Left main coronary trunk compression by dilated main pulmonary artery in atrial septal defect

Rapid progression of pulmonary artery dilatation in pulmonary hypertension

We report the case of a 47-year-old woman who was admitted to the cardiac department for worsening dyspnea. The last chest computed tomography (CT) showed a rapid increase in pulmonary artery dimension (65 mm in 2019, 76 mm in 2021). The symptoms reported by the patient were due to important extrinsic compression of the left main coronary artery (LMCA). In this case, it is very difficult to choose the best therapeutic strategy. In the end, we decided to treat the left main coronary for prevention. After 3 months no new clinical symptoms have developed.

Left main coronary artery compression in pulmonary hypertension

Extrinsic compression of the left main coronary artery (LMCA) by a dilated pulmonary artery (PA) in the setting of pulmonary arterial hypertension (PAH) is an increasingly recognized disease entity. LMCA compression has been associated with angina, arrhythmia, heart failure, and sudden cardiac death in patients with PAH. Recent studies suggest that at least 6% of patients with PAH have significant LMCA compression. Screening for LMCA compression can be achieved with computed coronary tomography angiography, with a particular emphasis on assessment of PA size and any associated downward displacement and reduced takeoff angle of the LMCA. Indeed, evidence of a dilated PA (>40 mm), a reduced LMCA takeoff angle (<60°), and/or LMCA stenosis on CCTA imaging should prompt further diagnostic evaluation. Coronary angiography in conjunction with intravascular imaging has proven effective in diagnosing LMCA compression and guiding subsequent treatment. While optimal medical therapy and surgical correction remain in the clinician's arsenal, percutaneous coronary intervention has emerged as an effective treatment for LMCA compression. Given the prevalence of LMCA compression, its associated morbidity, and mortality, and the wide array of successful treatment strategies, maintaining a high degree of suspicion for this condition, and understanding the potential treatment strategies is critical.

Hybrid approach for treating patient with chronic thromboembolic pulmonary hypertension and extrinsic compression of left main coronary artery

Background ― Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare life-threatening form of pulmonary artery hypertension. CTEPH is potentially curable by performing surgical operation – pulmonary thrombendarteriectomy. Unfortunately, about 36% of patients with CTEPH are considered as inoperable because of different conditions including left main coronary artery compression syndrome (LMCS), caused by compression with delated pulmonary artery. Appropriate management of patients with CTEPH and LMCS remains unknown. Case report ― We report for the first time a case of a successful hybrid treatment of patient with CTEPH and LMCS. Due to high pulmonary vascular resistance (PVR) and LMCS (90% stenosis) the risk for pulmonary thrombendarteriectomy for patient was considered as high. The multidisciplinary team decided to start treatment with new method of treatment for patients with CTEPH – balloon pulmonary angioplasty. In 5 months 4 sessions of balloon pulmonary angioplasty were successfully performed. In a follow-up mean pulmonary artery pressure decreased from 57 to 37 mm Hg, PVR decreased from 20 to 7 WU. Coronary angiography showed no compression of left main coronary artery. The diameter of pulmonary artery decreased from 4.2 to 3.6 cm. Patient was reconsidered as operable and transferred to a surgical unit for pulmonary thrombendarteriectomy. Conclusion ― Effective balloon pulmonary angioplasty can lead to regression of left main compression syndrome in CTEPH patients. Balloon pulmonary angioplasty can be a “bridge-treatment” to pulmonary thrombendarteriectomy in patients with high operation risk.

Atrial septal defect causing angina

Left coronary artery compression syndrome is characterized by compression of the left main coronary artery between the aorta and an enlarged main pulmonary artery. A 39-year-old woman presented with angina with dyspnea on exertion for two years. Detailed investigations revealed an atrial septal defect, valvular lesions, and severe pulmonary hypertension with left main coronary artery compression. Patch closure of the atrial septal defect, left coronary artery bypass, and valve repair was carried out. The patient recovered well and was asymptomatic on follow-up. The optimal management of such patients is yet to be clarified.

