Author + information
- Received February 15, 2017
- Revision received March 1, 2017
- Accepted March 9, 2017
- Published online June 5, 2017.
- Julien Wain-Hobson, MD,
- Calin Ivascau, MD,
- Vincent Roule, MD and
- Farzin Beygui, MD, PhD∗ ()
- Cardiology & Cardiac Surgery Departments & EA4650, Caen University Hospital, Normandie Universite, Caen, France
- ↵∗Address for correspondence:
Dr. Farzin Beygui, Caen University Hospital, Avenue de la Cote de Nacre, Caen, France.
A 37-year-old man with a history of active smoking and heroin addiction was admitted after successful pre-hospital intravenous fibrinolysis for ST-segment elevation myocardial infarction. Coronary angiography (Figure 1) performed systematically after fibrinolysis showed a dynamic severe systolic compression (black arrow) of the left main coronary artery (LM) with a “milking effect” (Online Video 1) and a thrombotic lesion (white arrow) of the left circumflex artery. Intracoronary optical frequency domain imaging showed a thrombotic lesion of the left circumflex coronary artery (Figure 2A) and an ovoid deformation of the LM (Figure 2B), which was free of atherosclerosis. Cardiac multislice computed tomography (Figure 3) showed that the LM originated near the right coronary artery with an initial course between the aorta and the pulmonary artery. Because of the assumed high risk for sudden cardiac death (1), the patient underwent coronary artery bypass surgery with native vessel ligation, confirming the ectopic course of the LM (Figure 4).
Ectopic origin of the LM arising from the right aortic coronary sinus is a rare condition, found in 0.025% to 0.15% of patients undergoing coronary angiography (2). The inter-aortico-pulmonary course of the LM is associated with a high risk for sudden cardiac death and requires adequate correction. Surgical options are bypass grafting, pulmonary artery translocation, ostium reimplantation, or unroofing technique in case of an intramural aortic segment (3). LM stenting has also been performed as an alternative with a risk for stent compression (4).
The unusual location of a “milking” effect on the LM should lead to adequate imaging modalities for the detection and correction of an ectopic inter-aortico-pulmonary course of the LM.
For a supplemental video and its legend, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received February 15, 2017.
- Revision received March 1, 2017.
- Accepted March 9, 2017.
- 2017 American College of Cardiology Foundation
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