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
Footnotes
Reprint requests to Oz M. Shapira, MD, Department of Cardiothoracic Surgery, Boston Medical Center, 88 E Newton St, Boston, MA 02118.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.
© 1998 American Heart Association, Inc.
Images in Cardiovascular Medicine
Functional Left Main Coronary Artery Obstruction Due to Aortic Dissection
, 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 wall layers, interposition tube graft, and resuspension of the
aortic valve, requiring a short period of deep hypothermia and
circulatory arrest. The postoperative ECG was normal (Figure 1, bottom), and TEE showed normal left ventricular function.
Serum creatine kinase levels were not elevated during the entire
course. At 6-month follow-up, the patient was doing
well.
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Figure 1.
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Figure 2.
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Figure 3.
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Figure 4.
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