Severe Compression of the Left Main Coronary Artery in a Patient with Chronic Thromboembolic Pulmonary Hypertension

Extrinsic compression of the left main coronary artery (LMCA) can occur in patients with an enlarged pulmonary artery trunk secondary to severe pulmonary hypertension (PH). This phenomenon rarely occurs in PH; moreover, few reports have shown that chronic thromboembolic PH can be a triggering factor for this syndrome. Herein, we describe a patient with extrinsic compression of the LMCA with chronic thromboembolic PH who underwent pulmonary endarterectomy and coronary artery bypass grafting successfully. Intravenous ultrasonography (IVUS) was effective for detecting and assessing the compression.

Percutaneous Coronary Intervention for a Patient with Left Main Coronary Compression Syndrome

Left main coronary compression syndrome rarely occurs in patients with severe pulmonary hypertension. A 65-year-old woman with severe pulmonary hypertension due to an atrial septal defect suffered from angina on effort. Cardiac computed-tomography and coronary angiography revealed considerable stenosis of the left main coronary artery (LMA) caused by compression between the dilated main pulmonary artery trunk and the sinus of valsalva. Stenting of the LMA under intravascular ultrasound imaging was effective for the treatment of angina. We herein report the diagnosis and management of this condition with a brief literature review.

Complications of pulmonary hypertension: a pictorial review

Pulmonary hypertension (PH) is a rare disease with a significant morbidity and mortality if untreated. The disease has a multifactorial aetiology and is often associated with insidious onset of signs and symptoms. Multimodality imaging is often required for establishing the diagnosis, evaluating the underlying haemodynamic compromise and follow-up after institution of therapy. The range of potential complications associated with PH vary widely. We aimed to summarize the imaging findings of complications that the radiologist should be familiar with.

Association of CYP2C19 variants and epoxyeicosatrienoic acids on patients with microvascular angina

Categorization as a cytochrome P450 (CYP) 2C19 poor metabolizer (PM) is reported to be an independent risk factor for cardiovascular disease. Epoxyeicosatrienoic acids (EETs) are metabolites of arachidonic acid by CYP2C19 epoxygenases and anti-inflammatory properties, especially in microvascular tissues. We examined the association of CYP2C19 polymorphisms and EETs on microvascular angina (MVA) caused by coronary microvascular dysfunction. We examined CYP2C19 genotypes in patients with MVA ( n = 71) and healthy subjects as control ( n = 71). MVA was defined as the absence of coronary artery stenosis and epicardial spasms and the presence of inversion of lactic acid levels between intracoronary and coronary sinuses in acetylcholine-provocation test or the adenosine-triphosphate-induced coronary flow reserve ratio was below 2.5. CYP2C19 PM have two loss-of-functon alleles (*2, *3). We measured serum dihydroxyeicosatrienoic acid (DHET) as representative EET metabolite. MVA group showed significantly higher CYP2C19 PM incidence (35% vs. 16%; P = 0.007) and high sense C-reactive protein (hs-CRP) levels (0.127 ± 0.142 vs. 0.086 ± 0.097 mg/dl; P = 0.043) than those of controls. Moreover, in MVA group, hs-CRP levels in CYP2C19 PM were significantly higher than that of non-PM (0.180 ± 0.107 vs. 0.106 ± 0.149 mg/dl, P = 0.045). Multivariate analysis indicated that smoking, hypertension, high hs-CRP, and CYP2C19 PM are predictive factors for MVA. In MVA group, DHET levels for CYP2C19 PM were significantly lower than that of non-PM [10.9 ± 1.64 vs. 14.2 ± 5.39 ng/ml, P = 0.019 (11,12-DHET); 15.2 ± 4.39 vs. 17.9 ± 4.73 ng/ml, P = 0.025 (14,15-DHET)]. CYP2C19 variants are associated with MVA. The decline of EET-based defensive mechanisms owing to CYP2C19 variants may affect coronary microvascular dysfunction.

