J INVASIVE CARDIOL 2018;30(8):E71-E72.
Key words: acute myocardial infarction, cardiac computed tomography, cardiac imaging
A 76-year-old male with a history of hypertension, dyslipidemia, smoking, and a family history of coronary artery disease presented to his local hospital following a non-ST segment elevation myocardial infarction. Selective coronary angiography was unsuccessful due to a severely dilated aneurysmal aortic root and associated aortic valve regurgitation, despite the use of the following catheters: Tiger 4.0; Judkins left 4, 5, 6; EBU 6.0; Amplatz left 1, 2, 3; MPB, and Judkins right 4.0. The patient was referred to our tertiary center for computed tomography (CT) aorta and coronary angiography. CT aorta demonstrated aortic dilatation of 7.4 cm just beyond the sinotubular junction (Figure 1), with slight displacement of the coronary ostia secondary to the marked aneurysmal dilatation. CT coronary angiography was inconclusive; it reported severe calcification in the left main stem (LMS) with concern of flow-limiting disease, a likely 70% stenosis in the mid right coronary artery (RCA), and indeterminate findings in the left anterior descending (LAD) and circumflex (LCX) arteries due to calcification. Echocardiography reported moderate-severe aortic regurgitation, with preserved left ventricular systolic function.
Repeat coronary angiography was performed at our center. Sub-selective coronary angiography of the RCA was possible with a 7 Fr Amplatz Left 3.0 guide catheter demonstrating unobstructive disease. Selective coronary angiography of the LMS was achieved with telescopic extension of a 7 Fr EBU 5.0 guide catheter with a 6 Fr GuideLiner coaxial guide-catheter extension (Vascular Solutions) (Figure 2), demonstrating severe LMS calcific stenosis and atheromatous but unobstructed LAD and LCX arteries. The patient subsequently underwent successful aortic root replacement with a tissue aortic valve, and concurrent coronary artery bypass graft surgery from the aorta to the LAD. He stepped down from cardiothoracic intensive care within 24 hours postoperatively.
Selective coronary angiography in patients with severely dilated aortas awaiting surgery is challenging, but was critical in this case given the severe LMS stenosis. This was achieved in a relatively straightforward manner with the use of a mother-in-child guide-catheter extension. This method is more simple than more traditional methods, whereby a 125 cm 4 Fr multipurpose angiographic catheter is inserted through a 110 cm 5 or 6 Fr EBU or Amplatz left catheter, and allows percutaneous coronary intervention when indicated.
*Joint first authors.
From the St George’s University Hospitals NHS Foundation Trust, London, United Kingdom.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted March 14, 2018.
Address for correspondence: Rupert Williams, BSc (Hons), PhD, MRCP, Department of Cardiology, St. George’s University Hospitals NHS Foundation Trust,
London, SW17 0QT. Email: firstname.lastname@example.org