1Asklepios Klinik St. Georg Kardiologie & internistische Intensivmedizin Hamburg, Deutschland; 2Asklepios Klinik St. Georg Abteilung Herzchirurgie Hamburg, Deutschland
Background: Dynamic compression of coronary arteries seen in the coronary angiography often result from an intramural course, also known as myocardial bridging. These bridges are typically located in the medial segments of mainly the left anterior descending artery. Here we present a rare case of a patient showing a dynamic compression of the distal left main coronary artery requiring further investigation.
Case presentation: A 59-year old female patient was referred to our department with the working diagnosis of an infectious endocarditis of the aortic valve. The patient had a known history of a surgical replacement of the aortic valve with a xenograft only one year ago. The medical course was affected by relapsing episodes of mild fever end elevated parameters of inflammation in the laboratory tests, but blood cultures remained sterile. In the echocardiography the aortic valve was described as mildly insufficient with suspicious thickening of the cusps arguing for a relapsing infectious endocarditis. A second surgical approach was planned and the patient was send to the cathlab for another coronary angiography within the scope of routine perioperative work up. During the coronary angiography the patient presented in a stable clinical condition with no history of chest pain. The right coronary artery showed a dominant course with slightly ectatic wall abnormalities without significant stenosis. The angiography of the left coronary artery revealed a relevant dynamic compression of the distal left main coronary artery and proximal parts of the circumflex and left anterior descending artery. There were no signs of a dissection and the patient was totally stable and remained pain free. However, the impressive dynamic compression was not suitable for a typical intramural course and required further investigation due to it’s malignant localization and unclear cause. An urgently performed ecg-triggered computer tomography revealed a relevant subvalvular pseudoaneurysm with dynamic extension compromising the left main coronary artery. The Patient was sent to the theater for another aortic valve replacement. The pseudoaneurysm was successfully treated by reconstruction of the subvalvular aspect of the left ventricle. In the end the patient took a pleasant postoperative course and could be send to a rehabilitation department only ten days after the procedure. The possible dental focus of the infectious endocarditis which was found in the workup was treated before discharge as well.
Conclusion: Dynamic systolic compression of the left main coronary artery is a very uncommon finding in the coronary angiography and should trigger further investigation immediately. The causes can be much more detrimental than the typically benign myocardial bridging found in the more medial segments of the coronary arteries. In this case a subvalvular pseudoaneurysm due to an infectious endocarditis caused the dynamic compression of the coronary arteries. These pseudoaneurysms are rare but typically found in patients with state after valve replacement and infectious course.