Author + information
- Received August 15, 2016
- Revision received September 12, 2016
- Accepted September 22, 2016
- Published online December 12, 2016.
- Koki Shishido, MD∗ (, )
- Noriaki Moriyama, MD,
- Toshimitsu Shimizu, RT and
- Shigeru Saito, MD
- ↵∗Reprint requests and correspondence:
Dr. Koki Shishido, Department of Cardiology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, 247-8533, Japan.
A 62-year-old female tourist without significant cardiovascular risk factors presented with acute chest pain. She came from the United States to Japan 5 days earlier by plane. When she had been transferred to our emergency department by ambulance, she was in cardiogenic shock, and her initial blood pressure was 63/48 mm Hg. The electrocardiogram (ECG) demonstrated widespread ST-segment depression plus ST-segment elevation in lead aVR (Figure 1A). The echocardiogram showed severe hypokinesis of left ventricular (LV) wall motion with paradoxical interventricular septum (Online Video 1). The emergent coronary angiogram showed very tight narrowing in an anomalous left main coronary artery (LMCA) arising from the right coronary cusp (Figure 1B). A drug-eluting stent (Ultimaster 3.5/18 mm, Terumo Corporation, Tokyo, Japan) was successfully implanted in the LMCA lesion with intra-aortic balloon counterpulsation (Figure 1C). Blood pressure, hypotension, and ECG change were recovered after primary percutaneous coronary intervention. Two weeks later, we could see the patent LMCA stent, which was sandwiched between the pulmonary artery (PA) and aorta by computed tomography imaging (Figures 1D and 1E). In addition, we could find a lot of thrombus in both pulmonary arteries (Figures 1F and 1G). We hypothesized that her LMCA was compressed between the ascending aorta and PA because the PA pressure had gone up suddenly due to massive acute pulmonary thromboembolism. Pulmonary thrombus improved by use of an anticoagulation drug a few weeks later. The echocardiogram demonstrated good LV function with complete resolution of the right ventricular dysfunction (Online Video 2). This case illustrates a very unusual etiology of myocardial infarction in LMCA.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 15, 2016.
- Revision received September 12, 2016.
- Accepted September 22, 2016.
- 2016 American College of Cardiology Foundation