© 2015, Wiley Periodicals, Inc. DOI: 10.1111/joic.12191
CLINICAL IMAGING Successful Emergency PCI in a Case With AMI Induced by Two-Vessel Spontaneous Coronary Artery Dissection XINGWEI HE, M.D., YUJIAN LIU, M.D., ZHUXI LI, M.S., and HESONG ZENG, M.D., P H .D. From the Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
(J Interven Cardiol 2015;28:609–611)
A 52-year-old Chinese man was presented to the emergency department with severe chest pain for 2 hours. His coronary risk factors were severe hypertension, type 2 diabetes mellitus and smoking. He presented pale, diaphoretic with a blood pressure (BP) of 85/60, pulse 102, respiratory rate 26, O2 saturation 89%. Lungs were clear. Cardiac examination revealed cardiac sound low without cardiac murmurs. His initial electrocardiography (ECG) showed sinus rhythm with complete right bundle branch block (RBBB) and pathologic “Q” wave in inferior leads
(Fig. 1). Laboratory investigations showed Troponin-I and CK-MB isoenzyme were raised at 0.808 ng/ml (normal range 0.00–0.04 ng/ml), 7.8 (normal range 0.3–4.3 ng/ml), respectively. He was diagnosed acute myocardial infarction (AMI) and underwent emergent coronary angiography (CAG). CAG showed two-vessel spontaneous coronary artery dissection (SCAD) involving the proximal to middle segment of the left anterior descending (LAD) artery (Fig. 2), and the right coronary artery (RCA) extending into the middle segment (Fig. 3). The circumflex artery was normal. Given his hemodynamic
Figure 1. Electrocardiography at admission with complete right bundle branch block and pathologic “Q” wave in inferior leads.
Address for reprints: Hesong Zeng, Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. e-mail: [email protected]
Vol. 28, No. 6, 2015
Journal of Interventional Cardiology
609
HE, ET AL.
Figure 2. Angiogram shows dissection of LAD (white arrows).
Figure 4. Coronarography post PCI of RCA dissection.
instability and ongoing chest pain, rescue percutaneous coronary intervention (PCI) with stents was performed. We decided to treat the RCA disease first due to the ECG changes and obvious imaging feature. After placing a 6 Fr JR4.0 guiding catheter using a floppy guidewire (Runthrough Floppy1, Terumo), the true lumen was crossed and the guidewire was advanced into the distal RCA with free movement of the tip. After balloon dilatation with a 2.5 mm balloon, the RCA lesion was then stented with overlapping
3.0*36 mm, 3.5*36 mm, and 3.5*28 mm drug eluting stents (DESs), respectively, with Thrombolysis in Myocardial Infarction (TIMI) grade III flow (Fig. 4). However, the procedure did not relieve the chest pain of the patient and BP was still lower than 90/60 mmHg. Then, we proceeded to treat the LAD disease by placing three DESs (2.75*36, 3.0*36, and 3.5*14 mm) along the dissection, which successfully reduced the LAD to a single lumen with the restoration of flow (Fig. 5). Finally, the chest pain was relieved and the BP
Figure 3. Angiogram shows dissection of RCA (white arrows).
Figure 5. Coronarography post PCI of LAD dissection.
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Journal of Interventional Cardiology
Vol. 28, No. 6, 2015
Successful emergency PCI in a case with AMI
returned to normal. With indicated medical management given, including aspirin, clopidogrel, betablocker, statin, and strong advice to quit smoking, the patient was discharged on the 7th day after the procedure. No complications have been identified during regular follow-up. SCAD is an unusual but increasingly recognized cause of AMI or sudden cardiac death. It typically affects young females with a low atherosclerotic risk factor burden and the direct causes of this condition currently remain unknown. Though it has been reported that approximately 70%–80% of SCAD cases involved single coronary artery, the phenomenon for multi-vessel to be involved in SCAD case is an extremely low incidence 1. The optimal management remains controversial 2. Treatment strategies included medical therapy, PCI,
Vol. 28, No. 6, 2015
and coronary artery bypass graft (CAGB). PCI with stent is the preferred strategy in situations of hemodynamic instability or ongoing ischemia after identification of the true lumen and false lumen. The major challenge is how to advance the guide-wire into the true lumen and avoid propagating the dissection or perforation. Besides, accurately identifying the culprit vessel for the multi-vessel SCAD is also critical.
References 1. Mortensen KH, Thuesen L, Kristensen IB, et al. Spontaneous coronary artery dissection: A Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009;74:710–717. 2. Mathur M, Huda N, Cohen H, et al. Spontaneous right coronary artery dissection: A case of spontaneous resolution. JACC Cardiovasc Interv 2014;7:e9–e10.
