting with chest pain.

Compression of adjacent anatomical structures by pulmonary artery dilation

Pulmonary hypertension is the commonest condition leading to dilated pulmonary artery. We describe three different types of compression of adjacent anatomical structures by dilated pulmonary arteries. We included involvement of the left main coronary artery, left recurrent laryngeal nerve and tracheobronchial tree. Compression of these structures can cause major complications such as myocardial ischemia, hoarseness and major airway stenosis. We present a case for each scenario and review the literature for each of these complications, focusing on patients' characteristics and contemporary management.

S. Baptista L, de Resende MVC, Furlan V, Ribeiro EE. Left Main Ostial Compression in a Patient with Pulmonary Hypertension: Dynamic Findings by IVUS

BACKGROUND

Pulmonary artery dilatation is a common feature among patients with severe pulmonary hypertension. Left main coronary artery extrinsic compression by an enlarged pulmonary artery is a rare complication and a potential cause for chest pain and sudden cardiac death in patients with pulmonary hypertension. This situation is very rare and few reports have described it. Currently, the appropriate management of these patients remains unknown.

CASE REPORT

In the present report we describe the case of a 39-year-old woman who presented with a 2-year history of cardiac symptoms related to exercise. The patient underwent a 64-slice multidetector computed tomography (MDCT) coronary angiography, which showed left main coronary artery (LMCA) compression by a markedly enlarged pulmonary artery trunk (44 mm), without intraluminal stenosis or coronary artery calcium, as determined by the Agatston score. This compression was considered to be the cause of the cardiac symptoms. To confirm and plan the treatment, the patient underwent cardiac catheterization that confirmed the diagnosis of pulmonary hypertension and LMCA critical obstruction. Taking into account the paucity of information regarding the best management in these cases, the treatment decision was shared among a "heart team" that chose percutaneous coronary intervention with stent placement. An intra-vascular ultrasound was performed during the procedure, which showed a dynamic compression of the left main coronary artery. The intervention was successfully executed without any adverse events.

CONCLUSIONS

This case illustrates dynamic compression of the LMCA by IVUS, visually demonstrating the mechanism of the intermittent symptoms of myocardial ischemia in this kind of patient. It also shows that percutaneous stenting technique may be an appropriate treatment for this unusual situation.

Adult left-ventricular diverticulum and patent ductus arteriosus misdiagnosed as coronary artery disease with infarct aneurysm: a case report

Background

Left-ventricular diverticulum (LD) associated with patent ductus arteriosus (PDA) is extremely rare. We have not found any previous reports of the coexistence of these two malformations. Such an association presenting with chest pain mimicking an infarct aneurysm with angina or a takotsubo cardiomyopathy with chest pain is difficult to differentiate clinically. Here, we discuss several diseases characterized by left-ventricular apical protrusion with chest pain to familiarize clinicians with the differential diagnosis of these diseases.

Case presentation

A 58-year-old woman was referred to our hospital because of complaints of chest pain and dyspnoea, mainly on exertion. An electrocardiograph on admission showed a q-wave in lead I, a Q-wave in lead aVL, and an abnormal T-wave in the limb leads and leads V4 to V6. A transthoracic echocardiograph revealed a PDA and a protrusion arising from the apex of the left ventricle. The diagnosis on admission was PDA and coronary artery disease with infarct aneurysm. To evaluate the source of the chest pain, further evaluations were performed. Coronary angiography showed no abnormal findings. Left ventriculography confirmed the presence of an apical contractile out-pouching. Based on these findings, we revised the diagnosis as LD associated with PDA. The patient underwent transcatheter occlusion of the PDA and was discharged 3 days later. Unexpectedly, transcatheter occlusion resolved the paroxysmal chest pain in this case.

Conclusion

This is the first case report of LD combined with PDA. PDA should be considered in the list of differential diagnosis of chest pain. Several diseases characterized by left-ventricular apical protrusion with chest pain, such as LD, infarct aneurysm and takotsubo cardiomyopathy, can be misdiagnosed as one another. Therefore, it is important to familiarize clinicians with the differential diagnosis of these diseases.

[Giant pulmonary artery aneurysm: etiology and an exceptional 17 years natural course]

True pulmonary artery aneurysm (AAP) is rare and represent less than 1% of intra-thoracic aneurysms. We report a case of a AAP in a patient with a likely cor triatrium sinister, with an obstructive membrane responsible for pulmonary hypertension, explaining AAP. The long-term evolution of 17 years is made to an uncomplicated myocardial infarction. The patient died eight months later suddenly probably due to the rupture of the PAA.

Extrinsic compression of left main coronary artery by the pulmonary trunk secondary to pulmonary hypertension documented using 64-slice multidetector computed tomography coronary angiography

Compression of left main coronary artery (LMCA) secondary to pulmonary trunk dilatation is a newly recognized entity that has been associated with severe pulmonary hypertension. In this paper we present a case of extrinsic compression of LMCA caused by dilated pulmonary trunk secondary to pulmonary hypertension documented using 64-slice multidetector computed tomography (MDCT) coronary angiography. This case is followed by a review of the literature.

