Challenging differential diagnosis, Unusual setting of medical care, Educational Purpose (only if useful for a systematic review or synthesis), Rare co-existance of disease or pathology
Luciana F. Seabra, Henrique B. Ribeiro, Pedro Gabriel Melo de Barros e Silva, Marcelo J. Rodrigues, André G. Spadaro, Fábio Conejo, Roger R. Godinho, Sandro M. M. Faig, Thiago Andrade de Macedo, Luciana de P. S. Baptista, Marcos Valerio C. de Resende, Valter Furlan, Expedito E. Ribeiro
Department of Cardiology, Hospital Totalcor, São Paulo, SP, Brazil
Am J Case Rep 2015; 16:899-903
Available online: 2015-12-23
Pulmonary artery dilatation is a common feature among patients with severe pulmonary hypertension. Left main coronary artery extrinsic compression by an enlarged pulmonary artery is a rare complication and a potential cause for chest pain and sudden cardiac death in patients with pulmonary hypertension. This situation is very rare and few reports have described it. Currently, the appropriate management of these patients remains unknown.
CASE REPORT: In the present report we describe the case of a 39-year-old woman who presented with a 2-year history of cardiac symptoms related to exercise. The patient underwent a 64-slice multidetector computed tomography (MDCT) coronary angiography, which showed left main coronary artery (LMCA) compression by a markedly enlarged pulmonary artery trunk (44 mm), without intraluminal stenosis or coronary artery calcium, as determined by the Agatston score. This compression was considered to be the cause of the cardiac symptoms. To confirm and plan the treatment, the patient underwent cardiac catheterization that confirmed the diagnosis of pulmonary hypertension and LMCA critical obstruction. Taking into account the paucity of information regarding the best management in these cases, the treatment decision was shared among a “heart team” that chose percutaneous coronary intervention with stent placement. An intra-vascular ultrasound was performed during the procedure, which showed a dynamic compression of the left main coronary artery. The intervention was successfully executed without any adverse events.
CONCLUSIONS: This case illustrates dynamic compression of the LMCA by IVUS, visually demonstrating the mechanism of the intermittent symptoms of myocardial ischemia in this kind of patient. It also shows that percutaneous stenting technique may be an appropriate treatment for this unusual situation.
Keywords: Coronary Angiography, Adult, Coronary Occlusion - ultrasonography, Follow-Up Studies, Hypertension, Pulmonary - ultrasonography, multidetector computed tomography, Pulmonary Artery - ultrasonography, Ultrasonography, Interventional - methods