Case Report
Acute coronary syndrome due to extrinsic compression of the left main coronary artery in a patient with severe pulmonary hypertension: successful treatment with percutaneous coronary intervention

https://doi.org/10.1016/j.carrev.2007.07.003Get rights and content

Abstract

A patient with severe pulmonary (arterial) hypertension (PH) presented with a non-ST segment elevation myocardial infarction and recurrent angina at rest. Coronary angiography showed severe ostial left main coronary artery (LMCA) stenosis; coronary arteries were otherwise normal. Intravascular ultrasonography (IVUS) showed deformation of the LMCA due to extrinsic compression from a markedly dilated main pulmonary artery, which was confirmed by cardiac computed tomography. The LMCA was successfully stented using a paclitaxel-eluting stent resulting in complete resolution of angina. Extrinsic compression of the LMCA should be considered in patients with severe PH and angina; IVUS may aid in the diagnosis. Percutaneous stent implantation may be the preferred treatment in this high-risk group of patients.

Introduction

Extrinsic compression of the left main coronary artery (LMCA) was first reported by Corday et al. [1] in 1957. Several similar cases have been reported since [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]. The most common cause of LMCA compression is an enlarged pulmonary arterial trunk, but other causes include thoracic outlet syndrome and extrinsic encasement from either neoplastic or inflammatory processes [12]. Individuals with long-standing severe pulmonary (arterial) hypertension (PH) from either idiopathic causes or congenital heart disease (CHD) often have a markedly dilated main pulmonary artery (PA). Given the anatomical juxtaposition of the main PA and the origin of the LMCA, massive PA enlargement can result in extrinsic compression of the LMCA and lead to myocardial ischemia, infarction, or sudden cardiac death. This case report describes a patient with severe PH who presented with severe angina and non-ST elevation acute myocardial infarction due to extrinsic compression of the LMCA from a dilated PA. Symptoms resolved after LMCA stenting.

Section snippets

Case report

A 53-year-old woman was hospitalized for unstable angina. She had chronic hepatitis C and a history of cocaine and amphetamine abuse. A transthoracic echocardiogram revealed a dilated and hypertrophied RV with moderately depressed (ejection fraction ∼35%) RV systolic function, moderate tricuspid regurgitation, and an estimated RV systolic pressure of 80 mmHg. The left ventricular systolic function was normal.

Because of refractory angina, she was referred for diagnostic coronary angiography and

Discussion

Our case illustrates that (a) LMCA compression from an enlarged PA should be considered in patients with PH and angina, (b) the diagnosis of LMCA compression can be suspected by cardiac CT and confirmed by coronary angiography and IVUS, and (c) PCI may be the preferred treatment option for such patients.

Angina is frequently reported among subjects with PH [13]. Debate exists as to the etiology of angina in these individuals, with some investigators suggesting that it is due to distension of the

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  • Cited by (0)

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