Coronary Artery Straightening Causing Acute Severe Mitral Regurgitation

J INVASIVE CARDIOL 2018;30(2):E18-E19.

Key words: cardiac imaging, non-ST elevation myocardial infarction, mitral regurgitation

A 79-year-old woman with type 2 diabetes mellitus, hypertension, hyperlipidemia, permanent pacemaker, and coronary artery bypass graft 2 years prior presented with non-ST elevation myocardial infarction. She underwent coronary angiography and was found to have an atretic left internal mammary artery (LIMA) to left anterior descending (LAD) but without significant LAD stenosis, patent saphenous vein graft (SVG) to first obtuse marginal (OM1), patent SVG to right coronary artery, and severe tandem lesions in a very tortuous left circumflex (LCX) artery (Figure 1A; Video 1) for which she underwent percutaneous coronary intervention (PCI). Placement of a BMW coronary guidewire (Abbott Vascular) into the LCX resulted in the straightening of the vessel (Figure 1B; Video 2). The patient developed severe chest pain and became hypotensive; hypotension improved with phenylephrine. The LCX lesions were quickly predilated and then stented with two stents (Figure 1C; Video 3). Despite the establishment of TIMI 3 flow with PCI and good angiographic result, the patient developed respiratory distress and hypoxemia with continuation of chest pain. Following guidewire withdrawal (Figure 1D; Video 4), the patient’s chest pain resolved but she remained in respiratory distress. Right heart catheterization was performed and showed the following pressures: pulmonary artery, 26/14 mm Hg (18 mm Hg); pulmonary capillary wedge, 18 mm Hg; and V-wave at 30 mm Hg. Bedside transthoracic echocardiography (TTE) confirmed the presence of severe acute mitral regurgitation (MR) (Figure 2A; Video 5). The patient was monitored in the Cardiac Care Unit; by the first hour, her respiratory symptoms resolved. Repeat TTE showed her baseline mild MR (Figure 2B; Video 6). Two years later, the patient continued to have good functional capacity and remained asymptomatic.

Coronary artery straightening by guidewires can lead to pseudolesions, which may result in unnecessary stent implantation. Also, this phenomenon may result in occlusion of severely tortuous vessels, commonly seen in LIMA grafts,¹ which can make assessment of distal vessels very challenging. Moreover, these pseudolesions can result in false-positive fractional flow reserve.^2,3 In the current case, coronary straightening caused transient ischemia, resulting in acute MR that resolved shortly after PCI.

View the video series here.

References

1.    Zanchetta M, Pedon L, Rigatelli G, Olivari Z, Zennaro M, Maiolino P. Pseudo-lesion of internal mammary artery graft and left anterior descending artery during percutaneous transluminal angioplasty – a case report. Angiology. 2004;55:459-462.

2.    Zegers ES, Meursing BT, Zegers EB, Oude Ophuis AJ. Coronary tortuosity: a long and winding road. Neth Heart J. 2007;15:191-195.

3.    Sareen N, Baber U, Kezbor S, et al. Clinical and angiographic predictors of haemodynamically significant angiographic lesions: development and validation of a risk score to predict positive fractional flow reserve. EuroIntervention. 2017;12:e2228-e2235.

From the ¹Division of Cardiology, Case Western Reserve University (CWRU) School of Medicine, Cleveland, Ohio; and the ²Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.

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 June 12, 2017. 

Address for correspondence: John S. Douglas, Jr, MD, Andreas Gruentzig Cardiovascular Center, 1364 Clifton Road, Atlanta, GA 30322. Email: jdoug01@emory.edu