- Email: [email protected]
Coronary Kinking with Serious Consequences
International Journal of Cardiology 177 (2014) e39–e41
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Coronary Kinking with Serious Consequences Hendrik Bonnemeier ⁎ Klinik für Innere Medizin III, Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, D-24105 Kiel, Germany
a r t i c l e
i n f o
Article history: Received 6 August 2014 Accepted 9 August 2014 Available online 15 August 2014 Keywords: Coronary kinking Hypertensive heart disease STEMI
A 49-year-old woman with a history of arterial hypertension presented to the emergency room with left-sided chest pain. Two years before, she was admitted with the same symptoms — noninvasive cardiac assessment including a stress electrocardiogram (ECG) revealed no abnormalities except for echocardiographic signs of concentric myocardial hypertrophy. The initial ECG recorded in the field by paramedics exhibited an acute inferior ST-segment-elevation myocardial infarction with STsegment elevation in II, III, aVF and ST-segment depression in aVL (Fig. 1A). Approximately 10 min after receiving aspirin, heparin, and a loading dose of clopidogrel, the patient had complete ST-segment resolution (Fig. 1B). An initial echocardiogram revealed severe myocardial hypertrophy without regional wall motion abnormalities. Serum chemistry revealed elevated levels of cardiac troponin T (0.18 μg/L) and creatine kinase MB isoenzyme (23 U/L). In view of these findings, the
⁎ Tel.: +49 431 597 1441; fax: +49 431 597 5190. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2014.08.063 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
patient received a glycoprotein IIb–IIIa inhibitor and was referred for cardiac catheterization. Left ventricular angiography demonstrated a good left ventricular systolic function without wall motion abnormalities (Fig. 2A, B). Coronary angiography revealed “corkscrew appearance”, suggestive for hypertensive heart disease (Fig. 2C). At first glance the coronary arteries exhibited no significant arteriosclerosis or thrombotic correlates (Fig. 3A, B). However, on closer appraisal only a few sequences of the coronary angiogram revealed a significant stenosis of the proximal right coronary artery (RCA) due to a severe systolic kinking (Fig. 3C). This finding was confirmed by intravascular ultrasound (IVUS) (Fig. 4). Thus, the RCA was successfully revascularized by primary implantation of a 4.0 × 9 mm stent (Fig. 5). The present case illustrates that myocardial infarction may be a specific complication of coronary kinking. Particularly the presence of left ventricular hypertrophy, additional catecholaminergic triggers and/or increased thrombocyte activation, may contribute to the genesis of ischemia in this predominantly angiographic diagnosis. This case is remarkable because it exemplifies focal coronary atherosclerosis. This phenomenon presumably results from turbulent blood flow and elevated wall stress at vessel sites in the area of coronary artery kinking. These sites – significantly exposed to mechanical forces – are most likely to develop atherosclerosis. Conflict of interest No conflicts of interest.
e40
H. Bonnemeier / International Journal of Cardiology 177 (2014) e39–e41
Fig. 1. Initial electrocardiogram (ECG) in the field, exhibiting acute inferior ST-segment-elevation myocardial infarction (A) and ST-segment resolution in the presence of severe left ventricular hypertrophy (B) 10 min after initiation of antithrombotic therapy. The ECG at discharge (5 days after admission) exhibits the typical pattern of subacute inferior myocardial infarction with inverted T waves in II, III, aVF, as well as in V4, V5, and V6 (C).
Fig. 2. End-systolic and -diastolic left ventricular angiogram exhibiting good systolic left ventricular pump function. Angiogram of the left coronary artery exhibiting typical “corkscrew appearance”, suggestive for hypertensive heart disease.
H. Bonnemeier / International Journal of Cardiology 177 (2014) e39–e41
end-diastole
mid-systole
e41
end-systole
Fig. 3. End-diastolic, mid-systolic, and end-systolic angiographic frames of the right coronary artery. Only during end-systole the right coronary artery displays a proximal relevant stenosis (white arrow).
Fig. 4. End-diastolic and end-systolic intravascular ultrasound (IVUS) images in the area of the kinking of the proximal right coronary artery (white lines). During end-systole the lumen area was significantly reduced. There were signs of focal atherosclerosis exclusively in the area of kinking.
