Chronic Dissection of Left Sinus of Valsalva Obscuring Left Main Coronary Artery

J INVASIVE CARDIOL 2019;31(7):E233.

Key words: angiography, chronic dissection, computed tomography, sinus of Valsalva

A 44-year-old woman with type 2 diabetes and hypertension was referred for coronary angiography after non-ST segment elevation myocardial infarction. Echocardiography demonstrated left ventricular ejection fraction of 61% with normal regional-wall motion and severe aortic regurgitation. We were unable to identify the left coronary artery. The right coronary artery origin was normal, with no stenosis. There was good collateral flow from the right posterolateral branch to the obtuse marginal branch (Figure 1A and Video 1). We accidentally engaged the right conus branch with an Amplatz left (AL) 0.75 diagnostic catheter. Angiography demonstrated good collateral flow from the conus branch to the mid left anterior descending artery with retrograde flow to the left main coronary artery (LMCA) and left coronary cusp (Figure 1B and Video 2). There was no stenosis in the LMCA. Coronary computed tomography angiography revealed a focal dissection flap in the left sinus of Valsalva, creating a false lumen covering the origin of the LMCA (Figure 1C). The intimal flap in the left coronary sinus was also attached to the left aortic leaflet, causing incomplete closure of the aortic valve.

In this patient, we demonstrated chronic dissection of the left sinus of  Valsalva, totally obscuring the LMCA, with good collaterals supplying the left coronary system from the right coronary artery.

View Supplemental Video.

From Her Majesty Cardiac Center, Siriraj Hospital, Bangkok, Thailand.

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.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 12, 2018.

Address for correspondence: Korakoth Towashiraporn, MD, 7th floor, Her Majesty Cardiac Center, Siriraj Hospital, Bangkok Noi, Bangkok, Thailand, 10700. Email:  korakonov@yahoo.com