How should I treat a retrograde dissection of the aortic sinus of Valsalva during a percutaneous coronary intervention?

Abstract

*Corresponding author: Department of Cardiology, Chang Gung Memorial Hospital at Keelung, 222 Maijin Road, Keelung 20401, Taiwan. E-mail: miran888@ms61.hinet.net PRESENTATION OF THE CASE A 53-year-old man, a 20-cigarettes-per-day smoker, presented to the emergency department because of a new onset of episodic exertional dizziness and chest pain associated with cold sweating over the previous month. He was not obese and on no medications, had no medical history and no family history of cardiac disease. There was no specific abnormality upon physical examination and he had normal blood pressure. An electrocardiogram (ECG) showed sinus rhythm, negative T waves in the inferior leads and flattened T-waves in leads V1 to V4. An echocardiography showed a normal ejection fraction and hypokinesis of the posterior/inferior wall. He was diagnosed as having unstable angina. Coronary angiography revealed a 70% lumen narrowing at the mid-left anterior descending coronary artery (LAD) (Figure 1A and Moving image 1) and a subtotal occlusion in the proximal, mildly calcified RCA, with distal blood flow of thrombolysis in myocardial infarction (TIMI) grade 1 (Figure 1B and Moving image 1). The distal RCA was well-opacified and collateralised from the left coronary artery. Ventriculography revealed mild localised hypokinesis of the inferior wall, with an ejection fraction of 65%. Coronary angioplasty of the occluded RCA was attempted via the right femoral artery using a 6 Fr arterial sheath. The RCA was cannulated with a 6 Fr Judkins right 4 cm curved guiding catheter (JR4; Cordis Corp., Miami, FL, USA). Fifteen minutes into the procedure, during the application of a 0.014 inch Miracle 3 wire (Asahi Neo’s; Asahi Intecc Co. Ltd; CASE SUMMARY