Severe Left Main Coronary Artery Stenosis and Aortic Regurgitation in a Patient Presenting with Takayasu Arteritis

Abstract

We herein report the case of a 46-year-old woman with Takayasu arteritis (TA), severe stenosis in the left main coronary artery (LMCA), and severe aortic regurgitation. Prednisolone and tacrolimus were initiated as TA treatments. Two months after initiating medical therapy, the aortic regurgitation severity improved to a moderate grade, although there was no obvious improvement in LMCA stenosis. Thus, after confirming the resolution of inflammation, we performed coronary artery bypass grafting alone without any aortic valve intervention. In TA patients with severe LMCA stenosis, surgical management of the coronary artery should therefore be considered only after successfully administering anti-inflammatory therapy.

Keywords: Takayasu arteritis; anti-inflammatory therapy; coronary artery bypass grafting; coronary artery disease.

Figure 1.

TTE showed (a) severe AR and (b, c) a localized high blood flow velocity (100 cm/s) in the left main trunk (red arrow). (d) After 2 months of prednisolone therapy, TTE showed an improvement to moderate grade AR. Ao: aorta, AR: aortic regurgitation, LA: left atrium, LV: left ventricle, RA: right atrium, RV: right ventricle, TTE: transthoracic echocardiography

Figure 2.

Computed tomography angiography showed wall thickening of the (a, b) aortic arch and the right brachiocephalic artery, and (c, d) severe stenosis of the ostia of the left main coronary artery. After 2 months of prednisolone therapy, (e) wall thickening of the ascending aorta had mildly improved, but (f) there were no obvious improvements in the stenosis of the ostia of the left main coronary artery. Ao: aorta, BCA: brachiocephalic artery, LAD: left anterior descending artery, LCX: left circumflex artery, PT: pulmonary trunk, RCA: right coronary artery

Figure 3.

Fluorodeoxyglucose-positron emission tomography showed a strong uptake in the walls of the ascending aorta, and the right brachiocephalic artery (a-d). Ao: aorta, BCA: brachiocephalic artery

Figure 4.

Twelve-lead electrocardiogram when the patient felt chest pain. ST-elevation in the aVR lead and extensive ST depression in the other leads was observed.

Figure 5.

Treatment progress chart. Prednisolone was initiated at 40 mg/day (1 mg/kg/day) and thereafter was gradually decreased by 5 mg/day every 2 weeks. The tacrolimus trough level was controlled at 5-10 ng/mL. After the initiation of treatment, her CRP levels and ESR declined. CRP: C-reactive protein, ESR: erythrocyte sedimentation rate, PSL: prednisolone, TAC: tacrolimus

Figure 6.

Coronary angiography and aortography demonstrated 75% stenosis of the LMCA and Sellers II degree AR.