Fig. 5. Angiography of the RCA after successful stent implantation in the area of coronary kinking (white arrow).
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Coronary Kinking with Serious Consequences Hendrik Bonnemeier ⁎ Klinik für Innere Medizin III, Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, D-24105 Kiel, Germany
a r t i c l e
i n f o
Article history: Received 6 August 2014 Accepted 9 August 2014 Available online 15 August 2014 Keywords: Coronary kinking Hypertensive heart disease STEMI
A 49-year-old woman with a history of arterial hypertension presented to the emergency room with left-sided chest pain. Two years before, she was admitted with the same symptoms — noninvasive cardiac assessment including a stress electrocardiogram (ECG) revealed no abnormalities except for echocardiographic signs of concentric myocardial hypertrophy. The initial ECG recorded in the field by paramedics exhibited an acute inferior ST-segment-elevation myocardial infarction with STsegment elevation in II, III, aVF and ST-segment depression in aVL (Fig. 1A). Approximately 10 min after receiving aspirin, heparin, and a loading dose of clopidogrel, the patient had complete ST-segment resolution (Fig. 1B). An initial echocardiogram revealed severe myocardial hypertrophy without regional wall motion abnormalities. Serum chemistry revealed elevated levels of cardiac troponin T (0.18 μg/L) and creatine kinase MB isoenzyme (23 U/L). In view of these findings, the
⁎ Tel.: +49 431 597 1441; fax: +49 431 597 5190. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2014.08.063 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
patient received a glycoprotein IIb–IIIa inhibitor and was referred for cardiac catheterization. Left ventricular angiography demonstrated a good left ventricular systolic function without wall motion abnormalities (Fig. 2A, B). Coronary angiography revealed “corkscrew appearance”, suggestive for hypertensive heart disease (Fig. 2C). At first glance the coronary arteries exhibited no significant arteriosclerosis or thrombotic correlates (Fig. 3A, B). However, on closer appraisal only a few sequences of the coronary angiogram revealed a significant stenosis of the proximal right coronary artery (RCA) due to a severe systolic kinking (Fig. 3C). This finding was confirmed by intravascular ultrasound (IVUS) (Fig. 4). Thus, the RCA was successfully revascularized by primary implantation of a 4.0 × 9 mm stent (Fig. 5). The present case illustrates that myocardial infarction may be a specific complication of coronary kinking. Particularly the presence of left ventricular hypertrophy, additional catecholaminergic triggers and/or increased thrombocyte activation, may contribute to the genesis of ischemia in this predominantly angiographic diagnosis. This case is remarkable because it exemplifies focal coronary atherosclerosis. This phenomenon presumably results from turbulent blood flow and elevated wall stress at vessel sites in the area of coronary artery kinking. These sites – significantly exposed to mechanical forces – are most likely to develop atherosclerosis. Conflict of interest No conflicts of interest.
e40
H. Bonnemeier / International Journal of Cardiology 177 (2014) e39–e41
Fig. 1. Initial electrocardiogram (ECG) in the field, exhibiting acute inferior ST-segment-elevation myocardial infarction (A) and ST-segment resolution in the presence of severe left ventricular hypertrophy (B) 10 min after initiation of antithrombotic therapy. The ECG at discharge (5 days after admission) exhibits the typical pattern of subacute inferior myocardial infarction with inverted T waves in II, III, aVF, as well as in V4, V5, and V6 (C).
Fig. 2. End-systolic and -diastolic left ventricular angiogram exhibiting good systolic left ventricular pump function. Angiogram of the left coronary artery exhibiting typical “corkscrew appearance”, suggestive for hypertensive heart disease.
H. Bonnemeier / International Journal of Cardiology 177 (2014) e39–e41
end-diastole
mid-systole
e41
end-systole
Fig. 3. End-diastolic, mid-systolic, and end-systolic angiographic frames of the right coronary artery. Only during end-systole the right coronary artery displays a proximal relevant stenosis (white arrow).
Fig. 4. End-diastolic and end-systolic intravascular ultrasound (IVUS) images in the area of the kinking of the proximal right coronary artery (white lines). During end-systole the lumen area was significantly reduced. There were signs of focal atherosclerosis exclusively in the area of kinking.
Fig. 5. Angiography of the RCA after successful stent implantation in the area of coronary kinking (white arrow).