Compression of the Left Main Coronary Artery by a Giant Pulmonary Artery Aneurysm

Abstract

W e present a 70-year--old man who had a past medical history of dilated idiopathic pulmonary artery, incidentally diagnosed at the age of 23 years. He was asymptomatic until a year ago when he was admitted for an episode of anginal chest pain in the context of paroxysmal atrial fibrillation. At rapid rates, he showed pathological ST segment descent. A coronary angiography showed a slight stenosis of the left main coronary artery (LMCA). At that time, the mean pulmonary artery pressure was 36 mm Hg. After recovering sinus rhythm, the patient became asymptomatic and was discharged with β-blockers.A year later, the patient was admitted with resting angina. The echocardiogram ( Figure A) and the computed tomography-angio showed that the aneurysm had increased to 80 mm and compressed the LMCA (Figure B). This finding was confirmed on coronary angiography and intravascular ultrasound that showed a critical stenosis of LMCA ( Figure C, insert 1, and online-only Data Supplement Movie I) and normal luminal diameter of anterior descending artery ( Figure C, insert 2). In addition, the mean pulmonary artery pressure had increased >60 mm Hg.Because of the high surgical risk posed aneurysm surgery, percutaneous revascularization of LMCA with drug-eluting stent was performed with good final result ( Figure D, insert 1, and online-only Data Supplement Movie II). We also initiated specific treatment of pulmonary hypertension (PH) with phosphodiesterase-5 inhibitors and an endothelin receptor antagonist. The patient became asymptomatic and was discharged to reevaluate the surgical indication of aneurysm according to the clinical and PH evolution in the follow-up. One year later, the patient is asymptomatic with no adverse events.Extrinsic compressions of LMCA by a pulmonary artery aneurysm are extremely rare and usually associated with PH. Only case reports and small series have described this entity as a cause of angina and sudden death, and, currently, the appropriate management of these patients remains unknown.

Percutaneous Coronary Intervention for Left Main Compression Syndrome due to Severe Idiopathic Pulmonary Arterial Hypertension: One Year Follow-up Using Intravascular Imaging

“…Due to the high rate of surgical mortality among patients with PH, LMCA stenting is usually favored for revascularization strategy (6). Recently, several papers have described the use of LMCA stenting in patients with LMCA compression induced by a dilated PA, with excellent early post-procedural and short-term outcomes (1,7,8). However, there are few reports regarding the application of intravascular imaging for follow-up and the detailed medical conditioning of PH after the procedure.…”

Left main coronary artery compression due to pulmonary artery aneurysm: Three-year clinical and angiographic follow-up after stenting

“…Due to the fact that the pulmonary artery aneurysm usually compress the ostium and proximal segment of the LMCA, and because of the slightly elevated perioperative risk of patients with PAH, [5] PCI with stent implantation in the LMCA is often considered the strategy of choice. [3,6] The type of coronary stent to be implanted is another matter of controversy, once the PAH evolution might be unpredictable and its etiology may vary.…”

“…Most reports of similar cases present up to 12-month clinical follow-up. [5,6,14] In today's clinical and interventional practice, LMCA PCI is feasible and has been proven safe, especially in situations of elevated clinical risk and/or favorable angiographic characteristics and low anatomic complexity.…”

Angina in left main coronary artery occlusion by pulmonary artery aneurysm

“…Moreover, in this setting, coronary artery bypass grafting was high-risk because of the severe right ventricular disfunction and disappointing results reported in literature. 7 Therefore, we started an antihypertensive therapy. At the 1-year follow-up, the patient reported a significant improvement in terms of angina, and a stress test did not show any difference compared to the previous result, suggesting that the angina was not exclusively attributable to myocardial ischemia.…”