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Survival after total occlusion of left main coronary artery during coronary angiography: A case report
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 3 ( 2 0 1 3 ) 1 8 7 e1 8 9
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/jicc
Case Report
Survival after total occlusion of left main coronary artery during coronary angiography: A case report Tarun Kumar e,*, Shivanand Patil c, Basant Kumar e, Ashish Agarwal e, K. Subramanyam d, Rangaraj Ramalingam b, Cholenahally Nanjappa Manjunath a a
Director and Head of Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India b Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India c Associate Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India d Assistant Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India e Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India
article info
abstract
Article history:
We report a case of acute left main coronary artery occlusion treated with stenting of the
Received 3 February 2013
left main coronary artery. The patient had a thrombotic distal left main stenosis and after
Accepted 3 April 2013
diagnostic coronary angiography developed a total occlusion of the left main artery.
Available online 18 April 2013
Stenting of the unprotected left main coronary artery was successfully performed as a salvage procedure and patient completely recovered without any persistent myocardial
Keywords:
damage.
Coronary angiography
Copyright ª 2013, Indian College of Cardiology. All rights reserved.
Left main stenting Coronary occlusion
1.
Introduction
An acute obstruction of left main coronary artery (LMCA) is encountered approximately in only 0.5% of acute myocardial infarction (AMI) cases.1 Acute myocardial infarction due to acute obstruction of LMCA, which has poor prognosis, causes severe left ventricular dysfunction and life-threatening malignant arrhythmias as a consequence of large infarction
area.2 The outcome of left main occlusion depends upon rapidity of opening of occluded coronary artery.3
2.
Case report
A 60-year-old man who had 20 pack year history of smoking was admitted to the coronary care unit with a complaint of
* Corresponding author. Tel.: þ91 9008400420. E-mail address: [email protected] (T. Kumar). 1561-8811/$ e see front matter Copyright ª 2013, Indian College of Cardiology. All rights reserved. http://dx.doi.org/10.1016/j.jicc.2013.04.005
188
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 3 ( 2 0 1 3 ) 1 8 7 e1 8 9
intermittent episode of typical retrosternal chest pain lasting for 5e10 min accompanied by history of pain radiating to left upper limb and associated with increased sweating from last 3 days. He had a history of diabetes mellitus for 8 years and was on oral hypoglycaemic treatment. The patient had no previous history of coronary artery disease. On physical examination, his blood pressure was 110/70 mmHg, and his pulse rate was 90 beats/min. Cardiovascular and respiratory examination was normal. The ECG (Fig. 1) showed sinus rhythm and ST segment coving in leads aVR, and ST segment depression in leads V3eV6 and T wave inversion in lead 1,avl. The plasma levels of both troponin I and creatinine kinase-MB on admission were elevated. The other laboratory findings including echocardiography were showing no regional was motion abnormality and normal left ventricular function. Patient was diagnosed as a case of Non ST segment elevated myocardial infarction with suspected left main disease and posted for coronary angiography. During coronary angiography small amount of contrast was given to know the engagement of coronary catheter revealed thrombus containing distal left main disease. As soon as first coronary shoot taken patient developed severe chest pain and the coronary angiogram (Videos 1 and 2) revealed a completely occluded distal left main. Patient developed severe chest pain and blood pressure dropped to 70 mm of systolic blood pressure. Immediately diagnostic catheter was exchanged with 7 french left coronary guiding catheter and lesion (Video 3) crossed with 0.01400 floppy guidewire and lesion (Video 4) dilated with 2.5 10 balloon @ 8 atm and distal flow established. Patient chest pain subsided and blood pressure improved to 110/ 70 mm. Further coronary angiography (Video 5) revealed thrombus containing left main disease, proximal LAD has mild disease, non-flow limiting lesion and acutely arising left
circumflex (Non-dominant) with ostial disease of 50% stenosis. Emergency (Video 6) stenting was performed, with a stent (Non-drug eluting stent was taken because of financial constraint) of 3.0 mm in diameter and 18.0 mm in length placed across left main to proximal left anterior descending artery and the (Video 7) thrombolysis in myocardial infarction grade 3 flow was achieved. After the coronary stenting, the patient’s ECG (Fig. 2) showed no new ST/T wave changes or development of new Q waves. Echocardiography was performed after the procedure was showing no regional wall motion abnormality and normal left ventricular ejection fraction. Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jicc.2013.04.005
Fig. 1 e On admission showing sinus rhythm ST depression in v3ev6 & T wave inversion in 1,avl.
Fig. 2 e After left main angioplasty e no new Q wave or ST/T wave changes.
