Ostium Of Left Main Coronary Artery Research Articles

MULTIDRUG RESISTANT DYSLIPIDEMIA: A CASE REPORT

Abstract Introduction Recently introduced lipid–lowering agents (PCSK9–i, bempedoic acid) can efficiently treat statin–intolerant patients, who couldn‘t reach LDL target before. Nonetheless, there are still cases where the pharmacological management may have strong limitations. Case Report A 71 year–old woman, with multiple cardiovascular risk factors (diabetes, hypertension and familial dylipidemia, LDL–C 276) underwent heart transplantation for a hypertrophic cardiomyopathy with an evolution towards a dilated phenotype in 2005. Before the transplant, she was on low–dose statin treatment (pravastatin 10 mg/die) that was suspended years later owing to hyper–CKemia (600 U/L), despite her being totally asymptomatic. A second attempt with simvastatin/ezetimibe 40/10 mg resulted again in elevation of CK levels, associated with significant muscular pain. Thus, just ezetimibe was continued. In 2020, 15 years after the transplant, the patient underwent a coronary angiography showing a moderate coronary allograft vasculopathy (ISHLT CAV2). Specifically, a sub occlusive ostial left main coronary artery lesion was treated by percutaneous angioplasty and stent implantation. Since a lower LDL target was needed (LDL–C 55 mg/dL), Alirocumab was introduced. However, 6 months later, no significant LDL levels reduction had been observed. The shift to evolocumab led to the same result, although the patient reported full therapeutic compliance. In the suspicion of anti–drug antibodies development, we opted for Inclisiran without achieving a significant decrease in LDL–C levels. In parallel with the search for genetic mutations in the PCSK9 gene and other genes involved in cholesterol metabolism (including LDLR, APOB, and LDLRAP1 and resulting positive only for common variants in LDLR receptor), therapy with bempedoic acid was initiated, again without substantial benefit (LDL–C 118 mg/dL). Conclusion Despite cholesterol management has been simplified by the introduction of new drugs, it may still be complex in patients requiring very low LDL–C levels in some specific cases. Drugs with a LDL receptor–independent mechanism of action (e.g., evinacumab) may allow the achievement of therapeutic goals suggested by clinical guidelines.

MULTIDRUG RESISTANT DYSLIPIDEMIA: A CASE REPORT

Objective: Recently introduced lipid-lowering agents (PCSK9-i, bempedoic acid) can efficiently treat statin-intolerant patients, who couldn’t reach LDL target before. Nonetheless, there are still cases where the pharmacological management may have strong limitations. Design and method: A 71 year-old woman, with multiple cardiovascular risk factors (diabetes, hypertension and familial dylipidemia, LDL-C 276) underwent heart transplantation for a hypertrophic cardiomyopathy with an evolution towards a dilated phenotype in 2005. Before the transplant, she was on low-dose statin treatment (pravastatin 10 mg/die) that was suspended years later owing to hyper-CKemia (600 U/L), despite her being totally asymptomatic. A second attempt with simvastatin/ezetimibe 40/10 mg resulted again in elevation of CK levels, associated with significant muscular pain. Thus, just ezetimibe was continued. In 2020, 15 years after the transplant, the patient underwent a coronary angiography showing a moderate coronary allograft vasculopathy (ISHLT CAV2). Specifically, a sub occlusive ostial left main coronary artery lesion was treated by percutaneous angioplasty and stent implantation. Since a lower LDL target was needed (LDL-C 55 mg/dL), Results: Alirocumab was introduced. However, 6 months later, no significant LDL levels reduction had been observed. The shift to evolocumab led to the same result, although the patient reported full therapeutic compliance. In the suspicion of anti-drug antibodies development, we opted for Inclisiran without achieving a significant decrease in LDL-C levels. In parallel with the search for genetic mutations in the PCSK9 gene and other genes involved in cholesterol metabolism (including LDLR, APOB, and LDLRAP1 and resulting positive only for common variants in LDLR receptor), therapy with bempedoic acid was initiated, again without substantial benefit (LDL-C 118 mg/dL). Conclusions: Despite cholesterol management has been simplified by the introduction of new drugs, it may still be complex in patients requiring very low LDL-C levels in some specific cases. Drugs with a LDL receptor-independent mechanism of action (e.g., evinacumab) may allow the achievement of therapeutic goals suggested by clinical guidelines.

