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Inferoposterior m ocardial infarction originating from an unexpected coronary vessel

C. van der Lee, G. Sianos

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51 -year-old woman presented to the emergency department with a four-hour history of severe chest pain. The patient had no previous cardiac history but she had undergone kidney transplantation six years A

C. van der Lee

G. S bs Thorax Centre, Department of Cardiology, Erasmus Medical Centre, Rotterdam

Correspondence to: C. van der Lee Thorax Centre, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam E-mail: [email protected]

318

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before for end-stage renal failure. She also had a history of insulin-dependent diabetes mellitus. On arrival, she developed ventricular fibrillation, which was successfully treated with defibrillation. The 12-lead ECG showed sinus rhythm at a rate of 62 beats/min, ST-segment elevation in leads II, III, AVF and V6 and depression in leads I, aVL and V1 to V4 (figure 1). There were no signs of right ventricular involvement. An acute inferoposterior myocardial infarction was diagnosed and the patient was transferred to the catheterisation laboratory for primary angioplasty. The left main stem, left circumflex (LCX) and right coronary artery (RCA) were normal. The left anterior

Netherlands Heart Journal, Volume 13, Number 9, September 2005

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IMAGING IN CARDIOLOGY

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Figure 2. Panel A andB. Angiographic (mightsuperwor and right anterior oblique) view of the left coronary descending artery. The arrow indicates the site of total occlusion. Panel C: Angiographic (right anterior oblique) view of the right coronary artery. The posterior descending artery is absent (indicated by the asterisk).

descending coronary artery (LAD) appeared totally occluded in the distal part (figure 2). The occlusion was dilated with a 2.5 mm balloon, which resulted in restoration of TIMI III flow and resolution of the STsegment changes (figure 3). The distal part ofthe LAD appeared to be a large vessel, crossing around the apex and supplying the posterior descending coronary artery (PDA). The patient's further in-hospital stay was uncomplicated. Conclusion This image demonstrates an inferoposterior infarction related to occlusion of a dominant LAD, which supplied the PDA. Usually, the PDA is supplied by the RCA (85%) or the LCX (7%). Furthermore, the coronary circulation might be co-dominant (7%). Rarely, the LAD is the dominant vessel, which vascularises the PDA.' a Reference 1

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Levin DC, Baltaxe HA. Angiographic demonstration of important anatomic variations of the posterior descending coronary artery. AmJRoentgenol Radium Ther Nucl Med 1972;116:41-9.

Netherlands Heart Journal, Volume 13, Number 9, September 2005

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Figure 3. Afterr balloon dilatation the posterior descending artety (indicated by the arrows) appeans to ortginatefrom the left coronary descending aretey. The asterisks indicate the septal ar-teries. In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Bohn Stafleu van Loghum, PO Box 246, 3990 GA Houten, e-mail: [email protected]. Also 'moving images' are welcomed and will be (after acceptance) published as a Web Site Feature and shown on our website: www.cardiologie.nl

Thissection is edited byM.J.M. Cramer andJJ. Bax.

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