Systolic compression of left main coronary artery by left ventricular pseudoaneurysm complicated by critical stenosis of left main coronary artery

A 69-year-old man was admitted to the hospital with complaints of exertional substernal chest pain and dyspnea for 3 weeks. His medical history consisted of dyslipidemia, type 2 diabetes mellitus, and valvular heart disease. He had a mitral commissurotomy through a left thoracotomy for mitral stenosis at age 16 years followed by mitral valve replacement with a 25 mm Carpentier Edwards bovine pericardial prosthesis in February, 2007. He also had a aortic valve replacement with a 19 mm Carpentier Edwards bovine pericardial prosthesis at that time. On this admission, he had a maximum troponin I level of 0.12 (normal < 0.05 ng/ml), a creatine kinase-MB fraction of 3.4 (normal < 5.0 ng/ml), and a creatine phosphokinase of 288 (normal 35-232 U/l). Coronary angiography revealed near complete systolic obliteration of the left main coronary artery with normal caliber in diastole and discrete stenosis of the mid left anterior descending coronary artery resulting in 40% obstruction of the vessel (Figure 1 A). Left ventriculography revealed systolic aneurysmal dilatation of a segment of the left ventricle (LV) compressing the left main coronary artery in systole and a LV ejection fraction of 50% (Figure 1 B). A thoracic computed tomography (CT) scan and a transesophageal echocardiogram (TEE) were obtained to provide anatomical delineation of the LV pseudoaneurysm The thoracic CT scan revealed an abnormal 3 cm × 2.4 cm contrast-filled structure to the left of the aorta, superior to the LV outflow tract, and inferior to the left main coronary artery likely representing a LV pseudoaneurysm. The TEE showed a normal LV ejection fraction, a small inferoposterior wall hypokinesis, and a LV pseudoaneurysm with a 1.3 cm opening originating below the mitral annulus anteriorly adjacent to the left atrial appendage extending superiorly to the left main coronary artery. The patient subsequently had a bovine patch repair of the LV pseudoaneurysm with resection of the left atrial appendage. A coronary angiogram obtained after surgery demonstrated a discrete fixed stenosis of the mid left main coronary artery resulting in 70% obstruction of the vessel (Figure 2). Intravascular ultrasound of the left main coronary artery stenosis revealed a cross sectional area of 2.9 mm2. The left main coronary artery was predilated with a 3.5 mm × 9 mm balloon inflated to 8 atm for 6 s. The stenosis was treated with a 4.0 mm × 12 mm everlimus drug-eluting stent that was deployed at 8 atm for Corresponding author: Wilbert S. Aronow MD Cardiology Division New York Medical College Macy Pavilion, Room 138 Valhalla, NY 10595, USA Phone: (914) 493-5311 Fax: (914)-235-6274 E-mail: [email protected] Letter to the editor