1. Successful PCI of left main coronary artery caused by pulmonary artery dilatation presenting as ACS

2. Case presentantion 73-year old female
treated for idiopatic pulmonary arterial hypertension since 2006, coronary angiography 2006 without stenosis
no other significant medical history
Medication: verapamil 240mg 1-0-0, bosentan 125mg 1-0-1, sildenafil 20mg 1-1-1, furosemide 40mg 1-0-0, selexipag (oral, selective prostacyclin receptor agonist – study drug) 8-0-8, warfarin 3mg 1-0-0
was admitted at 10 AM to our hospital for acute chest pain with dyspnoe since 7 AM
Physical examination : BP 130/80 mmHg, heart rate 69/min, systolic murmur parasternal right, mild perimaleolar oedema

3. Case presentation Laboratory results Electrocardiography
troponin I μg/l (cut-off for AMI 0.3), INR 2.03
Electrocardiography
sinus rhytm, incomplete right bundle branch block, ST depression 1mm I,aVL,V5-6
Echocardiography
non-dilated left ventricle, paradoxical septal movement, mild anterolateral hypokinesis
right ventricular dilatation and hypertrophy, moderete tricuspid regurgitation, pulmonary hypertension (calculated sTK 90mmHg)
Coronary angiography at 11 AM
via radial artery 6 F sheat (Terumo), diagnostic catheter Tiger (Terumo)

4. Coronary angiography
Severe stenosis of left main coronary artery (90%), no other significant stenosis, codominant system of heart circulation. Heart team decided to perform PCI.

5. Percutaneous coronary intervention
Preventive placement of intra-aortic ballon conterpulsation via right femoral artery, 6F guiding catheter XB3.5 (Cordis), two Advance wires (Abbott), direct implantation of Biomatrix 3,5/14mm stent (Biosensors) from left main to left anterior descending artery with final „kissing“ with two 3,5/10 mm baloons.

6. Case presentantion
After PCI she was without pain. No occurred complication. Maximal value of troponin I was µg/l. She was discharged from hospital after 6 days.
Computed coronary angiography showed patent stent in the left main coronary artery, dilatation and hypertrophy of right ventricle and dilatation of pulmonary artery (40x52mm).
At follow up the patient was symtomatic with stable dyspnoe (III. grade of functional class), no angina, computed tomography was performed after 6 and 16 months without significant restenosis or compression of the stent in the left main coronary artery.

7. Computed coronary angiography
August 2012
December 2013
(Ao – aorta, AP – pulmonary artery, LV – left ventricle)

8. Critical stenosis of left main coronary artery caused by dilated pulmonary artery is a rare, but serious complication of pulmonary arterial hypertension. Treatment with drug-eluting-stent is feasible with safe mid-term follow up.