Evaluation of post-dilatation on longitudinal stent deformation and postprocedural stent malapposition in the left main artery by optical coherence tomography (OCT): an in vitro study

BackgroundThe diameter of the ostial and proximal left main coronary artery can be greater than 5.0 mm. However, the diameters of the mostly available coronary drug-eluting stents (DESs) are ≤ 4.0 mm. Whether high-pressure dilatation can increase the diameter of stents from 4.0 to 5.0 mm and whether post-dilatation leads to longitudinal stent deformation (LSD) of 4.0-mm-diameter stents have rarely been studied. Therefore, this study aims to evaluate LSD and stent malapposition of six types of commercially available 4.0-mm-diameter stents in China in a 5.0-mm-diameter artificial blood vessel model by optical coherence tomography (OCT) in vitro.MethodsThe left main coronary artery was simulated by a truncated cone-shaped silicone tube. The internal diameters were 4.0 mm at one end of the silicone tube and 5.0 mm at the other end. Six different types of coronary stents widely used in China were selected for this study. Each stent was respectively implanted into the simulated blood vessel and dilated to a diameter of 4.2 mm according to the stent-balloon pressure compliance table. The stents were subjected to post-dilatation with a 5.0 × 15-mm noncompliant balloon. The LSD ratio of the longitudinal axis of each stent and stent malapposition were measured through OCT, and any fractures of the stents were determined.ResultsNone of the six types of stents fractured following post-dilatation. The longitudinal axes of the BuMA and Excrossal stents were slightly shortened, while the other stents were elongated after high-pressure post-dilatation. All stents expanded to a diameter of 5.0 mm without incomplete stent apposition, except for the Nano Plus stent, which remained malapposed after high-pressure post-dilatation.ConclusionAll 4.0-mm-diameter stents can be expanded to a diameter of 5.0 mm by noncompliant balloon post-dilatation without stent strut fracture. Most stents were found to be well apposed after high-pressure post-dilatation. However, LSD was observed after post-balloon dilatation. Stent malapposition might be positively correlated with the percentage change in stent length.

Long-Term Results of Stenting in Patients with Hemodynamically Significant Lesions of the Left Main Coronary Artery

The aim. To study the long-term results of stenting in patients with coronary artery disease with hemodynamically significant left main coronary artery (LMCA) stenoses.
 Materials and methods. The study included 67 patients (56 men, 11 women) with a mean age of 63 ± 2.1 years.
 Results. Among the 67 patients included in the study, 29 patients (43.3%) underwent percutaneous coronary inter-vention using a single-stent technique. These were patients with ostial LMCA lesions, lesions of the middle third of the LMCA and some patients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to establish contact with 25 patients (86.2%). Among these, 1 patient (3.4%) died of non-cardiac causes and 7 patients (24.1%) had a recurrence of angina within 2 years. The causes of angina recurrence in 2 cases (6.9%) were restenosis in the stent with transition to the mouth of the side branch, which required repeated stenting of the LMCA with transition to the left circumflex artery. In 5 patients (17.2%), angina recur-rence was associated with progression of coronary atherosclerosis of another localization.
 Among 67 patients with LMCA stenting, the two-stent technique was used in 38 patients (56.7%). These were pa-tients with Medina 1.1.0; 1.0.1; 1.0.0; 0.1.0; 0.0.1 lesions of the distal part of the LMCA. The median follow-up was 2 years. Using a questionnaire, we managed to contact 35 patients (92.1%). Among these, 4 patients (10.5%) died, but only one of them due to cardiac causes (2.6%), and 3 patients (7.9%) had recurrent angina within 2 years, two of whom underwent stenting by the T and protrusion (TAP) technique and one by culotte. The first two patients underwent angioplasty of restenosis in stents using balloons with a therapeutic coating. In the last patient, stent recoil in the left circumflex artery mouth was observed due to severe calcification, so this patient underwent re-implantation of the stent system in the recoil zone.
 Conclusions. The problem of choosing a method of revascularization for patients with hemodynamically significant LMCA lesions remains controversial to this day, despite the wide range of evidence. Doctors should jointly decide on the choice of treatment methodology solely in the interests of the patient, taking into account all the factors that may affect the patient’s quality of life in the long term.

