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Thrombosis in a right wrap around coronary artery leading to takotsubo syndrome phenotype diagnosed as an acute myocardial infarction: Lingering afterthoughts
International Journal of Cardiology 220 (2016) 534
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Thrombosis in a right wrap around coronary artery leading to takotsubo syndrome phenotype diagnosed as an acute myocardial infarction: Lingering afterthoughts John E. Madias ⁎ Icahn School of Medicine at Mount Sinai, New York, NY, United States Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States
a r t i c l e
i n f o
Article history: Received 28 April 2016 Accepted 28 June 2016 Available online 29 June 2016
To the Editor: Differentiation between acute myocardial infarction (AMI), particularly anterior AMI and takotsubo syndrome (TTS) is occasionally difficult, since the similarity in the clinical presentation and the electrocardiogram (ECG) features [1,2] of these 2 pathologies may be staggering. A particularly ardent task may be faced when the involved patient has a wraparound left anterior descending coronary artery (LAD), supplying both the anterior and inferior left ventricular myocardial territories [3]. A case in point is a reported [3] 63-year-old man who was admitted with sudden onset of chest pain and cardiogenic shock, whose ECG showed ST-segment elevation in leads II, III, aVF, and V2–6 leads, and ST-segment depression in lead aVR [4], and his echocardiogram (ECHO) revealed a classic TTS phenotype, with akinetic left ventricular apex, and hyperkinetic base. The patient required intubation with mechanical ventilation, and intra-aortic balloon pumping (IABP). At coronary arteriography he had total occlusion of the proximal right coronary artery (RCA) with a thrombus. After thrombus aspiration and stenting of the RCA the vessel was visualized to wrap around the cardiac apex, and to supply the occluded LAD, via the right posterior descending coronary artery, and the diagonal coronary artery via the right posterior lateral artery. The contrast left ventriculogram corroborated the ECHO findings. The patient was extubated, was weaned from IABP on day 3 of hospitalization, and received elective stenting to his stenotic distal branches of RCA posterior lateral branch, and atrio-ventricular branch. No major complications occurred, and the patient was discharged on day 23 of hospitalization. No comment was made whether the left
⁎ Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, United States. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2016.06.291 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
ventricular function returned to normal, or whether there were residual regional wall motion abnormalities, resulting from the AMI. Most probably the authors are correct that this case represents an AMI due to a total occlusion of a proximal RCA with wrap-around extension supplying directly (not via collaterals) an occluded LAD, and a stenotic diagonal artery, presenting as a TTS phenotype. Surprisingly, with this dramatic clinical presentation, this patient did not show any cardiac biomarker elevations, with the creatine kinase (CK), MB-CK, and troponin T reported as normal. Thus, this case probably represents “the first report describing an AMI with wrap-around RCA, mimicking TTC” [4], with what can be described as an aborted AMI, without any evidence of cardiomyocyte death, in-spite of the clinical presentation in cardiogenic shock, due to an expeditious intubation, mechanical ventilation, IABP support and revascularization. A lingering afterthought remains that this represented TTS, that caused destabilization of a vulnerable plaque with resultant thrombosis in the culprit proximal RCA [5], that led to an unusual clinical presentation and course in this patient. Conflicts of interest There is nothing to disclose which could be construed as conflict of interest in connection with the submission of this manuscript. References [1] R. Ogura, Y. Hiasa, T. Takahashi, et al., Specific findings of the standard 12-lead ECG in patients `with ‘takotsubo’ cardiomyopathy: comparison with the findings of acute anterior myocardial infarction, Circ. J. 67 (2003) 687–690. [2] M. Kosuge, K. Kimura, Electrocardiographic findings of takotsubo cardiomyopathy as compared with those of anterior acute myocardial infarction, J. Electrocardiol. 47 (2014) 684–689. [3] B. Ibanez, F. Navarro, J. Farre, et al., Tako-tsubo syndrome associated with a long course of the left anterior descending coronary artery along the apical diaphragmatic surface of the left ventricle, Rev. Esp. Cardiol. 57 (2004) 209–216. [4] H. Shibutani, Y. Akita, K. Yutaka, et al., Acute myocardial infarction with “wrap around” right coronary artery mimicking takotsubo cardiomyopathy: a case report, BMC Cardiovasc. Disord. 16 (2016) 71. [5] J.E. Madias, Could takotsubo syndrome trigger type I myocardial infarction? Am. J. Cardiol. 116 (2015) 1951.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Thrombosis in a right wrap around coronary artery leading to takotsubo syndrome phenotype diagnosed as an acute myocardial infarction: Lingering afterthoughts John E. Madias ⁎ Icahn School of Medicine at Mount Sinai, New York, NY, United States Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States
