Coronary microvascular dysfunction in patients with mild-to-moderate aortic stenosis – Insights from intracoronary acetylcholine testing

摘要

Representative case of an 84-year old man with exercise-related dyspnea and anginal symptoms at rest. Diagnostic assessments revealed a moderate aortic stenosis and microvascular spasm induced by acetylcholine provocation testing. Echocardiography - to assess the severity of the aortic stenosis - showed a Vmax of 379 cm/s and a mean pressure gradient (MPG) of 34 mmHg (A). Coronary angiography revealed unobstructed coronary arteries (RCA and LCA), a left ventricular end-diastolic pressure of 18 mmHg and a calculated aortic orifice area of 1.1 cm2(B). The aortic stenosis was thus considered moderate. Additional assessment of coronary vasomotion was carried out with acetylcholine testing (C). After intracoronary (i.c.) administration of 100 µg the patient reported a reproduction of his usual symptoms and ischemic ECG-changes (red arrows) without significant epicardial vasoconstriction could be observed (C, upper panel). Subsequent i.c. administration of 0.2 mg nitroglycerine (NTG) led to a resolution of the symptoms and normalization of the ECG (C, lower panel). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)