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PP-026: VENTRICULAR SEPTAL RUPTURE COMPLICATION OF ACUTE MYOCARDIAL INFARCTION SECONDARY TO CORONARY ARTERY EMBOLISM IN A PATIENT WITH ATRIAL FIBRILLATION
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Poster Discussions / International Journal of Cardiology 147S2 (2011) S103–S130
Conclusions: ECG is very important in acute phase of STEMI to show the characteristic ECG findings for detecting infarct related coronary artery, but it is important that the unexpected findings should be considered as we showed in this case. PP-023 A VERY LATE STENT THROMBOSIS ASSOCIATED WITH DISCONTINUATION OF ACETYLSALICYLIC ACID B. Evranos, S. Okutucu, F. Jam, A. Taher, S.G. Fatihoglu, L. Sahiner, E.B. Kaya, K. Aytemir, M.A. Oto, M.G. Kabakci, L. Tokgozoglu, H. Ozkutlu. Hacettepe Universitesi Kardiyoloji Anabilim Dali, Ankara, Turkey Objective: A 75 years old diabetic, hypertensive patient would go to modified radical mastectomy surgery because of her mammarian cancer. A drug eluting stent (cypher, sirolimus eluting stent) was implanted 4 years ago. She had used dual antiplatelet therapy for 1 year and continued to use aspirin. She had no chest pain, dyspnea in the preoperative evaluation, her exercise capacity was equivocal so a coronary computerized tomography (CT) was performed before the surgery: the Left anterior descending (LAD) stent was patent and there were hemodynamicly significant lesions in the distal parts of right coronary artery (RCA) and noncritic plaques in circumflex artery (Cx). But because delaying the surgery would increase the stage of cancer and low risk of surgery she had gone to mastectomy. Aspirin was stopped 3 daysbefore the surgery. Methods: After the successful mastectomy, routine ECG was performed. There was ST segment elevation in Leads V1–6, DI and AVL. She had no chest pain because of analgesics. Her cardiac enzymes were elevated. Results: Coronary angiography was performed and there was noncritic lesions in RCA, a 70–80% lesion in the proximal of the Cx, LAD stent was full of thrombus and there was no flow to the distal of the stent (figure 1). 6000 IU heparin bolus was given and 12IU/kg heparin was continued, clopidogrel 300 mg loading dose and 75 mg maintainance dose and aspirin 100 mg was started. 0.014 inch floppy wire was used to pass the thrombus, dilatation was performed by 2.0 × 20 mm and 3.0 × 20 mm (monorail maverick) balloons and 3.5x 30 mm bare metal stent (biotronik lekton motion) was implanted. Conclusions: Very late stent thrombosis is an uncommon but life-threatening complication after drug-eluting stent implantation in patients with coronary artery disease. Discontinuation of antiplatelet therapy is reported to be the most powerful predictor of stent thrombosis. PP-024 CORONARY ARTERY ANEURYSM AFTER DRUG ELUTING STENT IMPLANTATION: CASE REPORT AND REVIEW OF THE LITERATURE N. Hajlaoui. Cardiology department of the military hospital of Tunis, Tunisia Objective: Drug eluting stents (DES) have had a profound impact on the practice of interventional cardiology. Important safety concerns regarding DES have been widely published and acknowledged. The primary emphasis has been placed on late stent thrombosis and the adverse sequel which result. Another emerging adverse effect of DES is coronary artery aneurysm (CAA) formation. Methods: We report the case of a 71 years old woman who has hypertension. She underwent a percutaneous coronary angioplasty of a complex bifurcation lesion of the LAD. A cypher stent (sirolimus eluting stent) was implanted. The ostium of the diagonal was dilated with balloon throughout the struts of the stent. Results: The immediate angiographic result was excellent with TIMI 3flow without dissection or thrombus. The patient has developed angina and was controlled twenty one months after. An aneurysm of the LAD in the middle part of the stent with significant stenosis was revealed by the coronary angiogram.
