Left Main Coronary Artery Extrinsic Compression in Patients With Pulmonary Arterial Hypertension

Saia, Francesco; Dall’Ara, Gianni; Marzocchi, Antonío; Dardi, Fabio; Palazzini, Massimiliano; Manes, Alessandra; Taglieri, Nevio; Marrozzini, Cinzia; Rinaldi, Andrea; Galiè, Nazzareno

doi:10.1016/j.jcin.2018.08.002

Cited by 12 publications

(24 citation statements)

References 3 publications

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“…This cohort was followed-up over a mean of 4.5 years, and during that time survival was similar compared with a matched population with PAH and angina who did not have extrinsic compression of the LMCA. 5 A second-generation drug-eluting stent was used most often, on the basis of its superior radial strength and low restenosis rate. Because of the absence of atherosclerosis, Galie et al concluded that neither…”

Section: Discussionmentioning

confidence: 99%

“…Because stent positioning can be more challenging without atherosclerosis, they also suggested a Judkins left guide catheter and suggested avoiding very short stents. 5 Surgical approaches such as PA aneurysm repair have been described, but the perioperative risk in patients with PAH is high. 6 Because of the high likelihood of success with PCI, it is a reasonable first therapeutic option for extrinsic compression of the LMCA by an enlarged PA.…”

Section: Novel Teaching Pointsmentioning

confidence: 99%

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Left Main Coronary Artery Compression in Pulmonary Arterial Hypertension: Percutaneous Treatment to Improve Symptoms

et al. 2021

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A 51-year-old woman with pulmonary arterial hypertension presented with progressive chest pain and dyspnea. Computed tomography imaging showed significant enlargement of her main pulmonary artery (PA) and was suggestive of left main coronary artery (LMCA) compression by the PA. The patient underwent percutaneous coronary intervention, which confirmed the diagnosis and a stent was deployed to the LMCA. Three months after the procedure the patient has near resolution of her symptoms. LMCA compression by an enlarged PA is an important cause of chest pain in patients with pulmonary arterial hypertension and can be managed safely and effectively with percutaneous coronary intervention and stenting.

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Section: Discussionmentioning

confidence: 99%

Section: Novel Teaching Pointsmentioning

confidence: 99%

Left Main Coronary Artery Compression in Pulmonary Arterial Hypertension: Percutaneous Treatment to Improve Symptoms

et al. 2021

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“…39 PCI avoids the risk of cardiopulmonary bypass, and the typical ostial location of the stenosis and the lack of significant atherosclerosis makes it a relatively low-risk procedure, a finding that has been borne out in both short-and intermediate-term followup. 4,5,33,40,41 Indeed, PCI is not only technically feasible (Figure 4), but it is often performed with a single stent and is associated with low rates of residual angina and restenosis (Table 1). 4,35,40 In fact, in one recent prospective study, the majority of patients who underwent PCI in the setting of LMCA compression achieved sustained resolution of angina.…”

Section: Invasive Managementmentioning

confidence: 99%

“…4,5,33,40,41 Indeed, PCI is not only technically feasible (Figure 4), but it is often performed with a single stent and is associated with low rates of residual angina and restenosis (Table 1). 4,35,40 In fact, in one recent prospective study, the majority of patients who underwent PCI in the setting of LMCA compression achieved sustained resolution of angina. 4 All patients tolerated PCI and both short-and long-term follow-up, up to 5 years, has demonstrated promising and safe results.…”

Section: Invasive Managementmentioning

confidence: 99%

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Left main coronary artery compression in pulmonary hypertension

Labin

Saggar

Yang

et al. 2020

Cathet Cardio Intervent

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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.

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Clinical relevance of adding intravascular ultrasound to coronary angiography for the diagnosis of extrinsic left main coronary artery compression by a pulmonary artery aneurysm in pulmonary hypertension

Martín

Cabezas

Huertas

et al. 2020

Catheter Cardiovasc Interv

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Objectives We sought to assess the clinical value of adding intravascular ultrasound (IVUS) evaluation to coronary angiography (CA) to guide extrinsic left main coronary artery (LMCA) compression diagnosis and treatment in pulmonary hypertension (PH). Background LMCA compression due to a pulmonary artery aneurysm (PAA) is a severe complication of PH. Although guidelines encourage the use of IVUS for LMCA disease evaluation, it has hardly been used in this scenario. Methods We analyzed morbimortality of type 1 and 4 PH patients with clinically suspected LMCA compression by a PAA between 2010 and 2018 in a reference unit. LMCA compression was prospectively assessed with CA ± IVUS. Angiographic‐LMCA compression was considered conclusive when LMCA stenosis>50% was present in four predetermined projections; inconclusive, when LMCA stenosis>50% was present in <4 projections and negative if no stenosis>50% was present. Patients with conclusive and inconclusive CA underwent IVUS. IVUS‐LMCA compression was defined as systolic minimum lumen area < 6 mm2. Results LMCA compression was suspected in 23/796 patients (3%). CA was conclusive for compression in 7(30.5%), inconclusive in 9(39%), and negative in 7(30.5%). IVUS confirmed LMCA compression in 6/7(86%) patients with conclusive CA and in 2/9(22%) with inconclusive CA. Patients fulfilling IVUS criteria for LMCA compression underwent stent implantation. At 20 months follow‐up a composite end‐point of death, stent restenosis/thrombosis, or lung transplant was reported in three patients (13%). Conclusions CA can misdiagnose LMCA extrinsic compression. IVUS discriminates better whether significant compression by a PAA exists or not, avoiding unnecessary LMCA stenting. Patients treated following this strategy show a low rate of major clinical events at 20 months follow‐up.

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Left Main Coronary Artery Extrinsic Compression in Patients With Pulmonary Arterial Hypertension

Cited by 12 publications

References 3 publications

Left Main Coronary Artery Compression in Pulmonary Arterial Hypertension: Percutaneous Treatment to Improve Symptoms

Left Main Coronary Artery Compression in Pulmonary Arterial Hypertension: Percutaneous Treatment to Improve Symptoms

Left main coronary artery compression in pulmonary hypertension

Clinical relevance of adding intravascular ultrasound to coronary angiography for the diagnosis of extrinsic left main coronary artery compression by a pulmonary artery aneurysm in pulmonary hypertension

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