Left main coronary artery dissection revealed by transoesophageal echocardiography.

A 68-year-old woman was referred to our department after presenting late anterior ST-elevation myocardial infarction. Coronary angiography revealed severe atherosclerosis and a giant aneurysm of the proximal left anterior descending coronary artery (Supplementary material online, ). A surgical approach combining aneurysm exclusion and coronary artery bypass grafting (CABG) using the left internal mammary artery was recommended. Echocardiography showed a preoperative left ventricular ejection fraction (LVEF) of 38%. Intraprocedurally, the ascending aortic cannulation caused an extensive aortic haematoma with dissection. Aortic dissection was repaired using Bahnson’s technique (supracoronary aortic replacement); cannulation was replaced in carotid and femoral position and planned CABG was performed.

In the immediate post-operative period, patient was unstable under extracorporeal membrane oxygenation. Left ventricular ejection fraction decreased to 15%. Electrocardiogram was unchanged, whereas high-sensitive troponin I raised to 50 000 ng/L (N < 34 ng/L). Three-dimensional transoesophageal echography (TOE) demonstrated a flap in the ascending aorta (Supplementary material online, ) below the aortic tube extending to the origin of the left main coronary artery (, Supplementary material online, ). Emergent coronary angiography confirmed the dissection of the entire left coronary artery (, Supplementary material online, ), which was treated by direct stenting of the left main and the left circumflex arteries (Supplementary material online, ). At follow-up 6 months later, the patient described New York Heart Association Class II dyspnoea with a calculated LVEF of 30%.

Modified mid-oesophageal transoesophageal echocardiography view (bi-commissural view; transducer angle: ∼60°) showing a flap in the left coronary artery similar to that one observed in the ascending aorta (Supplementary material online, ). LA, left atrium; LAA, left atrial appendage; LV, left ventricle.

Coronary angiography revealed the dissection of the left main coronary artery (white arrows) extending to the entire left coronary artery.

Intraoperative aortic dissection is a rare and potentially fatal complication of open-heart operations. Intraoperative aortic dissection is most commonly iatrogenic in origin. In some cases of ascendant aortic dissection, the intimal flap propagates retrogradely to involve the origin of one or both coronary arteries. Intraoperative TOE usually helps assessing aorta, valves, global, and regional left ventricular function. To our best knowledge, this observation is the first to describe a left main coronary artery dissection initially diagnosed using Three-dimensional TOE and confirmed by coronary angiography.

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