Conclusions: Drug eluting stents (DES), which locally elute antiproliferative drugs, can dramatically inhibit neo-intimal growth.however, several pathological studies have indicated that DES may delay healing after vascular injury, and DES implantation may be theoretically associated with a risk of coronary artery aneurysm formation PP-025 ACUTE MYOCARDIAL INFARCTION AFTER GEMCITABINE THERAPY – A CASE REPORT E. Aksakal, A. Arisoy, M. Acikel. Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey Objective: Gemcitabine is a nucleoside analogue that is structurally related to cytosine arabinoside and it is primarily used in the treatment of non-small cell lung cancer, bladder carcinoma and pancreatic adenocarsinoma. Herein we present an acute myocardial infarction (AMI) associated gemcitabine therapy in a patient who have three coronary stent, was diagnosed lung cancer. Methods: A 66 year-old-man was admitted to our clinic with a diagnosis of non-ST elevation myocardial infarction (NSTEMI). Coronary angiography was performed and revealed significant three vessel stenosis. We have recommended coronary artery bypass surgery. Pulmonary nodule was detected on chest X-ray and than bronchoscopy was performed. The result of bronchial biopsy was reported as non-small cell lung cancer. A council consisted of Cardiology, cardiovascular surgery, oncology and chest disease clinics decided percutaneous coronary interventional therapy because of the poor long term prognosis for this patient. Therefore bare metal stent was implanted to left anterior descending artery (LAD), left circumflex artery (LCx) and right coronary artery (RCA). One month later gemcitabine and cisplatin therapy was initiated by oncology clinic (gemcitabine 1740 mg and cisplatin 70 mg). In the second cycle, he received gemcitabine IV 1740 mg/30min. and cisplatin IV 70 mg/3h. After 90 min of gemcitabine infusion, he experienced severe chest pain accompanied by inferior AMI. Electrocardiography showed ST-segment elevation in leads DII-DIIIaVF and reciprocal ST depression in DI-aVL-V1–3. Echocardiography revealed hypokinesis of the inferior wall, with an overall ejection fraction of 55%. Urgent coronary angiography revaled in-stent restenosis in three coronary artery stents (RCA; 95%, LCx; 60% and LAD; 60%) (Figures 1a and 1b). Primary percutaneous transluminal coronary angioplasty (PTCA) was successfully performed to the culprit lesion (RCA in-stent restenosis). We have decided angiograhic evaluation one month later for other lesions. The patient who receives regular medical treatment admitted to hospital for severe chest pain, one month later. He hospitalized with NSTEMI diagnosis. Coronary angiogarphy showed in-stent restenosis in RCA (80%), LCx (60%) and LAD (80%). PTCA was performed for these three coronary lesions. The patient was discharged with medical therapy, four days later. Conclusions: The vasospastic and thrombotic coronary events may happen in the patients who were treated as mono and multi chemo-therapy with gemcitabine. Gemcitabine therapy may lead to new-onset or accelerated restenosis in patients with coronary artery stent placement. Therefore, complaints of chest pain in these patients might be evaluated for coronary heart disease. PP-026 VENTRICULAR SEPTAL RUPTURE COMPLICATION OF ACUTE MYOCARDIAL INFARCTION SECONDARY TO CORONARY ARTERY EMBOLISM IN A PATIENT WITH ATRIAL FIBRILLATION H. Akilli, M. Tekinalp, A. Aribas, C. Duman. Cardiology Department of Meram Medical School of Selcuk University, Konya, Turkey Objective: Atrial fibrillation is a common condition and may be associated with thromboembolic complications in as many as 18% of patients per year. However, a coronary artery embolism with subsequent myocardial infarction is rare. Among the complications
Poster Discussions / International Journal of Cardiology 147S2 (2011) S103–S130
