Extrinsic compression of the left coronary ostium by the pulmonary trunk: management in a case of Eisenmenger syndrome

Abstract

Extrinsic compression of the left main coronary artery by a massively dilated pulmonary artery in patients who have severe pulmonary hypertension can lead to significant myocardial ischemia. A 58-year-old man with a large patent ductus arteriosus and Eisenmenger syndrome presented with angina at rest and worsening heart failure of 3 months' duration. The new symptoms were recognized to be secondary to extrinsic compression of the left main coronary artery ostium by a dilated main pulmonary artery and were successfully relieved by the placement of a metallic stent in the affected segment of the left main coronary artery. Multislice computed tomographic imaging after 6 months showed stent patency and the intimate relation of the stented vessel to the dilated main pulmonary trunk. We discuss diagnostic and management issues pertaining to this uncommon clinical entity.

Keywords: Angina pectoris/etiology; Eisenmenger complex/ complications; angioplasty, transluminal, percutaneous coronary; constriction, patho-logic/etiology; coronary stenosis/etiology; dilatation, pathologic/complications; ductus arteriosus, patent; hypertension, pulmonary/complications; stents; tomography, X-ray computed.

Fig. 1 A) Before stenting: note severe ostial narrowing of the left main coronary artery on selective coronary angiography, in a cranially angulated projection. B) After stenting: note wide lumen (arrow) of the left main coronary artery's ostium. Real-time motion images are available at www.texasheart.org/journal.

Fig. 2 Maximum-intensity projection from 64-slice computed tomographic image performed 6 months after stenting procedure. A) The relation of the stent (arrow) in the left coronary artery to the dilated pulmonary artery (PA). B) Another view of the massively dilated PA; the left main coronary artery stent (arrow) lies immediately below the PA. Ao = aortic root; PDA = patent ductus arteriosus; RV = right ventricle

Fig. 3 Three-dimensional volume-rendered computed tomographic images. A) Arrow points to the stent in the left main coronary artery (LMCA) where it arises from the aortic root. Note the relationship of the stented LMCA to the dilated pulmonary artery (PA). B) The LMCA (arrowhead) is seen branching to the left anterior descending and circumflex coronary arteries. Ao = aortic root