Here we report a case of left main disease who developed occlusion of left main coronary artery during coronary angiography which was managed successfully with left main stenting and patient recovered without any persistent myocardial damage.
3.
Discussion
Coronary angiography, though routinely performed, is not totally devoid of complications. Acute occlusion of the left main coronary artery (LMCA) is a rare but serious condition, which carries a very high mortality rate due to massive acute myocardial infarction (AMI)4 if not managed urgently. Acute left main occlusion during coronary angiography can result from a traumatic intimal dissection, from persistent Spasm, as a result of thrombus originating from the catheter, or, classically, from the mobilisation of an atheromatous
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 3 ( 2 0 1 3 ) 1 8 7 e1 8 9
plaque/thrombus.5,6 Acute LMCA occlusion usually results in severe left ventricular dysfunction and clinical worsening results in just few minutes. Previous reports showed that the presence of collaterals, a dominant RCA, and Sub-totally occluded LMCA was higher in the survival group as compared to the mortality group.7 Since most of the patients with acute occlusion of the LMCA would develop a sudden, profound deterioration of haemodynamics, simultaneous efforts to maintain systemic circulation and to achieve reperfusion of the occluded LMCA as soon as possible are essential for survival.8,9 Successful emergency reperfusion of the LMCA by angioplasty and stenting has been reported.10 Emergency CABG in patients with acute myocardial infarction and acute left main occlusion may be effective but time consuming, and carries the risk of extensive and irreversible myocardial damage.11 In our case, patient having thrombotic distal left main coronary artery lesion developed acute total occlusion of left main coronary artery during angiography possibly related to mobilisation of thrombus during contrast injection. Immediate left main coronary stenting was performed as a bailout procedure. Repeat ECHO examination did not showed any regional or global left ventricular dysfunction. This is one of the rare case showing left main coronary artery occlusion during coronary angiography. Similar presentation as acute left main occlusion has been described previously during coronary angiography but in that case thrombus originated from the catheter.3 In summary, we report a case of acute occlusion of the LMCA developed during coronary angiography, successfully treated with PTCA and stenting and patient discharged without any persistent myocardial damage.
Conflicts of interest All authors have none to declare.
189
references
1. Aygul N, Ozdemir K, Tokac M, et al. Value of lead aVR in predicting acute occlusion of proximal left anterior descending coronary artery and in-hospital outcome in ST-elevation myocardial infarction: an electrocardio-graphic predictor of poor prognosis. J Electrocardiol. 2008;41:335. 2. Wong SC, Sanborn T, Sleeper LA, et al. Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK trial registry. Should we emergently revascularize occluded coronaries for cardiogenic shocK. J Am Coll Cardiol. 2000;36:1077. 3. Sanz AJ, Herna´ndez F, Tasco´n JC. Thrombotic occlusion of the left main coronary artery during coronary angiography. J Invasive Cardiol. 2002 Jul;14(7):426e429. 4. Iwasaki K, Kusachi S, Hina K, et al. Acute left main coronary artery obstruction with myocardial infarction. Jpn Circ J. 1993;57:891e897. 5. Bourassa MG, Noble J. Complication rate of coronary arteriography. A review of 5250 cases studied by a percutaneous femoral technique. Circulation. 1976;53:106e114. 6. Engel HJ, Page Jr HL, Campbell WB. Coronary artery spasm as the cause of myocardial infarction during coronary arteriography. Am Heart J. 1976;91:501e506. 7. Prachar H, Dittel M, Enenkel W. Acute occlusion of left main coronary artery without ventricular damage. Clin Cardiol. 1991;14:176e179. 8. Bengtson JR, Kaplan AJ, Pieper KS, et al. Prognosis in cardiogenic shock after acute myocardial infarction in the interventional era. J Am Coll Cardiol. 1992;20:1482e1489. 9. Moosvi AR, Khaja F, Villanueva L, Gheorghiade M, Douthat L, Goldstein S. Early revascularization improves survival in cardiogenic shock complicating acute myocardial infarction. J Am Coll Cardiol. 1992;19:907e914. ¨ zdemir K, Altunkeser BB. Emergency ¨, O 10. Aygu¨l N, Aygu¨l MU revascularization procedures in patients with acute STelevation myocardial infarction due to acute total occlusion of unprotected left main coronary artery: a report of five cases. Turk Kardiyol Dern Ars. 2010;38:131e134. 11. Abuzahra MM, Mesa A, Treistman B. Unprotected left main coronary artery intervention for acute myocardial infarction and cardiogenic shock. Tex Heart Inst J. 2007;34:479e484.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/jicc
Case Report
Survival after total occlusion of left main coronary artery during coronary angiography: A case report Tarun Kumar e,*, Shivanand Patil c, Basant Kumar e, Ashish Agarwal e, K. Subramanyam d, Rangaraj Ramalingam b, Cholenahally Nanjappa Manjunath a a
Director and Head of Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India b Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India c Associate Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India d Assistant Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India e Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Rajiv Gandhi University of Health Sciences, Bangalore 560069, India
article info
abstract
Article history:
We report a case of acute left main coronary artery occlusion treated with stenting of the
Received 3 February 2013
left main coronary artery. The patient had a thrombotic distal left main stenosis and after
Accepted 3 April 2013
diagnostic coronary angiography developed a total occlusion of the left main artery.