a r t i c l e
i n f o
Article history: Received 28 April 2016 Accepted 28 June 2016 Available online 29 June 2016
To the Editor: Differentiation between acute myocardial infarction (AMI), particularly anterior AMI and takotsubo syndrome (TTS) is occasionally difficult, since the similarity in the clinical presentation and the electrocardiogram (ECG) features [1,2] of these 2 pathologies may be staggering. A particularly ardent task may be faced when the involved patient has a wraparound left anterior descending coronary artery (LAD), supplying both the anterior and inferior left ventricular myocardial territories [3]. A case in point is a reported [3] 63-year-old man who was admitted with sudden onset of chest pain and cardiogenic shock, whose ECG showed ST-segment elevation in leads II, III, aVF, and V2–6 leads, and ST-segment depression in lead aVR [4], and his echocardiogram (ECHO) revealed a classic TTS phenotype, with akinetic left ventricular apex, and hyperkinetic base. The patient required intubation with mechanical ventilation, and intra-aortic balloon pumping (IABP). At coronary arteriography he had total occlusion of the proximal right coronary artery (RCA) with a thrombus. After thrombus aspiration and stenting of the RCA the vessel was visualized to wrap around the cardiac apex, and to supply the occluded LAD, via the right posterior descending coronary artery, and the diagonal coronary artery via the right posterior lateral artery. The contrast left ventriculogram corroborated the ECHO findings. The patient was extubated, was weaned from IABP on day 3 of hospitalization, and received elective stenting to his stenotic distal branches of RCA posterior lateral branch, and atrio-ventricular branch. No major complications occurred, and the patient was discharged on day 23 of hospitalization. No comment was made whether the left
⁎ Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, United States. E-mail address: [email protected].
http://dx.doi.org/10.1016/j.ijcard.2016.06.291 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
ventricular function returned to normal, or whether there were residual regional wall motion abnormalities, resulting from the AMI. Most probably the authors are correct that this case represents an AMI due to a total occlusion of a proximal RCA with wrap-around extension supplying directly (not via collaterals) an occluded LAD, and a stenotic diagonal artery, presenting as a TTS phenotype. Surprisingly, with this dramatic clinical presentation, this patient did not show any cardiac biomarker elevations, with the creatine kinase (CK), MB-CK, and troponin T reported as normal. Thus, this case probably represents “the first report describing an AMI with wrap-around RCA, mimicking TTC” [4], with what can be described as an aborted AMI, without any evidence of cardiomyocyte death, in-spite of the clinical presentation in cardiogenic shock, due to an expeditious intubation, mechanical ventilation, IABP support and revascularization. A lingering afterthought remains that this represented TTS, that caused destabilization of a vulnerable plaque with resultant thrombosis in the culprit proximal RCA [5], that led to an unusual clinical presentation and course in this patient. Conflicts of interest There is nothing to disclose which could be construed as conflict of interest in connection with the submission of this manuscript. References [1] R. Ogura, Y. Hiasa, T. Takahashi, et al., Specific findings of the standard 12-lead ECG in patients `with ‘takotsubo’ cardiomyopathy: comparison with the findings of acute anterior myocardial infarction, Circ. J. 67 (2003) 687–690. [2] M. Kosuge, K. Kimura, Electrocardiographic findings of takotsubo cardiomyopathy as compared with those of anterior acute myocardial infarction, J. Electrocardiol. 47 (2014) 684–689. [3] B. Ibanez, F. Navarro, J. Farre, et al., Tako-tsubo syndrome associated with a long course of the left anterior descending coronary artery along the apical diaphragmatic surface of the left ventricle, Rev. Esp. Cardiol. 57 (2004) 209–216. [4] H. Shibutani, Y. Akita, K. Yutaka, et al., Acute myocardial infarction with “wrap around” right coronary artery mimicking takotsubo cardiomyopathy: a case report, BMC Cardiovasc. Disord. 16 (2016) 71. [5] J.E. Madias, Could takotsubo syndrome trigger type I myocardial infarction? Am. J. Cardiol. 116 (2015) 1951.