Ann Thorac Surg 2009;87:1298. doi:10.1016/j.athoracsur.2008.07.060
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Pulsatile Coronary Artery Luminal Compression Caused by Aortic Dissection
Satoshi Ohki, MD*,
Yukinori Moriyama, MD,
Naoyuki Sata, MD,
Kenkichi Miyahara, MD
Divisions of Cardiovascular Surgery and Cardiology, Shinkyo Hospital, Kagoshima, Japan
* Address correspondence to Dr Ohki, Division of Cardiovascular Surgery, Shinkyo Hospital, 3-41-1 Usuki, Kagoshima, 890-0073, Japan (Email: ooki-ths{at}umin.ac.jp).
A 57-year-old woman was transferred to our hospital with acute onset of severe chest pain. The electrocardiogram showed features of acute anteroseptal myocardial ischemia. Echocardiography showed severe left ventricular hypokinesia with an ejection fraction of less than 0.45. Emergency coronary angiogram demonstrated pulsatile luminal compression of the proximal left anterior descending artery with no ostial occlusion. The true lumen was compressed to 99% stenosis in one phase (white arrows) (Fig 1), but in another phase the luminal compression disappeared completely (Fig 2). A computed tomographic scan was performed to assess the integrity of the thoracic aorta; the scan revealed an extensive type A aortic dissection involving the aortic root with an intimal flap (Fig 3). Myocardial ischemia seemed to be caused by dissection into the left coronary artery. While awaiting surgery, the patient's hemodynamic condition deteriorated rapidly, despite maximum pharmacological support. Severe cardiorespiratory failure required tracheal intubation, followed by an operation under deep hypothermia. An intimal tear was found on the ascending aorta with the ostium of the left coronary artery deeply dissected. A hemi-arch repair was done associated with left coronary revascularization using saphenous vein grafts, but the patient's cardiac function remained severely depressed even after repair, and femoro-femoral extracorporeal life support was applied. The hemodynamics improved considerably, and the extracorporeal life support was removed 2 days later.
Total or partial ostial coronary artery occlusion is one of the most lethal complications in acute aortic dissection. In our case, coronary luminal compression was more prominent in the distal segment rather than the proximal main trunk, probably due to expansion of the patent false lumen with no or poor re-entry into the distal artery.