Available online 18 April 2013
Stenting of the unprotected left main coronary artery was successfully performed as a salvage procedure and patient completely recovered without any persistent myocardial
Keywords:
damage.
Coronary angiography
Copyright ª 2013, Indian College of Cardiology. All rights reserved.
Left main stenting Coronary occlusion
1.
Introduction
An acute obstruction of left main coronary artery (LMCA) is encountered approximately in only 0.5% of acute myocardial infarction (AMI) cases.1 Acute myocardial infarction due to acute obstruction of LMCA, which has poor prognosis, causes severe left ventricular dysfunction and life-threatening malignant arrhythmias as a consequence of large infarction
area.2 The outcome of left main occlusion depends upon rapidity of opening of occluded coronary artery.3
2.
Case report
A 60-year-old man who had 20 pack year history of smoking was admitted to the coronary care unit with a complaint of
* Corresponding author. Tel.: þ91 9008400420. E-mail address: [email protected] (T. Kumar). 1561-8811/$ e see front matter Copyright ª 2013, Indian College of Cardiology. All rights reserved. http://dx.doi.org/10.1016/j.jicc.2013.04.005
188
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 3 ( 2 0 1 3 ) 1 8 7 e1 8 9
intermittent episode of typical retrosternal chest pain lasting for 5e10 min accompanied by history of pain radiating to left upper limb and associated with increased sweating from last 3 days. He had a history of diabetes mellitus for 8 years and was on oral hypoglycaemic treatment. The patient had no previous history of coronary artery disease. On physical examination, his blood pressure was 110/70 mmHg, and his pulse rate was 90 beats/min. Cardiovascular and respiratory examination was normal. The ECG (Fig. 1) showed sinus rhythm and ST segment coving in leads aVR, and ST segment depression in leads V3eV6 and T wave inversion in lead 1,avl. The plasma levels of both troponin I and creatinine kinase-MB on admission were elevated. The other laboratory findings including echocardiography were showing no regional was motion abnormality and normal left ventricular function. Patient was diagnosed as a case of Non ST segment elevated myocardial infarction with suspected left main disease and posted for coronary angiography. During coronary angiography small amount of contrast was given to know the engagement of coronary catheter revealed thrombus containing distal left main disease. As soon as first coronary shoot taken patient developed severe chest pain and the coronary angiogram (Videos 1 and 2) revealed a completely occluded distal left main. Patient developed severe chest pain and blood pressure dropped to 70 mm of systolic blood pressure. Immediately diagnostic catheter was exchanged with 7 french left coronary guiding catheter and lesion (Video 3) crossed with 0.01400 floppy guidewire and lesion (Video 4) dilated with 2.5 10 balloon @ 8 atm and distal flow established. Patient chest pain subsided and blood pressure improved to 110/ 70 mm. Further coronary angiography (Video 5) revealed thrombus containing left main disease, proximal LAD has mild disease, non-flow limiting lesion and acutely arising left
circumflex (Non-dominant) with ostial disease of 50% stenosis. Emergency (Video 6) stenting was performed, with a stent (Non-drug eluting stent was taken because of financial constraint) of 3.0 mm in diameter and 18.0 mm in length placed across left main to proximal left anterior descending artery and the (Video 7) thrombolysis in myocardial infarction grade 3 flow was achieved. After the coronary stenting, the patient’s ECG (Fig. 2) showed no new ST/T wave changes or development of new Q waves. Echocardiography was performed after the procedure was showing no regional wall motion abnormality and normal left ventricular ejection fraction. Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jicc.2013.04.005
Fig. 1 e On admission showing sinus rhythm ST depression in v3ev6 & T wave inversion in 1,avl.
Fig. 2 e After left main angioplasty e no new Q wave or ST/T wave changes.
