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Simultaneous acute closure of the right coronary artery and left anterior descending artery in a young male
Encerramanto agudo simultâneo da artéria coronária direita e da artéria descendente anterior esquerda num homem jovem
Ewa Szczerba, Karol Zbroński, , Zenon Huczek, Robert Kowalik, Grzegorz Opolski
First Department of Cardiology, Medical University of Warsaw, Warsaw, Mazovia, Poland
Received 15 January 2016, Accepted 20 June 2016

A 28-year-old man with no cardiovascular history or cardiovascular risk factors, who denied cigarette smoking or taking any medications, drugs, supplements or steroids, was referred to the cardiology department after an out-of-hospital cardiac arrest preceded by a four-hour angina episode. The initial rhythm (ventricular fibrillation) was successfully defibrillated. Subsequently, the electrocardiogram suggested inferior and inferobasal ST-elevation myocardial infarction (Figure 1).

Figure 1.

Teletransmitted electrocardiogram demonstrating inferior and inferobasal ST-elevation myocardial infarction and suggesting closure of the right coronary artery.

The coronary angiogram showed simultaneous acute thrombosis of the right coronary artery (RCA) (Figure 2a) and of the left anterior descending (LAD) artery (Figure 3a). Initially, to visualize suspected plaque rupture and to aid the decision whether to implant stents, multiple aspiration thrombectomies were performed, resulting in removal of substantial amounts of thrombotic material (Figure 4). After intravenous and intracoronary administration of abciximab, an everolimus-eluting stent was implanted into the RCA, restoring good epicardial coronary flow (Figure 2b). In the LAD spontaneous reperfusion occurred, revealing a massive thrombus (Figure 3b). After aspiration thrombectomy, a stent was implanted (Figure 3c). Echocardiographic examination revealed inferior wall and basal septal akinesis with ejection fraction of 35%. Right ventricular enlargement (5.4 cm in apical 4-chamber view) and hypokinesis (tricuspid annular plane systolic excursion [TAPSE] 14 mm) were present. Right ventricular function was improved on control echocardiography (TAPSE 27 mm).

Figure 2.

Acute thrombosis of the right coronary artery, TIMI flow 0 (a); status following stent implantation, TIMI flow 3 (b).

Figure 3.

Acute thrombosis of the left anterior descending artery, TIMI flow 0 (a); spontaneous reperfusion revealing a massive thrombus in segment 7 (b); status following stent implantation, TIMI flow 3 (c).

Figure 4.

Thrombotic material retrieved via aspiration thrombectomies.

Additional diagnostics available in our center failed to identify the cause of massive thrombus formation in both coronary arteries. An inflammatory etiology causing massive atherosclerotic plaque destabilization seemed unlikely, as C-reactive protein levels were normal on admission (Table 1). The patient was referred to the hematological department due to suspicion of thrombophilia.

Table 1.

Selected baseline laboratory results.

Total cholesterol (mg/dl)  144 
LDL cholesterol (mg/dl)  75 
HDL cholesterol (mg/dl)  52 
Triglycerides (mg/dl)  86 
C-reactive protein (mg/l)  1.7 
Fibrinogen (mg/dl)  200 
Glucose (mg/dl)  83 
TSH (μIU/ml)  2.93 
Creatinine (mg/dl)  1.03 

HDL: high-density lipoprotein; LDL: low-density lipoprotein; TSH: thyroid-stimulating hormone.

Ethical disclosureProtection of human and animal subjects

The authors declare that no experiments were performed on humans or animals for this study.

Confidentiality of data

The authors declare that they have followed the protocols of their work center on the publication of patient data.

Right to privacy and informed consent

The authors declare that no patient data appear in this article.

Conflicts of interest

The authors have no conflicts of interest to declare.

Corresponding author.
Copyright © 2016. Sociedade Portuguesa de Cardiologia

Metrics

  • Impact Factor: 0.454(2014)
  • SCImago Journal Rank (SJR):0,24
  • Source Normalized Impact per Paper (SNIP):0,398