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usually best visualized in 45 degree left anterior oblique view with a 30 degree cranial angulation. In this syndrome, the LMCA appears to be inferiorly displaced ...
Extrinsic Compression of Left Main Coronary Artery by the Pulmonary Trunk Secondary to Pulmonary Hypertension Documented Using 64-Slice Multidetector Computed Tomography Coronary Angiography

Address for correspondence: Mohammad Reza Movahed, MD PhD, FACP, FACC, FSCAI University of Arizona Sarver Heart Center and the Southern Arizona VA Health Care System Department of Medicine Division of Cardiology 1501 North Campbell Ave. Tucson, AZ 85724 [email protected]

Morteza Safi, MD, Vahid Eslami, MD, Abbas Arjmand Shabestari, MD, Habib Saadat, MD, Mohammad Hasan Namazi MD, Hosein Vakili, MD, Mohammad Reza Movahed, MD Cardiology Department (Safi, Eslami, Saadat, Namazi, Vakili) Shahid Beheshti University of Medical Sciences, Tehran, Iran; Radiology Department (Shabestari) Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Cardiology, University of Arizona School of Medicine, Sarver Heart Center and the Southern Arizona VA Health Care System (Movahed), Tucson, Arizona

Compression of left main coronary artery (LMCA) secondary to pulmonary trunk dilatation is a newly recognized entity that has been associated with severe pulmonary hypertension. In this paper we present a case of extrinsic compression of LMCA caused by dilated pulmonary trunk secondary to pulmonary hypertension documented using 64-slice multidetector computed tomography (MDCT) coronary angiography. This case is followed by a review of the literature.

Introduction The extrinsic compression of left main coronary artery (LMCA) secondary to pulmonary artery trunk dilatation is a relatively newly described syndrome that has been associated with severe pulmonary hypertension. It is primarily related to congenital heart disease or idiopathic pulmonary hypertension1 – 6 but other causes of pulmonary hypertension can be the triggering factor for this syndrome. The following case is an example of extrinsic LMCA compression caused by secondary pulmonary hypertension related to chronic sarcoidosis and pulmonary embolism.

The patient underwent 64-slice multidetector computed tomography (MDCT) coronary angiography for further evaluation of the LMCA stenosis and right atrial mass. The right atrial mass can be seen in Figure 3 which is suggestive of right atrial thrombus. Extrinsic compression of the LMCA by dilated pulmonary arterial trunk without intraluminal stenosis was documented by MDCT angiography (Figure 4 and Figure 5). Furthermore, multiple emboli were found in the pulmonary arteries (Figure 6). The patient underwent successful removal of the right atrial mass which was confirmed to be a large intraatrial thrombus.

Case report A 64-year-old female with a ten year history of biopsy-proven sarcoidosis was admitted with increasing dyspnea. Her echocardiography revealed a large mobile mass (3.5×2.6 cm) occupying her large right atrium (6.4 cm) and severe pulmonary arterial hypertension with estimated systolic pulmonary arterial pressure of 90 mm Hg. She was referred for urgent cardiac surgery for removal of the right atrial mass. Coronary angiography prior to cardiac surgery showed a high grade ostial LMCA stenosis (Figure 1 and Figure 2). Myocardial perfusion scan with technetium 99 sestamibi did not show any regional ischemia.

Discussion The cause of ostial LMCA stenosis needs to be evaluated in a patient with long standing severe pulmonary hypertension for possible extrinsic compression of the LMCA secondary to dilated pulmonary arterial trunk. This compression is usually best visualized in 45 degree left anterior oblique view with a 30 degree cranial angulation. In this syndrome, the LMCA appears to be inferiorly displaced in close contact with the left coronary cusp. In comparison to a control group, the mean angle between coronary cusp and LMCA was 23±13 in these patients vs 70±15 in the control group6 . The functional and prognostic significant of extrinsic left main coronary compression is not known.7 Malignant

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Clin. Cardiol. 32, 8, 426–428 (2009) Published online in Wiley InterScience. (www.interscience.wiley.com) DOI:10.1002/clc.20457  2009 Wiley Periodicals, Inc.

Received: June 6, 2008 Accepted with revision: July 24, 2008

management with nifedipine and nitrates, and died from cardiogenic shock 2 days after presentation. Other reports have not demonstrated significant ischemia in patients similar to our patient with pulmonary hypertension and LMCA compression.2 – 10 Based on the published literature, the optimal management of LMCA compression in patients with pulmonary hypertension is not known. Successful treatment of LMCA compression during surgical correction

Figure 1. Coronary angiography shows ostial stenosis of the left main coronary artery seen RAO with cranial angulation. Abbreviation: RAO, right anterior oblique.

Figure 3. Axial CT—angiographic view revealing a filling defect (arrow) in the right atrial luminal space, implying a thrombus. Abbreviation: CT, computed tomography.

Figure 2. Ostial left main stenosis can be seen again in the LAO view with cranial angulations. Abbreviation: LAO, left anterior oblique.

arrhythmia and left ventricular dysfunction caused by LMCA compression may contribute to a higher incidence of sudden death in patients with pulmonary hypertension.8,9 In one report, a patient with extrinsic LMCA compression suffered from a non-Q wave myocardial infarction,1 despite

Figure 4. Reconstructed coronal maximum intensity projection view of coronary MDCT angiography showing an enlarged pulmonary artery trunk (curved arrow) displaying the left main coronary artery resulting in remarkable compressive narrowing of its ostium (arrowhead). Abbreviation: MDCT, multidetector computed tomography. Clin. Cardiol. 32, 8, 426–428 (2009) M. Safi et al: Left main compression by pulmonary trunk Published online in Wiley InterScience. (www.interscience.wiley.com) DOI:10.1002/clc.20457  2009 Wiley Periodicals, Inc.

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In our patient, massive pulmonary embolism was thought to be originating from deep vein thrombosis and the right atrial thrombus seen on the CT scan. Due to the lack of significant ischemia based on the perfusion scan and in order to reduce long cardiopulmonary bypass time, coronary artery bypass surgery was not performed. Furthermore, it was thought that removal of multiple pulmonary emboli may reduce pulmonary arterial pressure, the size of pulmonary trunk and the left main coronary artery compression in the long run. However, as we discussed earlier, the definite management of this entity is not known. It would have been reasonable to perform coronary bypass surgery at the time of embolectomy. At this time, treatment of these patients needs to be individualized until additional data about optimal management are available.

References 1. Figure 5. Volume rendered image of coronary MDCT angiography demonstrating compressive effect of enlarged pulmonary artery trunk leading to left main coronary artery narrowing. Abbreviation: MDCT, multidetector computed tomography.

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Figure 6. Axial CT angiographic view demonstrating a filling defect in the right pulmonary artery consistent with pulmonary embolism (arrow). Abbreviation: CT, computed tomography.

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of ASD,2 as well as LMCA stenting,11 has been reported. There are few reports describing successful coronary bypass surgery during pulmonary thromboendarterectomy12 or lung transplantation13 in such patients. For risk assessment, some authors advocate intravascular ultrasound or fractional flow reserve studies in order to assess the degree of stenosis before performing any revascularization.9

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Clin. Cardiol. 32, 8, 426–428 (2009) M. Safi et al: Left main compression by pulmonary trunk Published online in Wiley InterScience. (www.interscience.wiley.com) DOI:10.1002/clc.20457  2009 Wiley Periodicals, Inc.

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