A Rare Case of Robotic Revascularization for Obstructed Left Main with Automated Suture Fastener

In comparison to traditional, manual knot-tying, the use of an automated titanium suture fastening device has demonstrated a considerable reduction in cardiopulmonary bypass time, aortic cross-clamp time, and operative time in valve procedures. However, there aren't many reports in the literature on the side effects related to using such device. Here we present a case in which the automated titanium suture fastener resulted in left main coronary artery ostium obstruction following its use in the aortic position and subsequent treatment with robotic Coronary Artery Bypass Grafting (CABG).

Long-term clinical outcomes of percutaneous coronary intervention for ostial left main coronary artery disease.

There are limited data regarding the long-term prognosis of percutaneous coronary intervention treatment for left main (LM) ostial stenosis. The present study sought to investigate the long-term clinical outcomes and risk factors for adverse events in LM ostial lesions following drug-eluting stent implantation (DES) in a large cohort of an LM registry database. Patients presenting with LM coronary disease from January 2004 to December 2016 at Fuwai Hospital were included. The primary endpoint was target vessel failure (TVF), a composite endpoint of cardiac death, target vessel myocardial infarction and target vessel revascularisation. Cox proportional hazards models were constructed to identify independent predictors. Among 4,625 LM patients, 627 (13.6%) patients were identified with LM ostial lesions. There were more female patients in the ostial group (31.3%), compared with the shaft (18.1%) and bifurcation groups (19.9%) (p<0.0001). Among patients with DES implantation, 3-year TVF occurred in 44 patients (7.5%) in the ostial group, which is comparable with the other two groups. Myocardial infarction (MI) was significantly lower in the ostial group (2.0%) compared with the bifurcation group (4.2%) (p=0.02), especially for MI events originating in the LM vessel (p=0.02). For patients with ostial LM disease who received percutaneous coronary intervention (PCI) treatment, procedural complications were an independent risk factor for long-term cardiac death or MI, while a more recent PCI proved to be a protective factor. PCI treatment for ostial LM lesions achieved favourable long-term outcomes, with a similar MI risk compared with the mid-shaft group but a significantly lower risk of MI compared with the distal group.

A Case of Native Aortic Valve Thrombus Complicating Intermittent Occlusion of a Left Main Coronary Artery.

Intermittent left main coronary artery ostium obstruction (LMOO) caused by native aortic valve thrombus (NAVT) is an extremely rare condition. It may therefore be challenging to identify the cause using only coronary angiography, even though the clinical presentation and electrocardiography (ECG) strongly suggest myocardial infarction. We herein report a 53-year-old man with NAVT complicating intermittent occlusion of left main disease in preexisting coronary artery stenosis.

Predictors and Prognostic Implications of Myocardial Injury After Transcatheter Aortic Valve Replacement.

