Recurrent myocardial infarction in a patient with median arcuate ligament syndrome: a case report and literature review

Abstract

Median arcuate ligament (MAL) syndrome, otherwise known as celiac artery compression syndrome, is rare and is characterized by celiac artery compression by the median arcuate ligament. We report a unique case of MAL syndrome with recurrent myocardial infarction as the primary manifestation, and offer new pathophysiological insights. A man in his early 50s experienced recurrent upper abdominal pain, electrocardiographic changes, and elevated troponin concentrations, which suggested myocardial infarction. Contrast-enhanced computed tomography showed considerable celiac artery stenosis due to MAL syndrome. The patient was diagnosed with MAL syndrome and acute myocardial infarction. He declined revascularization owing to economic constraints, and opted to have conservative treatment with Chinese herbal extracts and medications. He succumbed to sudden cardiac death during a subsequent abdominal pain episode. The findings from this case show that MAL syndrome can present with recurrent myocardial infarction rather than typical intestinal angina symptoms. The pathophysiological link may involve intestinal and cardiac ischemia. An accurate diagnosis and appropriate management of MAL syndrome require careful evaluation and investigation.

Keywords: Myocardial infarction; abdominal pain; case report; celiac artery; median arcuate ligament syndrome; troponin.

Figure 1.

(a) In column 1, 12-lead electrocardiography (ECG) shows slight horizontal ST-segment elevation and high T waves in leads V2 to V5 on 3 October 2018. In column 2, 12-lead ECG shows restoration of the ST segment to baseline and a slight reduction in T wave amplitude in leads V2 to V5 on 4 October 2018. In column 3, 18-lead ECG shows ST segment elevation in leads I, II, aVL, aVF, V2 to V6, and V3R to V5R on 30 October 2018. In column 4 (5 minutes after the ECG shown in column 3), the ST segment has returned to baseline and the patient’s pain has spontaneously subsided. In column 5 (2 hours after the ECG shown in column 3), the ECG is normal. In column 6, 18-lead ECG remains normal on 31 October 2018. In column 7, an 18-lead ECG is normal at admission on 30 November 2018. In column 8, ECG shows complete atrioventricular conduction block and a ventricular escape rhythm after resuscitation on 30 November 2018 and (b) ECG after resuscitation on 30 November 2018 shows complete atrioventricular conduction block and a ventricular escape rhythm in lead II.

Figure 2.

Coronary angiography shows the left circumflex artery (LCX), left anterior descending artery (LAD), and right coronary artery (RCA). (a) The right anterior oblique (RAO) view at 30° shows the LCX. (b) The left anterior oblique (LAO) view at 45° combined with the cranial (CRA) view at 30° shows the LAD. (c) The anteroposterior (AP) view + CRA 30° shows the LAD and (d) LAO 45°shows the RCA.

Figure 3.

Computed tomographic scanning with contrast enhancement shows severe stenosis of the celiac artery. Arrows in panels a and b show the median arcuate ligament and compressed celiac artery. Arrows in panels c and d show the compressed celiac artery.