Author + information
- Received November 27, 2010
- Accepted December 9, 2010
- Published online June 1, 2011.
- Amir Ravandi, MD, PhD and
- William F. Penny, MD⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. William F. Penny, Division of Cardiology, University of California, San Diego, VA Medical Center, 3350 La Jolla Village Drive (111A), San Diego, California 92161
The patient is an 86-year-old man who presented to the hospital with 4 h of retrosternal chest pain and an anterior ST-segment elevation myocardial infarction on electrocardiogram. His past medical history included pulmonary sarcoidosis, a bioprosthetic aortic valve implanted in 1997, and long-standing aortic root dilation that had been followed clinically because of high reoperative risk.
He was taken to the cardiac catheterization laboratory for emergent percutaneous coronary intervention but diagnostic coronary angiography was difficult because of the enlarged aortic root. With a 5-F multipurpose catheter, the left coronary artery was engaged, revealing a total occlusion of the ostial left main coronary artery (LM) (Fig. 1A, Online Video 1A). Subsequent angiography produced transient TIMI (Thrombolysis In Myocardial Infarction) flow grade 1 and then TIMI flow grade 2 through a 99% slitlike lesion of the ostial LM with minimal other obstructive coronary artery disease (Fig. 1B, Online Video 1B). The right coronary artery was normal. An aortogram was then performed, demonstrating a dissection flap adjacent to the LM ostium and 2+ aortic insufficiency (Fig. 2, Online Video 2). During diagnostic imaging, the patient had become hemodynamically unstable, requiring inotropic support and multiple rounds of defibrillation because of pulseless ventricular tachycardia, and intra-aortic balloon pump support was contraindicated by the aortic dissection and insufficiency. The cardiothoracic surgical team was consulted urgently, but a surgical approach was deemed not feasible because of the patient's age, hemodynamic instability, and comorbidities.
A percutaneous approach to revascularization was thus undertaken. A 6-F multipurpose guide was placed and the lesion was crossed into the left anterior descending artery with a 0.014-inch balanced middle weight wire (Abbott Vascular, Santa Clara, California). The ostial and proximal LM were pre-dilated with a 2.0 mm × 15 mm compliant balloon, followed by deployment of a 3.5 mm × 13 mm Cypher drug-eluting stent (Cordis Corp., Bridgewater, New Jersey) at 14 atm, resulting in TIMI flow grade 3 (Fig. 3, Online Video 3). The patient became hemodynamically stable after stent placement and was transferred to the critical care unit for post–ST-segment elevation myocardial infarction care.
After the procedure, a 64-slice computed tomography of the thorax was performed that showed that the origin of the dissection was the sinus of Valsalva at the LM, with the stent traversing into the aorta at the false lumen (Fig. 4).
Aortic root dissection involving the LM is a rare cause of ST-segment elevation myocardial infarction (1). The standard approach in treating patient with a type A dissection and LM involvement is surgical (2). The role of pre-operative diagnostic angiography is still controversial in that elucidating the coronary anatomy before surgery can potentially increase mortality, but a recent large case series has suggested that prior cardiac catheterization does not have an impact on mortality (3). However, in cases such as this case, in which the patient is excluded from surgical repair by hemodynamic instability or comorbid conditions, a percutaneous interventional approach of stenting of the LM can be considered an alternative.
For supplementary videos, please see the online version of this article.
The authors have reported that they have no relationships to disclose.
- Received November 27, 2010.
- Accepted December 9, 2010.
- American College of Cardiology Foundation