Cardiac Dual-source Computed Tomography for the Detection of Left Main Compression Syndrome in Patients with Pulmonary Hyper-tension

INTRODUCTION

Left Main Compression Syndrome (LMCS) represents an entity described as the extrinsic compression of the left main coronary artery (LMCA) by a dilated pulmonary artery (PA) trunk. We examined the presence of LMCS in patients with pulmonary hypertension (PH) using dual-source computed tomography (DSCT), as a non-invasive diagnostic tool.

METHODS

The following parameters were measured: PA trunk diameter (PAD), the distance between PAD and LMCA (LMPA) and the distance between PA and aorta (AoPA). These measurements were related with demographic, echocardiographic, hemodynamic and clinical parameters. Angiography was performed in two patients with LMCS suspected by cardiac computed tomographic angiography. Patients without PH but with angina were examined as controls, using DSCT cardiac angiography to assess the same measurements and to detect the prevalence of coronary artery disease.

RESULTS

PA diameter value over 40.00 mm has been associated with PH and LMCS. Furthermore, LMCS did not occur at a distance smaller than 0.50 mm between the PA and the LMCA, and did not correlate with the distance between the PA and the aorta or with cardiac index and NT-proBNP.

CONCLUSION

DSCT may represent the initial testing modality in PH patients with dilated PA trunk to exclude LMCS. A periodical rule-out of this rare entity, as assessed by DSCT, in patients with a severely dilated PA seems to be mandatory for PH patients contributing to survival improvement.

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.

Left main bronchus compression due to main pulmonary artery dilatation in pulmonary hypertension: two case reports

Pulmonary arterial dilatation associated with pulmonary hypertension may result in significant compression of local structures. Left main coronary artery and left recurrent laryngeal nerve compression have been described. Tracheobronchial compression from pulmonary arterial dilatation is rare in adults, and there are no reports in the literature of its occurrence in idiopathic pulmonary arterial hypertension. Compression in infants with congenital heart disease has been well described. We report 2 cases of tracheobronchial compression: first, an adult patient with idiopathic pulmonary arterial hypertension who presents with symptomatic left main bronchus compression, and second, an adult patient with Eisenmenger ventricular septal defect and right-sided aortic arch, with progressive intermedius and right middle lobe bronchi compression in association with enlarged pulmonary arteries.

[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.

Two rare conditions in an Eisenmenger patient: left main coronary artery compression and Ortner's syndrome due to pulmonary artery dilatation

The left-main coronary artery extrinsic compression due to enlarged pulmonary artery has been described in several case series. Ortner's syndrome is also a rare condition in some cardiovascular disorders. There have been no reports about these two rare conditions in the same patient. Hence, we report a very rare case of an Eisenmenger patient with severe pulmonary hypertension and dilated pulmonary artery which has compressed the left main coronary artery, severely narrowing it, and the left laryngeal recurrent nerve with subsequent Ortner's syndrome and brief literature review.

Left main coronary atresia in a child with absent pulmonary valve syndrome: early entrapment of an innocent bystander

Atresia of the left main coronary artery is a rare anomaly that, if left untreated, has an unfavorable outcome. We hereby report left main coronary artery atresia in a child with tetralogy of Fallot with absent pulmonary valve and discuss the possible developmental basis of the association.

Left main coronary artery stenosis secondary to severe pulmonary artery dilation

A 45-year-old lady with dyspnea and occasional precordial chest pain was diagnosed with a huge sinus venosus atrial septal defect and partial anomalous pulmonary venous return. Preoperative coronary angiography disclosed severe main stem stenosis, considered secondary to compression by the dilated pulmonary trunk. Atrial septal defect closure and pulmonary artery reduction plasty were performed. The left main coronary artery appeared completely patent. The postoperative course was uneventful, and the patient was asymptomatic on follow-up.

Extrinsic Compression of the Left Main Coronary Artery: A Case of Atrial Septal Defect with Enlarged Pulmonary Artery

We report the case of an adult referred to our center with an initial diagnosis of stenosis of the left main coronary artery (LMCA). A preoperative investigation disclosed an atrial septal defect (ASD) with pulmonary artery hypertension. The angiographic studies confirmed the diagnosis and showed external compression of the LMCA by an enlarged pulmonary artery. Surgical closure of the ASD and tricuspid valve ring annuloplasty with coronary artery bypass surgery (left internal mammary artery to left anterior descending artery) were undertaken. Six months after the surgery, the patient is doing well.