of acute myocardial infarction, ventricular septal rupture (VSR) is the most serious, together with rupture of the ventricular free wall and/or papillary muscle. To the best of our knowledge, this is) the first case of VSR secondary to coronary artery embolism. Methods: A 70 year-old female was admitted to the emergency department with the compliant of chest pain lasting for two days. Her medical story was remarcable for hypertension. Her initial electrocardiogram revealed atrial fibrillation with ventricular rate of 106 beats per minute and 2–3 mm ST elevation, Q waves, T wave inversion in lead V2-V6. Her blood presure was 90/60 mmHg. In physical examination: tachycardia, and apical 2/6 degree sistolic murmur were noted. Her fasting blood glucose, serum creatinin and troponin I values were 114 mg/dl, 1.41 mg/dl, 9.3ng/ml respectively. Transthoracic echocardiography revealed left ventricular systolic disfunction, aneurysm in the mid-apical inferoseptal wall and ventricular septal rupture. EF was 40% (figure). The diagnosis was subacut anterior myocardial infarction, ventricular septal rupture. Coronary angiography showed normal coronary arteries. An intraaortic balloon counterpulsation catheter was placed. The patient was given emergency surgery by consultation with cardiovascular surgeons. About 1.5 cm wide VSR was seen on apical part of interventricular septum in surgery and primary sutured. After operation during her manegement in intensive care unit the patient developed acute kidney failure and she died due to (deep) acidosis in second day of her operation. Conclusions: Coronary artery embolism is a rare cause of acute myocardial infarction and the precise diagnosis remains challenging for the cardiologists. The prevalence of this nonatherosclerotic entity remains unknown because of its difficulties on diagnosis in the acute setting. In general, 4 to 7% of all patients diagnosed with an AMI do not have atherosclerotic coronary disease at autopsy or coronary angiography. VSR after MI is rare but a very mortal complication. In this situation the diagnosis should be done quickly and surgery should perform in early period. Although, Acute MI due to coronary embolus secondary to AF was reported in literature before, according to our knowledge, this is the first case with complicated VSR.
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metabolism of methionine. Moderate elevation of homocysteine level is a risk factor for atherosclerotic disease in coronary, cerebral as well as peripheral arterial vessels. Normal concentration of total homocysteine in the serum/plasma is taken up to 15 mmol/L. We report an 18-year-old woman with an acute myocardial infarction associated with hyperhomocysteinemia and low vitamin B12 levels. Case: An 18-year-old woman presented to the emergency department with a chest pain which has been started thirteen hours ago and still continuing and hospitalized with the diagnosis of inferior acute myocardial infarction. No other significant risk factors for coroner artery disease including a family history of premature atherosclerosis were identified. On physical examination, blood pressure was 100/60 mmHg, respiratory rate was 24/min and pulse rate was 53/min. Heart sounds were rhythmic and bradycardic, 2/6 systolic murmur was heard in mezocardiac area. Electrocardiogram revealed marked inferior ST- segment elevations with reciprocal changes involving the anterior leads consistent with inferior acute myocardial infarction. Urgent coroner angiography was revealed a large occluding thrombus in the left circumflex coronary artery. Left main coronary artery, left anterior descending coronary artery and right coronary artery were patent without prominent luminal irregularities. The left circumflex coronary artery was successfully revascularized with the percutaneous transluminal balloon angioplasti and stent implantation. Laboratory tests showed elevated homocysteine levels of 26 mmol/l and low vitamin B12 level of 152 pg/ml. She was treated with intramuscular cyanocobalamine supplementation. Conclusions: Vitamin B12 deficiency may lead to severely elevated homocysteine levels. Severe hyperhomocysteinemia could be a risk factor for endothelial damage, vascular inflammation and thrombus formation which ultimately results in coronary artery thrombus formation. With this case, we intended to emphasize that homocysteinemia and vitamin B12 level studies should be seriously considered for patients with acute myocardial infarction which could not explained by atherosclerotic heart disease, particularly for young patients. PP-029 AN UNUSUAL ELECTROCARDIOGRAPHIC PRESENTATION OF OCCLUSION OF THE LEFT ANTERIOR DESCENDING ARTERY: INFEROLATERAL ST SEGMENT ELEVATION U. Dogan, M. Tekinalp, I. Can, A. Aribas. Department of Cardiology, Selcuk University, Meram School of Medicine, Konya, Turkey
