European Heart Journal Advance Access originally published online on August 16, 2006
European Heart Journal 2007 28(2):165; doi:10.1093/eurheartj/ehl194
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Stenting of the left main coronary artery stenosis due to extrinsic compression
1 Department of Cardiology, ‘Prof. Dr C.C. Iliescu’ Institute of Cardiovascular Diseases, Bucharest, Romania
2 Department of Interventional Cardiology, ‘Prof. Dr C.C. Iliescu’ Institute of Cardiovascular Diseases, Bucharest, Romania
* Corresponing author. Tel: +40 747043631; fax: +40 213175227. E-mail address: marinelaserban{at}yahoo.com
A 46-year-old woman was referred to the Cardiology Department with a history of dyspnoea, fatigue (NYHA class III), and angina on mild exertion. At the age of 14, she was operated for isolated pulmonary stenosis; 26 years after surgery, she was diagnosed with pulmonary regurgitation and pulmonary trunk dilatation.
On admission, the physical examination revealed a diastolic thrill and diastolic and systolic pulmonary murmurs. Electrocardiogram showed sinus rhytm, QRS axis at 70°, right atrial abnormality, right ventricular hypertrophy, and right bundle branch block. The chest X-ray (Panel A) revealed an enlarged cardiac silhouette involving the right chambers, the dilatation of the main pulmonary trunk, and the right main pulmonary artery.
A transthoracic echocardiogram confirmed the dilatation of the right heart, of the main pulmonary artery (69 mm), and of the main pulmonary branches (right 43 mm, left 45 mm), showed a non-dilated left ventricle with preserved systolic function, and permitted the evaluation of the pulmonary hypertension (a systolic value of 70 mmHg). An MRI exam revealed a close proximity between the dilated pulmonary artery and the aortic root (Panel B)
The cardiac catheterization confirmed the severe pulmonary hypertension (82/20/40 mmHg) without finding any shunt, the total pulmonary resistance was 1210 dyn s/cm5. Coronary angiography was performed, revealing a 90% ostial stenosis of the left main coronary artery (Panel C); there were no other atherosclerotic lesions found in the coronaries. On the basis of the MRI findings, it was thought that the left main stenosis might have been caused by extrinsic compression due to an aneurismally dilated pulmonary trunk.
The patient underwent percutaneous revascularization with direct stenting (a drug eluting stent 4 mmx12 mm) with excellent results (Panel D) and a favourable outcome (without angina and with an increased exercise tolerance).
Panel A. Chest X-ray (posteroanterior view): cardiomegaly involving the right chambers, enlarged pulmonary trunk (arrow a), and right main pulmonary artery (arrow b).
Panel B. MRI (axial section): the close proximity between the dilated pulmonary main artery and the aortic root.
Panel C. Coronary angiography (RAO cranial): ostial left main coronary artery stenosis of 90% (arrow)—extrinsic compression due to an aneurismally dilated pulmonary trunk.
Panel D. Coronary angioplasty: after stenting of the left main stenosis (arrow).
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