A case of acute coronary syndrome caused by extrinsic compression of the left main coronary artery due to pulmonary hypertension

Stenosis of the left main coronary artery (LMCA) due to extrinsic compression, producing symptoms of myocardial ischemia, is called left main compression syndrome. We report on a 43-year-old male with acute coronary syndrome who developed left main compression syndrome while waiting for a lung transplantation secondary to interstitial pneumonia, but underwent successful LMCA stenting as emergent treatment. Coronary angiography 3 months after the operation showed good stent patency in the LMCA, and the clinical course was favorable.

Endovascular therapy for left main compression syndrome. Case report and literature review

Extrinsic compression of the left main coronary artery (LMCA) can occur in patients with severe pulmonary hypertension and enlarged pulmonary artery trunk. It has been usually described in the setting of congenital defects such as atrial septal defect, ventricular septal defect, and, more rarely, isolated persistent ductus arteriosus. Functional and structural evaluation of such patients can currently be performed noninvasively with the use of cardiac CT scanning and/or MRI. The optimal management of symptomatic patients remains unknown. We report a case of extrinsic compression of the LMCA in a symptomatic patient with Eisenmenger syndrome who underwent unprotected LMCA stent implantation. We also performed a literature review of the reported cases concerning patients treated with LMCA stent implantation for the management of this condition.

Angina associated with left main coronary artery compression in pulmonary hypertension

Chest pain is a common complaint in patients with pulmonary arterial hypertension (PAH). Left main coronary artery (LMCA) compression by an enlarged pulmonary artery trunk (PAT) has been associated with angina, but appropriate diagnostic and treatment approaches remain poorly defined. We present two cases of angina caused by LMCA compression from an enlarged pulmonary artery, one of which also presented with new, severe left ventricular systolic dysfunction attributed to myocardial ischemia. Diagnosis of LMCA stenosis was made via coronary angiography followed by computed tomography-gated coronary angiography (CT-CA), which confirmed pulmonary artery enlargement as the source of extrinsic compression. Restoring LMCA patency with percutaneous intervention and/or aggressive treatment of pulmonary hypertension led to significant improvement in angina, cardiac function and quality of life. Given the negative impact on cardiac function, prompt diagnosis and treatment of extrinsic LMCA compression should be considered a priority.

Left main coronary artery and aortic root compression associated with atrial septal defect and pulmonary hypertension

The extrinsic compression of left main coronary artery (LMCA) by dilated pulmonary artery is rarely reported. Various congenital and acquired diseases were shown to cause extrinsic LMCA compression. Here we present a child with aortic root and LMCA compression due to dilated pulmonary trunk and causing angina like chest pain. The patient had also electrocardiographic evidence of myocardial ischemia. This case report will be a guide for the evaluation and surgical treatment of the patients with pulmonary hypertension and LMCA compression.

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.

Stenting to reverse left ventricular ischemia due to left main coronary artery compression in primary pulmonary hypertension

Angina is a common symptom of severe pulmonary hypertension. Although many theories for the source of this pain have been proposed, right ventricular ischemia is the one most commonly accepted as the cause. We report on two patients with primary pulmonary hypertension who had angina with normal activity or on provocation. One patient had severe left ventricular dysfunction. Both were found to have severe ostial stenosis of the left main coronary artery as a result of compression from a dilated pulmonary artery. Both patients underwent stenting of the left main coronary artery with excellent angiographic results, and complete resolution of the signs and symptoms of angina and left ventricular ischemia. Left ventricular ischemia due to compression of the left main coronary artery may be a much more common mechanism of angina and left ventricular dysfunction in patients with pulmonary hypertension than previously acknowledged. Stenting of the coronary artery can be done safely with the resolution of these symptoms.

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.

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.

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.