Figure 1. 2D transthoracic echocardiography apical four-chamber view (A4C) shows ventricular septal rupture (VSR) (arrow). PP-027 ACUTE MYOCARDIAL INFARCTION DUE TO LOW VITAMIN B12 LEVEL INDUCED HYPERHOMOCYSTEINEMIA IN A YOUNG WOMAN E. Aksakal, O. Demir, S. Demirelli, S. Karakelleoglu. Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey Objective: Naturally occurring sulfur containing aminoacid homocysteine is derived as an intermediate compound during the
Objective: Electrocardiogram is a simple tool used to evaluate coronary artery disease. Assessment of the elevation of ST segment helps to identify the localization of the infarct-related artery in AMI. ST segment elevation in precordial and inferior leads simultaneously due to occlusion of LAD is well reported in the literature. However, inferolateral ST elevation is extremely rare. Methods: A 36-year-old man presented with epigastric pain which started at rest and lasted four hours until the time of admission. The patient did not have history of cardiovascular disease. 12-lead ECG showed ST segment elevation in leads II, III, aVF and V3–6 and ST depression in leads aVL, V1–2 (Figure). On the coronary angiogram total occlusion of the distal segment of the LAD was documented. The LCx and RCA were patent. Due to the relief of the pain, resolution of the ST elevation (>50%) and small diameter of the distal LAD (<2 mm) PCI was not performed. Control angiography which was performed two days later showed that distal segment of the LAD was recanalized and normal flow was restored. LAD was type III and divided into two branches at the apex one of which turned toward the lateral wall and the other toward the inferior wall of the left ventricle. It was noted that the caliber of the artery was increased by greater than 100%. The patient did not experience any other ischemic attack and was discharged. Conclusions: ST segment elevation in inferolateral leads is a rare finding in acute LAD occlusion. Concomitant occlusion of LAD and
Poster Discussions / International Journal of Cardiology 147S2 (2011) S103–S130
Conclusions: ECG is very important in acute phase of STEMI to show the characteristic ECG findings for detecting infarct related coronary artery, but it is important that the unexpected findings should be considered as we showed in this case. PP-023 A VERY LATE STENT THROMBOSIS ASSOCIATED WITH DISCONTINUATION OF ACETYLSALICYLIC ACID B. Evranos, S. Okutucu, F. Jam, A. Taher, S.G. Fatihoglu, L. Sahiner, E.B. Kaya, K. Aytemir, M.A. Oto, M.G. Kabakci, L. Tokgozoglu, H. Ozkutlu. Hacettepe Universitesi Kardiyoloji Anabilim Dali, Ankara, Turkey Objective: A 75 years old diabetic, hypertensive patient would go to modified radical mastectomy surgery because of her mammarian cancer. A drug eluting stent (cypher, sirolimus eluting stent) was implanted 4 years ago. She had used dual antiplatelet therapy for 1 year and continued to use aspirin. She had no chest pain, dyspnea in the preoperative evaluation, her exercise capacity was equivocal so a coronary computerized tomography (CT) was performed before the surgery: the Left anterior descending (LAD) stent was patent and there were hemodynamicly significant lesions in the distal parts of right coronary artery (RCA) and noncritic plaques in circumflex artery (Cx). But because delaying the surgery would increase the stage of cancer and low risk of surgery she had gone to mastectomy. Aspirin was stopped 3 daysbefore the surgery. Methods: After the successful mastectomy, routine ECG was performed. There was ST segment elevation in Leads V1–6, DI and AVL. She had no chest pain because of analgesics. Her cardiac enzymes were elevated. Results: Coronary angiography was performed and there was noncritic lesions in RCA, a 70–80% lesion in the proximal of the Cx, LAD stent was full of thrombus and there was no flow to the distal of the stent (figure 1). 