Functional Left Main Coronary Artery Obstruction Due to Aortic Dissection
A38-year-old black man with a history of hypertension was admitted with a sudden onset of severe retrosternal chest pain radiating to his back. The initial physical examination was remarkable only for severe hypertension. The ECG (Figure 1⇓, top) showed marked anterolateral ST-segment depression with T-wave inversion, suggestive of acute myocardial ischemia. Treatment with aspirin, nitroglycerin, and intravenous heparin was begun. Shortly after admission, the patient developed severe hypotension, pulmonary edema, and a soft diastolic murmur of aortic regurgitation. After resuscitation, transesophageal echocardiography (TEE) was performed. The long-axis view of the aorta (Figure 2⇓) demonstrated a complex, spiral intimal flap in the proximal ascending aorta (solid arrow in all TEE images), diagnostic of type A aortic dissection, and severe aortic regurgitation. A short-axis image during systole (Figure 3⇓, top) showed the intimal flap as well as a patent orifice of the left main coronary artery (open arrow in all TEE images) with color flow during systole (Figure 3⇓, bottom). The same short-axis view during diastole (Figure 4⇓) showed obstruction of the orifice of the left main coronary artery by the intimal flap with no flow. The patient was transferred for emergency operation, during which the TEE findings were confirmed. The orifice of the left main coronary artery was found to be occluded by a flail intimal flap with severe anterior and lateral hypokinesis. The artery itself was not involved in the dissection process. The patient underwent repair of the aortic dissection with reconstruction of the aortic wall layers, interposition tube graft, and resuspension of the aortic valve, requiring a short period of deep hypothermia and circulatory arrest. The postoperative ECG was normal (Figure 1⇓, bottom), and TEE showed normal left ventricular function. Serum creatine kinase levels were not elevated during the entire course. At 6-month follow-up, the patient was doing well.
Reprint requests to Oz M. Shapira, MD, Department of Cardiothoracic Surgery, Boston Medical Center, 88 E Newton St, Boston, MA 02118.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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