Myocardial injury (MI) is not unusual after transcatheter aortic valve replacement (TAVR). To determine precipitating factors and prognostic outcomes of MI after TAVR, we retrospectively investigated relationships between MI after TAVR and aortic root dimensions, baseline patient characteristics, echocardiographic findings, and procedural features. Of 474 patients who underwent transfemoral TAVR for severe aortic stenosis in our tertiary center from June 2011 through June 2018, 188 (mean age, 77.7 ± 7.7 yr; 96 women [51%]) met the study inclusion criteria. Patients were divided into postprocedural MI (PMI) (n=74) and no-PMI (n=114) groups, in accordance with high-sensitivity troponin T levels. We found that MI risk was associated with older age (odds ratio [OR]=1.054; 95% CI, 1.013-1.098; P=0.01), transcatheter heart valve type (OR=10.207; 95% CI, 2.861-36.463; P=0.001), distances from the aortic annulus to the right coronary artery ostium (OR=0.853; 95% CI, 0.731-0.995; P=0.04) and the left main coronary artery ostium (OR=0.747; 95% CI, 0.616-0.906; P=0.003), and baseline glomerular filtration rate (OR=0.985; 95% CI, 0.970-1.000; P=0.04). Moreover, the PMI group had a longer time to hospital discharge (P=0.001) and a higher permanent pacemaker implantation rate (P=0.04) than did the no-PMI group. Our findings may enable better estimation of which patients are at higher risk of MI after TAVR and thus improve the planning and course of clinical care.

Clinical results at a long-term follow-up of percutaneous coronary intervention in ostial left main coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left main coronary ostial lesions are notable for being found more commonly among middle-aged women with fewer conventional coronary artery risk factors and for lower long-term patency of internal thoracic grafts. Isolated ostial left main coronary artery (LMCA) disease is involved in the 18% of lesions and have a management approach do well either with percutaneous coronary intervention (PCI) or cardiac surgery. Continuous improvement in the devices and the emergence of better drug-eluting stents (DES) has improved the results of PCI in these high-risk lesions. Purpose The main objective of this study was to evaluate the efficacy and safety of PCI in ostial LMCA disease at a 14-year follow-up. Methods We prospectively included 109 consecutive patients (72± 12 years, 72.5% male) with ostial LMCA disease treated with PCI between June 2006 and June 2020. We evaluated the presence of major adverse cardiovascular events (MACE) defined as cardiac death, non-fatal myocardial infarction, target lesion revascularization (TLR) and stent thrombosis after a 14-year clinical follow-up (median 63.6 months). Results 55.9% had stable coronary disease and 44.1% had acute coronary syndrome (35.9% Non-STEMI and 8.2% STEMI). 45% were diabetic patients and 36.6% presented moderate-severe left ventricular systolic dysfunction. The mean logistic EuroSCORE was 8.1 % and SYNTAX score was ≥ 23 in 72.5% of the patients. We implanted second-generation DES in the 83.5% of patients (76% zotarolimus-eluting stent) and post-dilatation was performed in the 68.8%. The angiographic success rate was 99%. Complication rate in the procedure was 5.5% without intra-procedure deaths. During follow-up, MACE rate at 14 years was 18.3% (13.7% of cardiac death, 4.6% of nonfatal myocardial infarction, 7.3% of TLR and thrombosis rate of 0.9%). 24.2% of patients had an angiographic follow-up. Conclusions In spite of high surgical risk, complex coronary anatomy and older aged patients, PCI in ostial LMCA disease is safe and effective with a low rate of major cardiovascular events at long-term follow-up.

Intravascular lithotripsy for ostial left main coronary artery disease.

Intravascular lithotripsy for ostial left main coronary artery disease.

TCTAP C-069 Angioplasty to Treat Ostial Left Main and Ostial Right Coronary Artery Critical Stenosis in a Case of Takayasu Arteritis

TCTAP C-069 Angioplasty to Treat Ostial Left Main and Ostial Right Coronary Artery Critical Stenosis in a Case of Takayasu Arteritis

Determination of Optimal Fluoroscopic Angulations for Left Main Coronary Artery Ostial Interventions: 3-Dimensional Computed Tomography Validation.