6000 IU heparin bolus was given and 12IU/kg heparin was continued, clopidogrel 300 mg loading dose and 75 mg maintainance dose and aspirin 100 mg was started. 0.014 inch floppy wire was used to pass the thrombus, dilatation was performed by 2.0 × 20 mm and 3.0 × 20 mm (monorail maverick) balloons and 3.5x 30 mm bare metal stent (biotronik lekton motion) was implanted. Conclusions: Very late stent thrombosis is an uncommon but life-threatening complication after drug-eluting stent implantation in patients with coronary artery disease. Discontinuation of antiplatelet therapy is reported to be the most powerful predictor of stent thrombosis. PP-024 CORONARY ARTERY ANEURYSM AFTER DRUG ELUTING STENT IMPLANTATION: CASE REPORT AND REVIEW OF THE LITERATURE N. Hajlaoui. Cardiology department of the military hospital of Tunis, Tunisia Objective: Drug eluting stents (DES) have had a profound impact on the practice of interventional cardiology. Important safety concerns regarding DES have been widely published and acknowledged. The primary emphasis has been placed on late stent thrombosis and the adverse sequel which result. Another emerging adverse effect of DES is coronary artery aneurysm (CAA) formation. Methods: We report the case of a 71 years old woman who has hypertension. She underwent a percutaneous coronary angioplasty of a complex bifurcation lesion of the LAD. A cypher stent (sirolimus eluting stent) was implanted. The ostium of the diagonal was dilated with balloon throughout the struts of the stent. Results: The immediate angiographic result was excellent with TIMI 3flow without dissection or thrombus. The patient has developed angina and was controlled twenty one months after. An aneurysm of the LAD in the middle part of the stent with significant stenosis was revealed by the coronary angiogram.
Conclusions: Drug eluting stents (DES), which locally elute antiproliferative drugs, can dramatically inhibit neo-intimal growth.however, several pathological studies have indicated that DES may delay healing after vascular injury, and DES implantation may be theoretically associated with a risk of coronary artery aneurysm formation PP-025 ACUTE MYOCARDIAL INFARCTION AFTER GEMCITABINE THERAPY – A CASE REPORT E. Aksakal, A. Arisoy, M. Acikel. Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey Objective: Gemcitabine is a nucleoside analogue that is structurally related to cytosine arabinoside and it is primarily used in the treatment of non-small cell lung cancer, bladder carcinoma and pancreatic adenocarsinoma. Herein we present an acute myocardial infarction (AMI) associated gemcitabine therapy in a patient who have three coronary stent, was diagnosed lung cancer. Methods: A 66 year-old-man was admitted to our clinic with a diagnosis of non-ST elevation myocardial infarction (NSTEMI). Coronary angiography was performed and revealed significant three vessel stenosis. We have recommended coronary artery bypass surgery. Pulmonary nodule was detected on chest X-ray and than bronchoscopy was performed. The result of bronchial biopsy was reported as non-small cell lung cancer. A council consisted of Cardiology, cardiovascular surgery, oncology and chest disease clinics decided percutaneous coronary interventional therapy because of the poor long term prognosis for this patient. Therefore bare metal stent was implanted to left anterior descending artery (LAD), left circumflex artery (LCx) and right coronary artery (RCA). One month later gemcitabine and cisplatin therapy was initiated by oncology clinic (gemcitabine 1740 mg and cisplatin 70 mg). In the second cycle, he received gemcitabine IV 1740 mg/30min. and cisplatin IV 70 mg/3h. After 90 min of gemcitabine infusion, he experienced severe chest pain accompanied by inferior AMI. Electrocardiography showed ST-segment elevation in leads DII-DIIIaVF and reciprocal ST depression in