Left Main Coronary Artery Compression in Patients With Pulmonary Arterial Hypertension

Left main coronary artery compression by dilated pulmonary artery in pulmonary arterial hypertension: a systematic review and meta-analysis

OBJECTIVE

Pulmonary arterial hypertension (PAH) can lead to left main coronary artery compression (LMCo), but data on the impact, screening and treatment are limited. A meta-analysis of LMCo cases could fill the knowledge gaps in this topic.

METHODS

Electronic databases were searched for all LMCo/PAH studies, abstracts and case reports including pulmonary artery (PA) size. Restricted maximum likelihood meta-analysis was used to evaluate LMCo-associated factors. Specificity, sensitivity and accuracy of PA size thresholds for diagnosis of LMCo were calculated. Treatment options and outcomes were summarized.

RESULTS

A total of five case-control cohorts and 64 case reports/series (196 LMCo and 438 controls) were included. LMCo cases had higher PA diameter (Hedge's g 1.46 [1.09; 1.82]), PA/aorta ratio (Hedge's g 1.1 [0.64; 1.55]) and probability of CHD (log odds-ratio 1.22 [0.54; 1.9]) compared to non-LMCo, but not PA pressure or vascular resistance. A 40 mm cut-off for the PA diameter had balanced sensitivity (80.5%), specificity (79%) and accuracy (79.7%) for LMCo diagnosis, while a value of 44 mm had higher accuracy (81.7%), higher specificity (91.5%) but lower sensitivity (71.9%). Pooled mortality after non-conservative treatment (n = 150, predominantly stenting) was 2.7% at up to 22 months of mean follow-up, with 83% survivors having no angina at follow-up.

CONCLUSION

PA diameter, PA/aorta ratio and CHD are associated with LMCo, while hemodynamic parameters are not. Data from this study support that a PA diameter cut-off between 40 and 44 mm can offer optimal accuracy for LMCo screening. Preferred treatment was coronary stenting, associated with low mid-term mortality and symptom relief. Diagnosis and management of left main coronary artery compression (LMCo) in patients with pulmonary arterial hypertension (PAH).

Establishing expert consensus for the optimal approach to holistic risk-management in pulmonary arterial hypertension: a Delphi process and narrative review

Background: Pulmonary arterial hypertension (PAH) is associated with significant morbidity and reduced life expectancy. Various medical therapies, together with non-medical therapies such as exercise training, have been shown to improve outcomes for patients. We performed a Delphi consensus process to establish optimal approaches to optimizing patient care.Methods: A steering group of PAH experts formulated 38 statements grouped into 6 themes: burden of PAH, risk-stratification, the role of clinical phenotyping in the management of PAH, assessing clinical response to treatment, maximizing the medical treatment pathway and the role of other management options. An online survey was sent to PAH health-care professionals throughout the UK to assess consensus with these statements. Consensus was defined as high if ≥70% and very high if ≥90% of the respondents agreed with a statement. A narrative review for each theme was then performedResults: Consensus was very high in 27 (71%) statements, high in 7 (18%) statements and was not achieved in 4 (11%) statements.Conclusions: Based on the consensus scores, the steering group derived 13 recommendations which, if implemented, should result in improved holistic care of patients with PAH.

Decreased size of the left anterior descending coronary artery is an independent predictor of deterioration in non-high-risk patients with acute pulmonary embolism

To evaluate the efficacy of measuring left coronary artery size to predict deterioration in non-high-risk acute pulmonary embolism (PE) patients. This retrospective study enrolled non-high-risk acute PE patients from January 2011 to December 2019. Patient deterioration was defined as the occurrence of adverse events within 30 days of hospital admission. Patients with adverse events were sex- and age-matched to patients without adverse events. Risk stratification was performed. Cross-sectional areas (CSAs) of the left main and left anterior descending (LAD) coronary artery inlets were measured. The main pulmonary artery (MPA) inlet and outlet and MPA LAD plane, which adjoined the LAD in the MPA, were reconstructed. CSAs, perimeters, and hydraulic diameters were measured to evaluate MPA size and deformation. Cardiac volume was also measured. Quantitative parameters were divided into tertiles. After adjustment by risk stratification, univariate and multivariate analyses were performed. Correlations between different parameters were analysed. Seventy-three patients with adverse events were matched to 73 patients without adverse events. The results of the univariate and multivariate analyses revealed that LAD inlet CSAs (middle and high) predicted adverse events (odds ratio: 0.28 and 0.07, 95% confidence interval: 0.10-0.77 and 0.02-0.22, p = 0.013 and < 0.0001). LAD inlet CSA was strongly and negatively correlated with MPA LAD hydraulic diameter and CSA (correlation coefficients: - 0.643 and - 0.604, p < 0.001). LAD inlet CSA measurement would facilitate adverse event prediction in non-high-risk acute PE patients on the basis of risk stratification. The dilated MPA may involve the decrease in LAD inlet CSA.

Extrinsic compression of left main coronary artery by aneurysmal pulmonary artery in severe pulmonary hypertension: its correlates, clinical impact, and management strategies

Aims

Although left main coronary artery (LMCA) compression (Co) by pulmonary artery (PA) aneurysm (A) has been reported in some pulmonary hypertension (PH) series, clinical importance and management of this complication remain to be determined. In this single-centre prospective study, we evaluated correlates, clinical impact, and management strategies of LMCA-Co in patients with PH.

Methods and results

Our study group comprised 269 (female 166, age 52.9 ± 17.3 years) out of 498 patients with confirmed PH who underwent coronary angiography (CA) because of the PAA on echocardiography, angina or incidentally detected LMCA-Co during diagnostic evaluation with multidetector computed tomography. The LMCA-Co ≥ 50% was documented in 22 patients (8.2%) who underwent CA, and stenosis were between 70% and 90% in 14 of these. Univariate comparisons revealed that a younger age, a D-shaped septum, a higher PA systolic, diastolic, and mean pressures and pulmonary vascular resistance, a larger PA diameter, a smaller aortic diameter and pulmonary arterial hypertension associated with patent-ductus arteriosus, atrial or ventricular septal defects were significantly associated with LMCA-Co. Bare-metal stents were implanted in 12 patients and 1 patient underwent PAA and atrial septal defect surgery and another one declined LMCA stenting procedure.

Conclusion

Our study demonstrates that LMCA-Co is one of the most important and potentially lethal complications of severe PH, and alertness for this risk seems to be necessary in specific circumstances related with PAA. However, long-term benefit from stenting in this setting remains as a controversy.

Left main coronary artery compression by pulmonary artery aneurism in patients with long standing pulmonary arterial hypertension

This review focuses on a rare complication of pulmonary arterial hypertension (PAH), extravasation compression of the left coronary artery (LCA) dilated by the pulmonary artery. The review described clinical manifestations and methods for diagnostics of LCA compression, and advantages of the endovascular correction of this complication in patients with pulmonary hypertension. Selection of a device to be implanted during the endovascular intervention in these patients was discussed with due account for concomitant treatment with oral anticoagulants. As an illustration of the issue under discussion, a clinical case of acute coronary syndrome in a female patient from the PAH Registry of the V. A. Almazov National Medical Research Center was provided.