Background Current recommendations for the best views for the left main coronary artery (LMCA) ostium intervention are empirical. Objectives To determine the optimal projection to visualize the LMCA ostium using only fluoroscopy. Methods The optimal projection to visualize the LMCA ostium was determined using fluoroscopic images of superimposing the lowest points of the distal ends of two J tipped wires in the noncoronary cusp (NCC) and right coronary cusp (RCC). This was validated independently using 3-dimensional computed tomography (3D-CT) reconstruction. Results Satisfactory images of the overlapping wires in NCC and RCC could be obtained in 90% (45/50). Between the fluoroscopic and the 3D-CT reconstruction approaches, the mean difference for NCC and RCC overlapping at horizontal axes is -1.8 with a 95% limit of agreement between −3.94 and 0.34 (p=0.10) and at vertical axes −1.6 with a 95% limit of agreement between −3.46 and 0.26 (p=0.09); and the mean difference for the optimal projection to visualize the LMCA ostium at horizontal axes is −3.22 with a 95% limit of agreement between -7.26 and 0.81 (p=0.11) and at vertical axes −2.31 with a 95% limit of agreement between −5.83 and 1.21 (p=0.09). The 3D angulation deviation for the optimal projection to visualize the LMCA ostium was 8.5° ± 4.7° when the LMCA ostium faced the NCC-RCC commissure (n = 32) and 22.3° ± 16.0° (p=0.009) when it did not (n = 13). Conclusions The optimal projection for LMCA ostial intervention can be determined using fluoroscopic images of superimposing wires in the NCC and RCC when the LMCA ostium faces the NCC-RCC commissure, as was the case in 71% of the patients studied.

Coronary allograft vasculopathy managed by Flash ostial balloon in a pediatric patient

Coronary allograft vasculopathy (CAV) is the most significant cause of morbidity and mortality in heart transplant recipients. Inflammation and endothelial dysfunction caused by graft rejection and viral infections leads to a combination of circumferential intimal fibromuscular hyperplasia, atherosclerosis, and inflammation affecting all layers of the vessel wall. Though obstructive CAV is often asymptomatic, posing a diagnostic challenge in post-transplant patients, early diagnosis and treatment aid faster recovery and improved outcomes. The role of percutaneous coronary intervention in the treatment of CAV is unknown and not well studied in the pediatric population. We present a first-in-human case of ostial left main coronary artery disease managed with flaring of the ostial coronary stent using a Flash ostial balloon in a pediatric patient with history of an orthotopic heart transplant.

Fractional flow reserve [FFR] guided stenting of left main coronary artery in acute coronary syndrome: A single centre experience

The present study assesses the clinical outcomes after left main coronary stenting, using clinical evaluation, angiography, and Fractional Flow Reserve (FFR). A prospective observational study was conducted on 72 patients undergoing left main coronary artery (LMCA) stenting, transthoracic echocardiography, coronary angiography, and percutaneous coronary intervention were done and FFR was recorded. At the end of 6 months, follow up check angiography, FFR study were performed. The stent was placed from LMCA to left anterior descending artery (LAD) artery among 45.83% of patients and 9.72% had from LMCA to Left circumflex artery. The mortality rate was 8.33%. The fractional flow reserve was 0.81 on an average ranging from 0.58 to 0.90. Relatively low incidence of major cardiac event was noted among patients with single vessel disease and ostial LMCA disease.

Acute myocardial infarction with left main coronary artery ostial negative remodelling as the first manifestation of Takayasu arteritis: a case report

BackgroundTakayasu arteritis is a chronic inflammatory disease involving the aorta and its major branches. Acute myocardial infarction rarely but not so much presents in patients with Takayasu arteritis, and the preferable revascularization strategy is still under debate.Case presentationA 22-year-old female with Takayasu arteritis presented with acute myocardial infarction. Coronary angiography and intravenous ultrasound (IVUS) showed that the right coronary artery (RCA) was occluded and that there was severe negative remodelling at the ostium of the left main coronary artery (LMCA). The patient was treated by primary percutaneous transluminal coronary angioplasty (PTCA) with a scoring balloon in the LMCA, without stent implantation. After 3 months of immunosuppressive medication, the patient received RCA revascularization by stenting. There was progressive external elastic membrane (EEM) enlargement of the LMCA ostium demonstrated by IVUS at 3 and 15 months post-initial PTCA.ConclusionHere, we report a case of Takayasu arteritis with involvement of the coronary artery ostium. Through PTCA and long-term immunosuppressive medication, we found that coronary negative remodelling might be reversible in patients with Takayasu arteritis.

