Acute myocardial infarction with simultaneous total occlusion of the left anterior descending artery and right coronary artery successfully treated with percutaneous coronary intervention

Abstract

Background: Simultaneous thrombosis in more than one coronary artery is an uncommon angiographic finding in patients with acute ST-segment elevation myocardial infarction. It is difficult to identify using 12-lead electrocardiography and usually leads to cardiogenic shock and fatal outcomes, including sudden cardiac death. Therefore, immediate revascularization and adequate mechanical circulatory support are required.

Case presentation: We report the case of a 58-year-old man who presented with vomiting and chest pain complicated by cardiogenic shock and complete atrioventricular block. Electrocardiography revealed ST-segment elevation in leads II, III, aVF, and V1-V6. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery and right coronary artery. The patient successfully underwent primary percutaneous coronary intervention with ballooning and stenting for both arteries. An Impella CP was inserted during the procedure. Fifty-seven days after admission, he had New York Heart Association class II heart failure and was transferred to a rehabilitation hospital.

Conclusions: Acute double-vessel coronary thrombosis, a serious event with a high mortality rate, requires prompt diagnosis and management to prevent complications such as cardiogenic shock and ventricular arrhythmias. A combination of judicious medical treatment, efficient primary percutaneous coronary intervention, and early mechanical support device insertion is crucial to improve the survival rate of patients with this disease.

Keywords: Acute myocardial infarction; Impella CP; Simultaneous total occlusion.

Fig. 1

Chest X-ray 4 months prior to myocardial infarction. Normal findings are obsreved

Fig. 2

Computed tomography 5 months prior to myocardial infarction. A Calcification of the left anterior descending artery is seen (arrow). B Slight calcification of the right coronary artery is seen (arrow)

Fig. 3

Magnetic resonance images of the brain 3 months prior to myocardial infarction. A Axial T2-weighted FLAIR MRI showing low intensity of the corona radiata (arrow). B Frontal view from magnetic resonance angiography showing stenosis of the left middle cerebral artery (arrow)

Fig. 4

Electrocardiogram obtained before myocardial infarction. No ischemic changes are seen

Fig. 5

Echocardiogram obtained before myocardial infarction. Normal vetricular function is seen in the long-axis, short-axis, and four-chamber views in diastole (A, B, C, respectively) and systole (a, b, c, respectively)

Fig. 6

Electrocardiogram of the patient on arrival at the emergency room. Complete atrioventricular block; ST-segment elevation in leads V1-V6, II, III, and aVF; and ST-segment depression in leads I and aVL are seen

Fig. 7

Emergency coronary angiography images. A Right coronary angiography image shows total occlusion of the proximal right coronary artery (arrow). B Left coronary angiography image shows total occlusion of the proximal left anterior descending artery (arrow)

Fig. 8

Post-stenting coronary angiography image. No residual stenosis and thrombolysis in myocardial infarction grade III recanalization are seen in the right coronary artery (A) and left anterior descending artery (B)

Fig. 9

Magnetic resonance images of the brain after 8 days of removal of Impella device. A Axial diffusion-weighted MRI showing hyperintensity in the corona radiata (arrow). B Axial T2-weighted FLAIR MRI showing similar findings (arrow). C Frontal view from magnetic resonance angiography showing stenosis of the left middle cerebral artery (arrow)