Author + information
- Received June 26, 2018
- Accepted July 17, 2018
- Published online September 17, 2018.
- aDepartment of Cardiology, Bern University Hospital, Bern, Switzerland
- bCenter for Congenital Heart Disease, Department of Cardiovascular Surgery, Bern University Hospital, Bern, Switzerland
- ↵∗Address for correspondence:
Prof. Lorenz Räber, Department of Cardiology, Bern University Hospital, 3010 Bern, Switzerland.
- acute coronary syndrome(s)
- computed tomography
- optical coherence tomography
- transposition of the great artery
An 18-year-old man underwent correction of a supravalvular pulmonary artery (PA) stenosis after neonatal correction of a dextrotransposition of the great arteries by a switch procedure. The coronary pattern presented with a common ostium for the left anterior descending artery and right coronary artery (RCA) after the transfer of the coronary (R1,A1;C2). The procedure was performed with a beating heart and normothermic bypass. The PA stenosis was corrected with a patchplasty of the anterior aspect of the pulmonary bifurcation and the PA main stem, staying above the level of the valvular commissures (Figure 1H, yellow dotted circle). After transferring to intensive care unit and extubation, the patient complained of chest pain and electrocardiogram showed ST-segment elevations in inferior leads that were not present during surgery. Emergent coronary angiography showed a subtotal occlusion in the proximal RCA (Figure 1A). After gentle pre-dilatation with 1.5-mm balloon and injection of nitroglycerine to the RCA, optical coherence tomography showed a slit-like narrowing of the vessel (Figures 1C and 1D) without atherosclerosis (Figure 1E, proximal reference). Percutaneous coronary intervention using a drug-eluting stent (4.5 mm × 15 mm) resulted in an adequate expansion (Figures 1B and 1F). Cardiac computed tomography after percutaneous coronary intervention (Figures 1G and 1H) showed the RCA (white arrowhead: implanted stent) passed just in front of a pulmonary sinus (black arrow). This finding implied that the supravalvular patch-enlargement of the main PA allowed for the expansion of the valvular sinus (might be explained by PA pressure change after extubation) leading to external compression of the proximal RCA.
This case highlights that intracoronary imaging can be useful to unravel a nonatherosclerotic etiology of acute myocardial infarction in a setting where atherothrombosis is unlikely. Furthermore, the case illustrates the importance of understanding the anatomic complexity in patients with congenital heart disease, which may be facilitated by the use of cardiac computed tomography.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 26, 2018.
- Accepted July 17, 2018.
- 2018 American College of Cardiology Foundation