Combined Coronary Artery Bypass Grafting and Transcatheter Aortic Valve Replacement in a Patient with Severe Post-Radiation Damage

Chest radiotherapy is a common treatment for mediastinal malignancy. The long-term effect of radiation can harm several of cardiovascular structures including pericardium, myocardium, valvular system, conduction system, and coronary arteries. Cardiovascular disease is the most common non-malignancy cause of death in radiation-treated patient, most often occurs many years after treatment. Valvular heart disease secondary to mediastinal radiation mainly affect the aortic and mitral valves. We present a unique case of 58 years old women with history of past mediastinal radiotherapy who presented with few episodes of true syncope, complete AV block, severe aortic stenosis and significant ostial left main and ostial right coronary artery disease.

Long-Term Outcomes After PCI or CABG for Left Main Coronary Artery Disease According to Lesion Location.

The aim of this study was to investigate the impact of lesion site (ostial or shaft vs. distal bifurcation) on long-term outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease. Long-term comparative data after PCI and CABG for LMCA disease according to lesion site are limited. Patients from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry were analyzed, comparing adverse outcomes (all-cause mortality [a composite outcome of death, Q-wave myocardial infarction, or stroke] and target vessel revascularization) between PCI and CABG according to LMCA lesion location during a median follow-up period of 12.0 years. In overall population, the adjusted risks for death and serious composite outcome were higher after PCI than after CABG for distal bifurcation disease, which was mainly separated beyond 5 years. These outcomes were not different for ostial or shaft disease. When comparing drug-eluting stents (DES) and CABG, the adjusted risks for death and serious composite outcome progressively diverged beyond 5 years after DES compared with CABG for distal bifurcation disease (death: hazard ratio: 1.78; 95% confidence interval: 1.22 to 2.59; composite outcome: hazard ratio: 1.94; 95% confidence interval: 1.35 to 2.79). This difference was driven mainly by PCI with a 2-stent technique for distal bifurcation. In contrast, the adjusted risks for these outcomes were similar between DES and CABG for ostial or shaft disease. Among patients with distal LMCA bifurcation disease, CABG showed lower mortality and serious composite outcome rates compared with DES beyond 5 years. However, there were no between-group differences in these outcomes among patients with ostial or shaft LMCA disease.

An unusual presentation requiring an unusual intervention

Stanford type A aortic dissection is associated with significant morbidity and mortality. Acute myocardial infarction is a rare complication and can occur in 3% of patients due to retrograde extension of the dissection leading to coronary malperfusion. Involvement of the right coronary artery is more common. On the other hand, Left Main Coronary Artery (LMCA) occlusion is unusual and if unrecognised, can result in rapid hemodynamic deterioration with cardiogenic shock and eventually death. Emergent surgical repair is the definitive treatment. Intra-Aortic Balloon Pump (IABP) is frequently used in the setting of cardiogenic shock due to LMCA stenosis. In this case it was inserted before the diagnosis of type A aortic dissection was made. This represents a unique case of type A aortic dissection resulting in severe ostial left main coronary artery stenosis in which the IABP was successfully used as a bridge therapy to definitive surgical repair.

