European Journal of Echocardiography 2008 9(1):139-140; doi:10.1016/j.euje.2007.04.003
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org
Type A aortic dissection with partial ostial occlusion of left main coronary artery
Narayanan Namboodiri* and
K. M. Krishnamoorthy
Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695 011, India
Received 1 January 2007; accepted after revision 28 April 2007; online publish-ahead-of-print 22 June 2007.
* Corresponding author. Tel: +91 447838258; fax: +91 471 2446433. E-mail address: kknnamboodiri{at}sctimst.ac.in
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Abstract
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A 48-year-old hypertensive male presented with acute retrosternal
pain and aortic regurgitation. The electrocardiogram showed
ST-segment depression with T-wave inversion in anterolateral
leads. Transesophageal echocardiography in long axis view of
aorta revealed a spiral intimal flap in ascending aorta extending
to the arch, diagnostic of Type A aortic dissection. The short
axis view of the aorta showed partial obstruction of the left
main coronary artery (LMCA) by the intimal flap with turbulent
flow at its ostium. An emergency repair of aortic dissection
with reconstruction of aortic wall was done. Postoperative period
and ECG were normal. At 12-months of follow up, patient was
doing well.
Keywords: Left main coronary; Transesophageal echocardiography
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Introduction
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Coronary malperfusion associated with aortic dissections is
relatively infrequent.
1,2 As this complication increases the
mortality rate considerably, it should be actively looked for
in patients with proximal aortic dissection. Here we describe
this uncommon complication of type A aortic dissection in an
adult male which was managed successfully with emergency surgery.
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Case report
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A 48-year-old hypertensive male presented with acute retrosternal
pain. At admission his pulse was 90 bpm with blood pressure
of 100/70 mmHg. A short early diastolic murmur was noted at
aortic area. The electrocardiogram showed ST-segment depression
with T-wave inversion in anterolateral leads. Transthoracic
echocardiogram revealed moderate aortic regurgitation (AR) with
suspicion of dissecting flap in the ascending aorta. Transesophageal
echocardiography (TEE) in long axis view of aorta revealed a
spiral intimal flap in ascending aorta extending to the arch,
diagnostic of Type A aortic dissection (
Figure 1). The
short axis view of the aorta showed partial obstruction of the
left main coronary artery (LMCA) by the intimal flap with turbulent
flow at the ostium of LMCA (
Figures 2 and
3). A diagnosis
of Type A aortic dissection with partial obstruction of LMCA
ostium resulting in anterolateral ischemia was made. An emergency
repair of aortic dissection with reconstruction of aortic wall
was done. Aortic valve was not replaced as it was intrinsically
normal. TEE findings were confirmed at surgery. Postoperative
period and ECG were normal. At 12 months of follow up, patient
was doing well.
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Discussion
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Coronary involvement has been described in 12 (6.1%) of 196
patients with acute Type A aortic dissection undergoing surgery.
2 Extrinsic compression of LMCA by the intimal flap, the mechanism
of coronary ischaemia seen in our patient was found in only
2 (1%) of these patients. Although the dynamic compression of
LMCA by the false channel created by the dissection has been
described by a few previously,
3,4 we could not demonstrate any
dynamic variation in the degree of compression with phases of
cardiac cycle in our patient. Decreased blood pressure and the
presence of AR accelerating the collapse of true lumen during
diastole in the ascending aorta had been postulated to result
in functional obstruction of LMCA by the intimal flap. Other
causes of coronary malperfusion in these patients are coronary
dissection and coronary disruption.
2
The involvement of ostia of coronaries can be visualized on TEE, aortogram or MR angiogram. As up to one-third of the patients with this rare coexistence are known to have in-hospital mortality, its detection aids in planning an aggressive coronary revascularization and early aortic repair.
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References
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- Neri E, Toscano T, Papalia U, Frati G, Masseti M, Capannini G, et al. Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J Thorac Cardiovasc Surg (2001) 121:552–60.[Abstract/Free Full Text]
- Kawahito K, Adachi H, Murata S, Yamaguchi A, Ino T, et al. Coronary malperfusion due to Type A aortic dissection: mechanism and surgical management. Ann Thorac Surg (2003) 76:1471–6.[Abstract/Free Full Text]
- Shapira OM, Davidoff R. Functional left main coronary artery obstruction due to aortic dissection. Circulation (1998) 98:278–80.[Free Full Text]
- Ashida K, Arakawa K, Yamagishi T, Tahara T, Ayaori M, Miyazaki K, et al. A case of aortic dissection with transient ST-segment elevation due to functional left main coronary artery obstruction. Jpn Circ J (2000) 64:130–4.[CrossRef][Medline]
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Abstract
Introduction
