Chest
Volume 120, Issue 4, October 2001, Pages 1412-1415
Journal home page for Chest

Selected Reports
Stenting To Reverse Left Ventricular Ischemia Due To Left Main Coronary Artery Compression in Primary Pulmonary Hypertension

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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.

Section snippets

Case 1

A 71-year-old woman was referred for management. She had a history of PPH, which had been diagnosed 12 years prior and had been treated conservatively. Although her major symptom had been dyspnea with effort, which had slowly progressed, she recently had presented with a syncopal episode and frequent chest discomfort that radiated down her right arm. The description of the chest discomfort was characteristic of angina, coming on more frequently and responsive to sublingual nitroglycerin. A

Discussion

Angina is a well-documented common symptom associated with severe pulmonary hypertension. Although the mechanism has been debated, there have been studies demonstrating right ventricular ischemia in the absence of coronary artery disease. The basis appears to be, in part, a reduction in the coronary driving pressure of the right ventricle.5 There are no studies implicating left ventricular ischemia in these patients, and because they are usually young, atherosclerotic coronary artery disease is

Conclusion

Left main coronary artery compression is a treatable cause of angina and LV ischemia in patients with PPH. We recommend that coronary angiography be performed on patients with severe pulmonary hypertension who present with effort angina or left ventricular dysfunction. As pulmonary hypertension progresses and is associated with a reduction in systemic BP, the left ventricular ischemia would predictably worsen over time and likely would be refractory to all medical treatments. In addition,

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