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Case Reports
. 2023 Sep 1;10(9):374.
doi: 10.3390/jcdd10090374.

ST-Segment Elevation: An Unexpected Culprit

David Sá Couto  1   2 , André Alexandre  1   2 , Ricardo Costa  1 , Andreia Campinas  1   2 , Mariana Santos  1   2 , Diana Ribeiro  1 , Severo Torres  1   2 , André Luz  1   2   3
Affiliations
Case Reports

ST-Segment Elevation: An Unexpected Culprit

David Sá Couto et al. J Cardiovasc Dev Dis. .

Abstract

The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1-V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.

Keywords: ST-segment; acute pulmonary embolism; aspiration thrombectomy; catheter-directed therapy; intervention cardiology; thrombolysis.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Twelve-lead electrocardiogram preformed after return of spontaneous circulation. Note the irregular rhythm with a few monomorphic premature ventricular complexes and ST-segment elevation in V1, V2, V3 and aVR, with ST-segment depression in DI, aVL and V6.
Figure 2
Figure 2
Coronary angiography showing absence of clinically significant epicardial coronary artery disease: left anterior descending (left picture) has a 50% stenosis, circumflex (middle picture), and right coronary artery (right picture) shows only mild irregularities.
Figure 3
Figure 3
Pulmonary angiography showing bilateral massive pulmonary embolism with complete proximal occlusion of the right pulmonary artery (left picture) and left lobar branch thrombotic occlusion (right picture).
Figure 4
Figure 4
Pulmonary angiography after aspiration thrombectomy and bilateral alteplase bolus. There was perfusion improvement despite the remaining high thrombotic burden and significant distal embolism.
Figure 5
Figure 5
Postprocedural ECG showing resolution of the expressive ST-segment elevation seen at admission. The patient was in atrial fibrillation and showed significant intraventricular conduction abnormalities, left axis deviation and persisting millimetric ST-segment elevation in V1.
Figure 6
Figure 6
Post-procedural thoracic Angio-CT showing persisting large bilateral pulmonary embolism with significant thrombotic burden.
Figure 7
Figure 7
Post-procedure transthoracic echocardiogram (apical 4-chamber view) with preserved biventricular systolic function and normal-sized cardiac chambers.
See this image and copyright information in PMC

References

    1. Pollack C.V., Schreiber D., Goldhaber S.Z., Slattery D., Fanikos J., O’Neil B.J., Thompson J.R., Hiestand B., Briese B.A., Pendleton R.C., et al. Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: Initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry) J. Am. Coll. Cardiol. 2011;57:700–706. doi: 10.1016/j.jacc.2010.05.071. - DOI - PubMed
    1. Stein P.D., Matta F., Hughes P.G., Hughes M.J. Nineteen-Year Trends in Mortality of Patients Hospitalized in the United States with High-Risk Pulmonary Embolism. Am. J. Med. 2021;134:1260–1264. doi: 10.1016/j.amjmed.2021.01.026. - DOI - PubMed
    1. Konstantinides S.V., Meyer G., Becattini C., Bueno H., Geersing G.J., Harjola V.-P., Huisman M.V., Humbert M., Jennings C.S., Jiménez D., et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) Eur. Heart J. 2020;41:543–603. doi: 10.1093/eurheartj/ehz405. - DOI - PubMed
    1. Ibanez B., James S., Agewall S., Antunes M.J., Bucciarelli-Ducci C., Bueno H., Caforio A.L.P., Crea F., Goudevenos J.A., Halvorsen S., et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC) Eur. Heart J. 2018;39:119–177. doi: 10.1093/eurheartj/ehx393. - DOI - PubMed
    1. Wang K., Asinger R.W., Marriott H.J. ST-segment elevation in conditions other than acute myocardial infarction. N. Engl. J. Med. 2003;349:2128–2135. doi: 10.1056/NEJMra022580. - DOI - PubMed

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