Here we report a case of left main disease who developed occlusion of left main coronary artery during coronary angiography which was managed successfully with left main stenting and patient recovered without any persistent myocardial damage.
3.
Discussion
Coronary angiography, though routinely performed, is not totally devoid of complications. Acute occlusion of the left main coronary artery (LMCA) is a rare but serious condition, which carries a very high mortality rate due to massive acute myocardial infarction (AMI)4 if not managed urgently. Acute left main occlusion during coronary angiography can result from a traumatic intimal dissection, from persistent Spasm, as a result of thrombus originating from the catheter, or, classically, from the mobilisation of an atheromatous
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 3 ( 2 0 1 3 ) 1 8 7 e1 8 9
plaque/thrombus.5,6 Acute LMCA occlusion usually results in severe left ventricular dysfunction and clinical worsening results in just few minutes. Previous reports showed that the presence of collaterals, a dominant RCA, and Sub-totally occluded LMCA was higher in the survival group as compared to the mortality group.7 Since most of the patients with acute occlusion of the LMCA would develop a sudden, profound deterioration of haemodynamics, simultaneous efforts to maintain systemic circulation and to achieve reperfusion of the occluded LMCA as soon as possible are essential for survival.8,9 Successful emergency reperfusion of the LMCA by angioplasty and stenting has been reported.10 Emergency CABG in patients with acute myocardial infarction and acute left main occlusion may be effective but time consuming, and carries the risk of extensive and irreversible myocardial damage.11 In our case, patient having thrombotic distal left main coronary artery lesion developed acute total occlusion of left main coronary artery during angiography possibly related to mobilisation of thrombus during contrast injection. Immediate left main coronary stenting was performed as a bailout procedure. Repeat ECHO examination did not showed any regional or global left ventricular dysfunction. This is one of the rare case showing left main coronary artery occlusion during coronary angiography. Similar presentation as acute left main occlusion has been described previously during coronary angiography but in that case thrombus originated from the catheter.3 In summary, we report a case of acute occlusion of the LMCA developed during coronary angiography, successfully treated with PTCA and stenting and patient discharged without any persistent myocardial damage.
Conflicts of interest All authors have none to declare.
189
references
1. Aygul N, Ozdemir K, Tokac M, et al. Value of lead aVR in predicting acute occlusion of proximal left anterior descending coronary artery and in-hospital outcome in ST-elevation myocardial infarction: an electrocardio-graphic predictor of poor prognosis. J Electrocardiol. 2008;41:335. 2. Wong SC, Sanborn T, Sleeper LA, et al. Angiographic findings and clinical correlates in patients with cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK trial registry. Should we emergently revascularize occluded coronaries for cardiogenic shocK. J Am Coll Cardiol. 2000;36:1077. 3. Sanz AJ, Herna´ndez F, Tasco´n JC. Thrombotic occlusion of the left main coronary artery during coronary angiography. J Invasive Cardiol. 2002 Jul;14(7):426e429. 4. Iwasaki K, Kusachi S, Hina K, et al. Acute left main coronary artery obstruction with myocardial infarction. Jpn Circ J. 1993;57:891e897. 5. Bourassa MG, Noble J. Complication rate of coronary arteriography. A review of 5250 cases studied by a percutaneous femoral technique. Circulation. 1976;53:106e114. 6. Engel HJ, Page Jr HL, Campbell WB. Coronary artery spasm as the cause of myocardial infarction during coronary arteriography. Am Heart J. 1976;91:501e506. 7. Prachar H, Dittel M, Enenkel W. Acute occlusion of left main coronary artery without ventricular damage. Clin Cardiol. 1991;14:176e179. 8. Bengtson JR, Kaplan AJ, Pieper KS, et al. Prognosis in cardiogenic shock after acute myocardial infarction in the interventional era. J Am Coll Cardiol. 1992;20:1482e1489. 9. Moosvi AR, Khaja F, Villanueva L, Gheorghiade M, Douthat L, Goldstein S. Early revascularization improves survival in cardiogenic shock complicating acute myocardial infarction. J Am Coll Cardiol. 1992;19:907e914. ¨ zdemir K, Altunkeser BB. Emergency ¨, O 10. Aygu¨l N, Aygu¨l MU revascularization procedures in patients with acute STelevation myocardial infarction due to acute total occlusion of unprotected left main coronary artery: a report of five cases. Turk Kardiyol Dern Ars. 2010;38:131e134. 11. Abuzahra MM, Mesa A, Treistman B. Unprotected left main coronary artery intervention for acute myocardial infarction and cardiogenic shock. Tex Heart Inst J. 2007;34:479e484.