Dynamic compression of the left main coronary artery by the left atrium

We report a case of a 67-year-old woman with a past medical history of severe mitral valve regurgitation with worsening congestive heart failure symptoms and angina. Coronary angiography revealed dynamic limitation of contrast flow during systole in the left main (LM) coronary artery, but no evidence of obstructive atherosclerotic disease. Intravascular ultrasound demonstrated a dynamic distortion and reduction of the LM coronary artery cross sectional area during systole. Cardiac computed tomography demonstrated left atrial enlargement with extrinsic distortion and compression of the LM coronary artery. A diagnosis was made of dynamic compression of the LM coronary artery secondary to systolic left atrial enlargement resulting from mitral regurgitation.

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.

Left main coronary artery and right pulmonary vein compression by a large pulmonary artery aneurysm

Pulmonary artery aneurysms are uncommon and may be associated with significant morbidity and mortality. The unique combination of left main coronary artery and upper right pulmonary vein compression by a large pulmonary artery aneurysm is reported. Furthermore, the aetiology, clinical manifestations, complications, diagnostic approach, and possible therapeutic interventions are briefly discussed.

Likelihood of left main coronary artery compression based on pulmonary trunk diameter in patients with pulmonary hypertension

PURPOSE

In patients with pulmonary hypertension, extrinsic compression of the left main coronary artery by a dilated pulmonary trunk may cause angina, left ventricular ischemia, and sudden death. We assessed coronary artery compression in relation to pulmonary trunk diameter and other demographic, echocardiographic, hemodynamic, and scintigraphic variables.

METHODS

Thirty-six patients (aged 15 to 86 years) with pulmonary hypertension, either idiopathic or associated with congenital heart disease, were enrolled. Left main coronary artery compression was defined angiographically as > or =50% obstruction associated with downward displacement of the vessel. Pulmonary trunk and aortic diameters were measured by transthoracic echocardiography.

RESULTS

Twenty-six patients had angina, of whom 7 had left coronary artery compression. Compression was related to pulmonary trunk diameter (P = 0.002) and to the ratio of pulmonary trunk diameter to aortic diameter (P = 0.02). Compression was not seen at pulmonary artery diameters <40 mm; among 19 patients with values > or =40 mm, the rate was 37%. Similarly, compression did not occur at pulmonary trunk to aortic diameter ratios <1.21; among 27 patients with ratios > or =1.21, the rate was 26%.

CONCLUSION

In pulmonary hypertension, noninvasive measurement of pulmonary trunk diameter may be helpful in determining the likelihood of left coronary artery compression and in selecting patients for diagnostic coronary angiography.

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.

Left main coronary artery compression by aneurysmal pulmonary artery in a patient with tetralogy of Fallot with absent pulmonary valve

We describe an 11-year-old girl with tetralogy of Fallot and absent pulmonary valve, who on selective coronary angiography was found to have extrinsic compression of the left main coronary artery by the aneurysmally dilated pulmonary artery. This abnormality has not been reported previously.

Extrinsic compression of the left main coronary artery by the pulmonary artery in patients with long-standing pulmonary hypertension

Left main coronary artery compression by the pulmonary artery may be seen in patients with pulmonary hypertension who are undergoing cardiac catheterization. Cardiac magnetic resonance imaging is useful in these patients to document extrinsic compression, which might otherwise be mistaken for intrinsic atherosclerotic disease.

Magnetic resonance imaging of ductus arteriosus Botalli apertus in adulthood

Ductus arteriosus Botalli apertus is a congenital cardiovascular malformation usually diagnosed in childhood by echocardiography and/or cardiac catheterization. Reports about magnetic resonance imaging of ductus arteriosus Botalli apertus are rare. We report about three adult female patients and one adult male patient in whom magnetic resonance imaging was able to demonstrate the pathology. In all four patients quantitative data about right ventricular function were calculated. Pulmonary hypertension with Eisenmenger syndrome detected by cardiac catheterization had developed in three of the four patients excluding operative closure of the ductus. The patient in whom pulmonary hypertension had not developed underwent successful operative closure of the ductus. Magnetic resonance imaging is a non-invasive tool that can be used for diagnosis of ductus arteriosus Botalli apertus and it allows to quantify right ventricular function. Magnetic resonance imaging can be used repetitively in patients with Eisenmenger syndrome which may be helpful for better timing of combined heart-lung transplantation as ultimate therapeutic strategy because deterioration of right ventricular function can be monitored.

Left main coronary artery compression during primary pulmonary hypertension

Primary pulmonary hypertension (PPH) is often associated with angina-like chest pain, the mechanism of which is controversial. A 37-year-old woman with severe PPH and angina had transient ischemic ECG changes and reversible anterior perfusion defect on 201thallium scintigraphy. Coronary angiography revealed severe stenosis of the left main coronary artery (LMCA) and otherwise normal vessels. After heart-lung transplantation, examination of the explanted heart showed normal coronary arteries. Compression of the LMCA by the dilated pulmonary artery trunk was responsible for myocardial ischemia. This mechanism should be considered in patients with PPH and angina and might contribute to the high sudden death rate.