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Cardiovascular Disease |

Spontaneous Left Main Spasm: A Therapeutic Dilemma

Yulanka Castro Dominguez, MD; Atish Mathur, MD; Pranaychandra Vaidya, MD
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Rutgers University - New Jersey Medical School, Bloomfield, NJ


Chest. 2015;148(4_MeetingAbstracts):68A. doi:10.1378/chest.2281754
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Abstract

SESSION TITLE: Cardiovascular Disease Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Spasm of the left main coronary artery (LMCA) is a very rare cause of acute coronary syndrome, with a reported incidence of 1%. We report 2 cases of severe left main spasm during coronary angiography, one successfully managed with medical therapy and a second requiring coronary artery bypass surgery (CABG) .

CASE PRESENTATION: Case #1. A 49 year old man with history of diabetes, hypercholesterolemia, tobacco use and percutaneous coronary intervention (PCI) with implantation of drug-eluting stent (DES) in proximal left anterior descending (LAD) artery, presented with one month history of worsening angina. Nuclear stress test showed moderate size reversible ischemia in the anterior wall with a left ventricular ejection fraction (EF) of 60%. Diagnostic left heart catheterization (LHC) showed severe 95% stenosis of the LMCA. Intracoronary nitroglycerin was administered with an improvement of the LMCA stenosis to 30% stenosis. Patient remained asymptomatic during and after the procedure and was discharged on oral nitrates and calcium channel blockers (CCB) in addition to aspirin and atorvastatin. Case #2. A 66 year old man with history of hypertension, hypercholesterolemia, peripheral artery disease, bilateral renal artery stenting and known non-flow limiting obstructive disease of proximal LAD presented with a non-ST elevation myocardial infarction (NSTEMI). LHC showed significant spasm of the LMCA (95%), which improved after intracoronary nitroglycerin with 30% residual stenosis. LV angiogram showed an EF of 35-40% with new akinesis and ballooning of the anterior wall and the apical segments. He was started on oral nitrates, CCB and ranolazine drug therapy. He continued to have recurrent chest pain with ischemic T-wave inversions in anterolateral leads despite maximum vasodilator therapy. He was taken for CABG where he received a left internal mammary artery (LIMA) graft to the LAD and a saphenous venous (SV) graft to the D1. His perioperative course was complicated with episodes of profound hypotension requiring re-exploration of the LIMA graft, IV nitroglycerin, counter pulsation with intra-aortic balloon pump and inotropic support. He ultimately recovered over the next few days.

DISCUSSION: PCI has been used effectively to treat vasospastic angina refractory to maximal medical therapy in cases where there is moderate to significant obstructive atherosclerotic disease. CABG is also a therapeutic option but still remains controversial. Some advocates report its effectiveness in persistent angina despite medical therapy, while other series report unfavorable results.

CONCLUSIONS: Given the large area of myocardium at risk when the LMCA is involved intervention should be considered early when spasm persists despite maximal medical therapy.

Reference #1: Ali, F., Faraz, H. A., & Siddiqui, M. U. (2013). Left main coronary artery spasm--a rare entity as a cause of myocardial infarction in a patient. The Journal of Invasive Cardiology, 25(2), E36-38.

DISCLOSURE: The following authors have nothing to disclose: Yulanka Castro Dominguez, Atish Mathur, Pranaychandra Vaidya

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