Journal of Interventional Cardiology
611
CLINICAL IMAGING Successful Emergency PCI in a Case With AMI Induced by Two-Vessel Spontaneous Coronary Artery Dissection XINGWEI HE, M.D., YUJIAN LIU, M.D., ZHUXI LI, M.S., and HESONG ZENG, M.D., P H .D. From the Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
(J Interven Cardiol 2015;28:609–611)
A 52-year-old Chinese man was presented to the emergency department with severe chest pain for 2 hours. His coronary risk factors were severe hypertension, type 2 diabetes mellitus and smoking. He presented pale, diaphoretic with a blood pressure (BP) of 85/60, pulse 102, respiratory rate 26, O2 saturation 89%. Lungs were clear. Cardiac examination revealed cardiac sound low without cardiac murmurs. His initial electrocardiography (ECG) showed sinus rhythm with complete right bundle branch block (RBBB) and pathologic “Q” wave in inferior leads
(Fig. 1). Laboratory investigations showed Troponin-I and CK-MB isoenzyme were raised at 0.808 ng/ml (normal range 0.00–0.04 ng/ml), 7.8 (normal range 0.3–4.3 ng/ml), respectively. He was diagnosed acute myocardial infarction (AMI) and underwent emergent coronary angiography (CAG). CAG showed two-vessel spontaneous coronary artery dissection (SCAD) involving the proximal to middle segment of the left anterior descending (LAD) artery (Fig. 2), and the right coronary artery (RCA) extending into the middle segment (Fig. 3). The circumflex artery was normal. Given his hemodynamic
Figure 1. Electrocardiography at admission with complete right bundle branch block and pathologic “Q” wave in inferior leads.
Address for reprints: Hesong Zeng, Division of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. e-mail: [email protected]
Vol. 28, No. 6, 2015
Journal of Interventional Cardiology
609
HE, ET AL.
Figure 2. Angiogram shows dissection of LAD (white arrows).
Figure 4. Coronarography post PCI of RCA dissection.
instability and ongoing chest pain, rescue percutaneous coronary intervention (PCI) with stents was performed. We decided to treat the RCA disease first due to the ECG changes and obvious imaging feature. After placing a 6 Fr JR4.0 guiding catheter using a floppy guidewire (Runthrough Floppy1, Terumo), the true lumen was crossed and the guidewire was advanced into the distal RCA with free movement of the tip. After balloon dilatation with a 2.5 mm balloon, the RCA lesion was then stented with overlapping
3.0*36 mm, 3.5*36 mm, and 3.5*28 mm drug eluting stents (DESs), respectively, with Thrombolysis in Myocardial Infarction (TIMI) grade III flow (Fig. 4). However, the procedure did not relieve the chest pain of the patient and BP was still lower than 90/60 mmHg. Then, we proceeded to treat the LAD disease by placing three DESs (2.75*36, 3.0*36, and 3.5*14 mm) along the dissection, which successfully reduced the LAD to a single lumen with the restoration of flow (Fig. 5). Finally, the chest pain was relieved and the BP
Figure 3. Angiogram shows dissection of RCA (white arrows).
Figure 5. Coronarography post PCI of LAD dissection.
610
Journal of Interventional Cardiology
Vol. 28, No. 6, 2015
Successful emergency PCI in a case with AMI
returned to normal. With indicated medical management given, including aspirin, clopidogrel, betablocker, statin, and strong advice to quit smoking, the patient was discharged on the 7th day after the procedure. No complications have been identified during regular follow-up. SCAD is an unusual but increasingly recognized cause of AMI or sudden cardiac death. It typically affects young females with a low atherosclerotic risk factor burden and the direct causes of this condition currently remain unknown. Though it has been reported that approximately 70%–80% of SCAD cases involved single coronary artery, the phenomenon for multi-vessel to be involved in SCAD case is an extremely low incidence 1. The optimal management remains controversial 2. Treatment strategies included medical therapy, PCI,
Vol. 28, No. 6, 2015
and coronary artery bypass graft (CAGB). PCI with stent is the preferred strategy in situations of hemodynamic instability or ongoing ischemia after identification of the true lumen and false lumen. The major challenge is how to advance the guide-wire into the true lumen and avoid propagating the dissection or perforation. Besides, accurately identifying the culprit vessel for the multi-vessel SCAD is also critical.
References 1. Mortensen KH, Thuesen L, Kristensen IB, et al. Spontaneous coronary artery dissection: A Western Denmark Heart Registry study. Catheter Cardiovasc Interv 2009;74:710–717. 2. Mathur M, Huda N, Cohen H, et al. Spontaneous right coronary artery dissection: A case of spontaneous resolution. JACC Cardiovasc Interv 2014;7:e9–e10.
Journal of Interventional Cardiology
611
