Left Main Coronary Spasm: an Extremely Rare Entity with Possible Life-Threatening Complications

Abstract

Coronary artery spasm is a known cause of acute coronary syndrome. However, left main coronary spasm is an extremely rare entity and can present in different ways depending on the duration and severity of the spasm. We present a 44-year-old female patient who presented with transient ST elevation in the lead aVR and ST depression in the lateral and inferior leads. Coronary angiography showed mid left main and ostial right coronary artery spasm that significantly improved after intracoronary nitroglycerine administration. Intravascular ultrasound showed no significant left main coronary atherosclerosis. She was treated chronically with calcium channel blockers (CCB), nitrates, and arginine with significant improvement. In conclusion, left main coronary spasm is an extremely rare entity with wide spectrum of clinical manifestations. Definite etiology is still questionable, and special precaution is needed during coronary angiography in order not to be confused with significant fixed lesions. Intravascular ultrasound can be valuable in excluding underlying atherosclerosis. Medical management with nitrates acutely then CCB is the mainstay of chronic management with PCI preserved to refractory cases.

Keywords

coronary intervention - left main coronary artery spasm - acute coronary syndrome - ischemia - cardiac catheterization - intravascular ultrasound

Note

The work was done at the University of Nebraska Medical Center, Omaha, NE.

• References

• 1 Lanza GA, Careri G, Crea F. Mechanisms of coronary artery spasm. Circulation 2011; 124 (16) 1774-1782
• 2 Ong P, Athanasiadis A, Hill S, Vogelsberg H, Voehringer M, Sechtem U. Coronary artery spasm as a frequent cause of acute coronary syndrome: The CASPAR (Coronary Artery Spasm in Patients With Acute Coronary Syndrome) Study. J Am Coll Cardiol 2008; 52 (7) 523-527
• 3 Ali F, Faraz HA, Siddiqui MU. Left main coronary artery spasm—a rare entity as a cause of myocardial infarction in a patient. J Invasive Cardiol 2013; 25 (2) E36-E38
• 4 Michelis KC, Olin JW, Kadian-Dodov D, d'Escamard V, Kovacic JC. Coronary artery manifestations of fibromuscular dysplasia. J Am Coll Cardiol 2014; 64 (10) 1033-1046
• 5 MacAlpin RN. Some observations on and controversies about coronary arterial spasm. Int J Cardiol 2015; 181: 389-398
• 6 Duygu H, Yavuzgil O, Erturk U, Zoghi M, Ozerkan F. ST-segment elevation in lead augmented vector right may also be caused by diffuse left main coronary artery vasospasm without fixed stenosis. Clin Cardiol 2008; 31 (4) 179-182
• 7 Zaya M, Mehta PK, Merz CN. Provocative testing for coronary reactivity and spasm. J Am Coll Cardiol 2014; 63 (2) 103-109
• 8 Lee SY, Yu CW, Choi YJ , et al. A comparison of clinical features of coronary artery spasm with and without thyrotoxicosis. Coron Artery Dis 2014; 25 (2) 125-132
• 9 Jung KY, Kang TS. A case of acute myocardial infarction with ST-segment elevation in a lead augmented right vector caused by a left main coronary artery vasospasm. Korean Circ J 2012; 42 (1) 50-53
• 10 Ong P, Athanasiadis A, Borgulya G, Voehringer M, Sechtem U. 3-year follow-up of patients with coronary artery spasm as cause of acute coronary syndrome: the CASPAR (coronary artery spasm in patients with acute coronary syndrome) study follow-up. J Am Coll Cardiol 2011; 57 (2) 147-152
• 11 Khatri S, Webb JG, Carere RG, Dodek A. Stenting for coronary artery spasm. Catheter Cardiovasc Interv 2002; 56 (1) 16-20
• 12 Mohammed AA, Yang A, Shao K , et al. Patients with left main coronary artery vasospasm inadvertently undergoing coronary artery bypass grafting surgery. J Am Coll Cardiol 2013; 61 (8) 899-900