DI-aVL-V1–3. Echocardiography revealed hypokinesis of the inferior wall, with an overall ejection fraction of 55%. Urgent coronary angiography revaled in-stent restenosis in three coronary artery stents (RCA; 95%, LCx; 60% and LAD; 60%) (Figures 1a and 1b). Primary percutaneous transluminal coronary angioplasty (PTCA) was successfully performed to the culprit lesion (RCA in-stent restenosis). We have decided angiograhic evaluation one month later for other lesions. The patient who receives regular medical treatment admitted to hospital for severe chest pain, one month later. He hospitalized with NSTEMI diagnosis. Coronary angiogarphy showed in-stent restenosis in RCA (80%), LCx (60%) and LAD (80%). PTCA was performed for these three coronary lesions. The patient was discharged with medical therapy, four days later. Conclusions: The vasospastic and thrombotic coronary events may happen in the patients who were treated as mono and multi chemo-therapy with gemcitabine. Gemcitabine therapy may lead to new-onset or accelerated restenosis in patients with coronary artery stent placement. Therefore, complaints of chest pain in these patients might be evaluated for coronary heart disease. PP-026 VENTRICULAR SEPTAL RUPTURE COMPLICATION OF ACUTE MYOCARDIAL INFARCTION SECONDARY TO CORONARY ARTERY EMBOLISM IN A PATIENT WITH ATRIAL FIBRILLATION H. Akilli, M. Tekinalp, A. Aribas, C. Duman. Cardiology Department of Meram Medical School of Selcuk University, Konya, Turkey Objective: Atrial fibrillation is a common condition and may be associated with thromboembolic complications in as many as 18% of patients per year. However, a coronary artery embolism with subsequent myocardial infarction is rare. Among the complications
Poster Discussions / International Journal of Cardiology 147S2 (2011) S103–S130
of acute myocardial infarction, ventricular septal rupture (VSR) is the most serious, together with rupture of the ventricular free wall and/or papillary muscle. To the best of our knowledge, this is) the first case of VSR secondary to coronary artery embolism. Methods: A 70 year-old female was admitted to the emergency department with the compliant of chest pain lasting for two days. Her medical story was remarcable for hypertension. Her initial electrocardiogram revealed atrial fibrillation with ventricular rate of 106 beats per minute and 2–3 mm ST elevation, Q waves, T wave inversion in lead V2-V6. Her blood presure was 90/60 mmHg. In physical examination: tachycardia, and apical 2/6 degree sistolic murmur were noted. Her fasting blood glucose, serum creatinin and troponin I values were 114 mg/dl, 1.41 mg/dl, 9.3ng/ml respectively. Transthoracic echocardiography revealed left ventricular systolic disfunction, aneurysm in the mid-apical inferoseptal wall and ventricular septal rupture. EF was 40% (figure). The diagnosis was subacut anterior myocardial infarction, ventricular septal rupture. Coronary angiography showed normal coronary arteries. An intraaortic balloon counterpulsation catheter was placed. The patient was given emergency surgery by consultation with cardiovascular surgeons. About 1.5 cm wide VSR was seen on apical part of interventricular septum in surgery and primary sutured. After operation during her manegement in intensive care unit the patient developed acute kidney failure and she died due to (deep) acidosis in second day of her operation. Conclusions: Coronary artery embolism is a rare cause of acute myocardial infarction and the precise diagnosis remains challenging for the cardiologists. The prevalence of this nonatherosclerotic entity remains unknown because of its difficulties on diagnosis in the acute setting. In general, 4 to 7% of all patients diagnosed with an AMI do not have atherosclerotic coronary disease at autopsy or coronary angiography. VSR after MI is rare but a very mortal complication. In this situation the diagnosis should be done quickly and surgery should perform in early period. Although, Acute MI due to coronary embolus secondary to AF was reported in literature before, according to our knowledge, this is the first case with complicated VSR.
