By Yukari Kobayashi, MD
When you see a patient presenting with cardiogenic shock and ST elevation myocardial infarction, especially when the electrocardiogram pattern suggests left main occlusion, you would refer him to the cardiac catheterization laboratory as soon as possible. In our case, after the simple echocardiographic evaluation to rule out Stanford type A acute aortic dissection, we immediately performed coronary angiography.
As shown in this figure and supplemental video file, we observed the movement of a filling defect from the left main to the left sinus of Valsalva and no atherosclerotic disease in the left main coronary artery. Fortunately, coronary angiography was the best “treatment” for this patient, because left coronary territory ischemia was improved and thereafter his hemodynamics were stabilized. However, an invasive coronary angiogram could possibly lead to cerebral, intestinal, or renal embolism. After reviewing the results of the ascending aortogram, thoracic CT, and transesophageal echocardiography, we were able to determine what was going on in this patient and referred him to surgery.
In the current case, laboratory data for antithrombin III, protein C, and protein S concentrations were normal. Anticardiolipin antibodies and lupus anticoagulant were negative. The conspicuous problem was that his hemoglobin level and hematocrit level were much higher than normal. That’s why we concluded that he presented with left main coronary thrombotic occlusion due to secondary polycythemia caused by heavy smoking.
From this case, I believe we can learn two things: (1) Coronary artery thrombosis due to intraaortic thrombus is rare but is an important disease entity as a cause of acute coronary syndrome; and (2) we need to consider the possibility of thrombus formation in the aorta when treating patients who are heavy smokers and have an elevated hemoglobin level.
Read full article / Yukari Kobayashi, MD, Yuhei Kobayashi, MD, Atsushi Hirohata, MD Left Main Coronary Thrombotic Occlusion Due to Secondary Polycythemia in a Normal Sinus of Valsalva. J INVASIVE CARDIOL 2013;25(8):421-422
Other interesting Clinical Images selections wherein multiple imaging modalities assisted in patient diagnoses:
Milosz Jaguszewski, Giulio Guagliumi, Ulf Landmesser Optical Frequency Domain Imaging for Guidance of Optimal Stenting in the Setting of Recanalization of Chronic Total Occlusion / An interesting case illustrating how high-resolution coronary optical frequency domain imaging examination can be used to guide revascularization of a complex chronic total occlusion. J INVASIVE CARDIOL 2013;25(7):367-368
Rodrigo Estévez-Loureiro, Olaf Franzen, Carlo DiMario Full Metal Atrium / Percutaneous edge-to-edge mitral valve repair and left atrial appendage closure to diminish the embolic risk in a 79-year-old patient were performed with the aid of transesophageal echocardiography. J INVASIVE CARDIOL 2013;25(6):321-322
I.B. Vijayalakshmi, Chitra Narasimhan, Ashish Agarwal Transcatheter Closure of Left Coronary Cameral Fistula With Amplatzer Duct Occluder II / The surgical and transcatheter coil closure of coronary arterial fistulas are described in the literature. We report our experience of a successful transcatheter closure of a coronary arterial fistula, arising from the left coronary artery and draining into the right ventricle, with the new Amplatzer duct occluder II device. J INVASIVE CARDIOL 2013;25(5):265-267
Abhishek Jaiswal and Todd C. Kerwin An Overhanging Intracoronary Stent: An Incidental Finding or the Sword of Damocles? / The incidental finding of a malpositioned ostial RCA stent masquerading as an echodense mass in the aortic root is illustrated. J INVASIVE CARDIOL 2013;25(4):208-209
Thomas Pilgrim, Bernhard Meier, Ahmed A. Khattab Death by Patent Foramen Ovale in a Soccer Player / This case should cause reconsideration of the current FDA restriction regarding indication for PFO closure to patients with a recurrent event despite medical treatment. J INVASIVE CARDIOL 2013;25(3):162-164
Witold Dubaniewicz, Radosław Targoński, Dariusz Ciećwierz Xience SBA Bifurcation Stent for Treating Distal Left Main Disease in NSTEMI Patient / The Xience SBA stent is a dedicated bifurcation device that may be associated with shorter duration procedures, lower contrast usage and a reduction in total fluoroscopy time. To our knowledge this is the first publication of this side branch access device for the treatment of left main coronary artery disease. J INVASIVE CARDIOL 2013;25(2):106-107
Andre Dias, Dhruti Mankodi, Spyros Smith Aorta to Right Atrial Fistula Presenting as a Rare Complication of Native Bicuspid Aortic Valve Endocarditis / A 54-year-old male with a past medical history significant for mild pulmonic stenosis and bicuspid aortic valve presented with a 10-day history of fever, fatigue, and exertional dyspnea. J INVASIVE CARDIOL 2013 Jan;25(1):61.
Ryutaro Ikegami, Keiichi Tsuchida, Hirotaka Oda, Acute Myocardial Infarction Caused by Spontaneous Coronary Intramural Hematoma / A 49-year-old male presented to our emergency department with sudden anterior chest pain. His electrocardiogram revealed ST-segment elevations in leads II, III and aVF. An inferior acute myocardial infarction was suspected. J INVASIVE CARDIOL 2012;24(12):692-693