(Circulation. 1998;98:278-280.)
© 1998 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Functional Left Main Coronary Artery Obstruction Due to Aortic Dissection
Oz M. Shapira, MD;
; Ravin Davidoff, MBBCh
From the Departments of Cardiothoracic Surgery (O.M.S.) and Cardiology
(R.D.), Boston Medical Center, Boston, Mass.
A38-year-old
black man with a history of hypertension was admitted with a sudden
onset of severe retrosternal chest pain radiating to his back. The
initial physical examination was remarkable only for severe
hypertension. The ECG (Figure 1
, top)
showed marked anterolateral ST-segment depression with T-wave
inversion, suggestive of acute myocardial ischemia. Treatment
with aspirin, nitroglycerin, and
intravenous heparin was begun. Shortly after admission, the
patient developed severe hypotension, pulmonary edema, and a
soft diastolic murmur of aortic
regurgitation. After resuscitation,
transesophageal echocardiography
(TEE) was performed. The long-axis view of the aorta (Figure 2) demonstrated a complex, spiral intimal
flap in the proximal ascending aorta (solid arrow in all TEE images),
diagnostic of type A aortic dissection, and severe aortic
regurgitation. A short-axis image during systole
(Figure 3, top) showed the intimal flap
as well as a patent orifice of the left main coronary artery
(open arrow in all TEE images) with color flow during systole (Figure 3, bottom). The same short-axis view during diastole
(Figure 4) showed obstruction of the
orifice of the left main coronary artery by the intimal flap
with no flow. The patient was transferred for emergency operation,
during which the TEE findings were confirmed. The orifice of the left
main coronary artery was found to be occluded by a flail
intimal flap with severe anterior and lateral hypokinesis. The artery
itself was not involved in the dissection process. The patient
underwent repair of the aortic dissection with reconstruction of the
aortic . . . [Full Text of this Article]
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