S111
metabolism of methionine. Moderate elevation of homocysteine level is a risk factor for atherosclerotic disease in coronary, cerebral as well as peripheral arterial vessels. Normal concentration of total homocysteine in the serum/plasma is taken up to 15 mmol/L. We report an 18-year-old woman with an acute myocardial infarction associated with hyperhomocysteinemia and low vitamin B12 levels. Case: An 18-year-old woman presented to the emergency department with a chest pain which has been started thirteen hours ago and still continuing and hospitalized with the diagnosis of inferior acute myocardial infarction. No other significant risk factors for coroner artery disease including a family history of premature atherosclerosis were identified. On physical examination, blood pressure was 100/60 mmHg, respiratory rate was 24/min and pulse rate was 53/min. Heart sounds were rhythmic and bradycardic, 2/6 systolic murmur was heard in mezocardiac area. Electrocardiogram revealed marked inferior ST- segment elevations with reciprocal changes involving the anterior leads consistent with inferior acute myocardial infarction. Urgent coroner angiography was revealed a large occluding thrombus in the left circumflex coronary artery. Left main coronary artery, left anterior descending coronary artery and right coronary artery were patent without prominent luminal irregularities. The left circumflex coronary artery was successfully revascularized with the percutaneous transluminal balloon angioplasti and stent implantation. Laboratory tests showed elevated homocysteine levels of 26 mmol/l and low vitamin B12 level of 152 pg/ml. She was treated with intramuscular cyanocobalamine supplementation. Conclusions: Vitamin B12 deficiency may lead to severely elevated homocysteine levels. Severe hyperhomocysteinemia could be a risk factor for endothelial damage, vascular inflammation and thrombus formation which ultimately results in coronary artery thrombus formation. With this case, we intended to emphasize that homocysteinemia and vitamin B12 level studies should be seriously considered for patients with acute myocardial infarction which could not explained by atherosclerotic heart disease, particularly for young patients. PP-029 AN UNUSUAL ELECTROCARDIOGRAPHIC PRESENTATION OF OCCLUSION OF THE LEFT ANTERIOR DESCENDING ARTERY: INFEROLATERAL ST SEGMENT ELEVATION U. Dogan, M. Tekinalp, I. Can, A. Aribas. Department of Cardiology, Selcuk University, Meram School of Medicine, Konya, Turkey
Figure 1. 2D transthoracic echocardiography apical four-chamber view (A4C) shows ventricular septal rupture (VSR) (arrow). PP-027 ACUTE MYOCARDIAL INFARCTION DUE TO LOW VITAMIN B12 LEVEL INDUCED HYPERHOMOCYSTEINEMIA IN A YOUNG WOMAN E. Aksakal, O. Demir, S. Demirelli, S. Karakelleoglu. Department of Cardiology, Faculty of Medicine, Ataturk University, Erzurum, Turkey Objective: Naturally occurring sulfur containing aminoacid homocysteine is derived as an intermediate compound during the
Objective: Electrocardiogram is a simple tool used to evaluate coronary artery disease. Assessment of the elevation of ST segment helps to identify the localization of the infarct-related artery in AMI. ST segment elevation in precordial and inferior leads simultaneously due to occlusion of LAD is well reported in the literature. However, inferolateral ST elevation is extremely rare. Methods: A 36-year-old man presented with epigastric pain which started at rest and lasted four hours until the time of admission. The patient did not have history of cardiovascular disease. 12-lead ECG showed ST segment elevation in leads II, III, aVF and V3–6 and ST depression in leads aVL, V1–2 (Figure). On the coronary angiogram total occlusion of the distal segment of the LAD was documented. The LCx and RCA were patent. Due to the relief of the pain, resolution of the ST elevation (>50%) and small diameter of the distal LAD (<2 mm) PCI was not performed. Control angiography which was performed two days later showed that distal segment of the LAD was recanalized and normal flow was restored. LAD was type III and divided into two branches at the apex one of which turned toward the lateral wall and the other toward the inferior wall of the left ventricle. It was noted that the caliber of the artery was increased by greater than 100%. The patient did not experience any other ischemic attack and was discharged. Conclusions: ST segment elevation in inferolateral leads is a rare finding in acute LAD occlusion. Concomitant occlusion of LAD and