Abstract 14310: Elephant Sitting on My Chest: A Tale of Two Vessels

Introduction: A dilated main pulmonary artery (MPA) seen in congenital heart disease (CHD) or pulmonary arterial hypertension (PAH) is a rare cause of angina due to left main coronary artery (LMCA) compression. Case: A 49 year old male with no prior cardiac history presented with substernal chest pain. He reported exercise intolerance for several years. On exam he had an oxygen saturation of 85%, loud P2, fixed split second heart sound and ejection click. Electrocardiogram showed right ventricular (RV) hypertrophy and no significant ST changes. Laboratory data revealed a negative troponin. An enlarged main and right pulmonary artery (RPA) (Figure 1A) was seen on computed tomography (CT) chest angiography for pulmonary embolism (CTPE) and on echocardiography he had a severely dilated RV with decreased function (Figure 1B,1C). Cardiac catheterization showed a step up in saturations from 56 to 71%, Qp:Qs of 1.5 mean MPA pressure of 53 mmHg, pulmonary capillary wedge pressure of 11mmHg and pulmonary vascular resistance (PVR) of 7WU. A slit-like narrowing of LMCA ostium was seen on coronary angiography and intravascular ultrasound (Figure 1D). He was diagnosed with a sinus venosus defect, anomalous right upper pulmonary venous drainage and suspicion for extrinsic compression of LMCA by the dilated RPA that was confirmed on cardiac CT (Figure 1E-I). He was started on triple therapy for PAH with a significant reduction in PA pressures (mean 36 mmHg and PVR 2.1 WU). Percutaneous stenting of the LMCA was deferred and he underwent successful sinus venosus defect repair with a 5mm fenestrated patch, baffling of the anomalous pulmonary veins and a 32 mm interposition graft in the MPA with reduction plasty of MPA/RPA. Conclusion: This is an unusual presentation of unrepaired CHD with angina due to a compressed LMCA from a dilated pulmonary artery. Treatment of the underlying PAH as well as repair of the defect including reduction plasty of the MPA is a consideration for symptomatic relief.

671 Myocardial Infarction Due to Left Main Coronary Artery Compression in Eisenmenger’s Syndrome

Compression of the left main coronary artery (LMCA) is increasingly recognised as a cause of angina, myocardial infarction and sudden death in patients with pulmonary hypertension [[1]Gailé N. Saia F. Pallazini M. et al.Left Main Coronary Artery Compression in Patients With Pulmonary Arterial Hypertension and Angina.JACC. 2017; 69: 2808-28017Crossref Scopus (70) Google Scholar,[2]Demerouti E.A. Manginas A.N. Athanassoupoulos G.D. et al.Complications leading to sudden cardiac death in pulmonary artery hypertension.Resp Care. 2013; 58: 1246-1254Crossref PubMed Scopus (50) Google Scholar]. Here we report a case of myocardial infarction with severe left ventricular dysfunction due to LMCA compression in a patient with Eisenmenger’s Syndrome. A 63-year-old female with Eisenmenger’s Syndrome due to a ventricular septal defect (VSD) and patent ductus arteriosus (PDA) presented with increasing dyspnoea over several weeks. Echocardiography illustrated severe global left ventricular systolic dysfunction (EF 17%), an unrestricted 12mm VSD, dilated and hypertrophied right ventricle with moderate tricuspid and pulmonary regurgitation. Estimated RV systolic pressure was 112mmHg. An ECG was revealed ST-elevation in aVR with widespread ST depression, with an elevated serum troponin of 6.7ug/L (<0.04). The patient had normal coronary angiography 2 years prior. Repeat coronary angiography revealed severe ostial LMCA stenosis due to extrinsic pulmonary artery compression, with the remaining vessels disease free. Percutaneous intervention to the LMCA was performed with a zotarolimus drug eluting stent with excellent angiographic result. Anti-platelets and up-titration of heart failure therapy was initiated. 2 years after discharge, she remains stable with a LVEF of 40% and NHYA Class II symptoms at home with her husband. In patients with pulmonary hypertension, progressive symptoms are often attributed to worsening pulmonary resistance or right heart dysfunction/ischaemia [[1]Gailé N. Saia F. Pallazini M. et al.Left Main Coronary Artery Compression in Patients With Pulmonary Arterial Hypertension and Angina.JACC. 2017; 69: 2808-28017Crossref Scopus (70) Google Scholar,[3]Gómez A. Bialostozky D. Zajarias A. et al.Right ventricular ischaemia in patients with primary pulmonary hypertension.JACC. 2001; 38: 1137-1142Crossref Scopus (179) Google Scholar]. LMCA compression represents an important and treatable cause of myocardial infarction and LV dysfunction with excellent medium-term outcomes.