Images in Cardiovascular Medicine Left Anterior Descending Coronary Artery Occlusion Secondary to Metastatic Squamous Cell Carcinoma Presenting as ST-Segment–Elevation Myocardial Infarction Gautam Reddy, MD; Mustafa I. Ahmed, MD; Steven G. Lloyd, MD, PhD; Brigitta C. Brott, MD; Vera Bittner, MD, MSPH
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52-year-old woman presented to the emergency department with intermittent dull substernal chest pain over the past 2 months that had become constant and severe over the past day. Six months before presentation, she had been diagnosed with squamous cell carcinoma of the tongue for which hemiglossectomy and radical neck dissection was performed. Two months before presentation, 18-fluorodeoxyglucose positron emission tomography detected hypermetabolic foci in the lungs that were proven on biopsy to be metastatic lesions. On retrospective review of the scan, a nonspecific hypermetabolic focus was noted in the septal myocardium [Figure (A)]. In the emergency department, her ECG showed an evolving anterior ST-segment–elevation myocardial infarction [Figure (B)]. She was taken to the cardiac catheterization laboratory where emergent coronary angiography was performed. This showed an abrupt termination of the distal left anterior descending coronary artery [Figure (C) and Movie I in the online-only Data Supplement]. The vessel appeared to have an abnormal epicardial course with an inward curve into the myocardium, possibly suggesting an overlying mass lesion [Figure (D) and Movie II in the online-only Data Supplement]. Attempts to cross the lesion with a coronary wire resulted in repeated buckling of the wire with an inability to confirm passage into the distal true lumen [Figure (E) and Movie III in the online-only Data Supplement]. No intervention was performed. Review of prior chest computed tomographic angiography scans showed a large apical myocardial lesion [Figure (F)]. Transthoracic echocardiography [Figure (G) and Movie IV in the online-only Data Supplement] showed corresponding myocardial masses with abnormal texture in the septal and apical left ventricular walls. Also seen were epicardial densities with a large circumferential pericardial effusion [Figure (H) and Movie V in the online-only Data Supplement]. ECG-gated cardiovascular magnetic resonance imaging was performed to characterize these lesions. On bright-blood steady-state free-precession 4-chamber images [Figure (I)], the mass was seen in the apices of both ventricles,
extending into the interventricular septum along with a large pericardial effusion. On cine runs, the involved segments were noncontractile with a small area of apical dyskinesis (Movie VI in the online-only Data Supplement). Black-blood T2-weighted fast-spin-echo transverse axial plane images [Figure (J)] showed increased signal intensity in the mass compared with the areas of normal myocardium, suggesting the presence of edema. Delayed-enhancement inversionrecovery sequences obtained 10 minutes after intravenous infusion of gadolinium–diethylenetriamine pentaacetate (0.2 mmol/kg) showed heterogeneous abnormal contrast retention in the mass [Figure (K)] likely secondary to edema and necrosis. Incidental findings included a large mediastinal mass posterior to the aorta and cavitating metastatic lesions in the lungs [Figure (L) and Movie VII in the online-only Data Supplement]. Taken together, these findings were consistent with tumor replacement of the myocardium and occlusion of the left anterior descending coronary artery, resulting in ST-segment–elevation myocardial infarction. We suspect that the patient had chronic angina secondary to progressive compression of the left anterior descending coronary artery with superimposed acute occlusion on the day of presentation. The patient remained clinically stable. A pericardial window was performed, and salvage chemotherapy was initiated. As of this writing, she has elected to focus on comfort measures. Her life expectancy is now estimated at
A
52-year-old woman presented to the emergency department with intermittent dull substernal chest pain over the past 2 months that had become constant and severe over the past day. Six months before presentation, she had been diagnosed with squamous cell carcinoma of the tongue for which hemiglossectomy and radical neck dissection was performed. Two months before presentation, 18-fluorodeoxyglucose positron emission tomography detected hypermetabolic foci in the lungs that were proven on biopsy to be metastatic lesions. On retrospective review of the scan, a nonspecific hypermetabolic focus was noted in the septal myocardium [Figure (A)]. In the emergency department, her ECG showed an evolving anterior ST-segment–elevation myocardial infarction [Figure (B)]. She was taken to the cardiac catheterization laboratory where emergent coronary angiography was performed. This showed an abrupt termination of the distal left anterior descending coronary artery [Figure (C) and Movie I in the online-only Data Supplement]. The vessel appeared to have an abnormal epicardial course with an inward curve into the myocardium, possibly suggesting an overlying mass lesion [Figure (D) and Movie II in the online-only Data Supplement]. Attempts to cross the lesion with a coronary wire resulted in repeated buckling of the wire with an inability to confirm passage into the distal true lumen [Figure (E) and Movie III in the online-only Data Supplement]. No intervention was performed. Review of prior chest computed tomographic angiography scans showed a large apical myocardial lesion [Figure (F)]. Transthoracic echocardiography [Figure (G) and Movie IV in the online-only Data Supplement] showed corresponding myocardial masses with abnormal texture in the septal and apical left ventricular walls. Also seen were epicardial densities with a large circumferential pericardial effusion [Figure (H) and Movie V in the online-only Data Supplement]. ECG-gated cardiovascular magnetic resonance imaging was performed to characterize these lesions. On bright-blood steady-state free-precession 4-chamber images [Figure (I)], the mass was seen in the apices of both ventricles,
extending into the interventricular septum along with a large pericardial effusion. On cine runs, the involved segments were noncontractile with a small area of apical dyskinesis (Movie VI in the online-only Data Supplement). Black-blood T2-weighted fast-spin-echo transverse axial plane images [Figure (J)] showed increased signal intensity in the mass compared with the areas of normal myocardium, suggesting the presence of edema. Delayed-enhancement inversionrecovery sequences obtained 10 minutes after intravenous infusion of gadolinium–diethylenetriamine pentaacetate (0.2 mmol/kg) showed heterogeneous abnormal contrast retention in the mass [Figure (K)] likely secondary to edema and necrosis. Incidental findings included a large mediastinal mass posterior to the aorta and cavitating metastatic lesions in the lungs [Figure (L) and Movie VII in the online-only Data Supplement]. Taken together, these findings were consistent with tumor replacement of the myocardium and occlusion of the left anterior descending coronary artery, resulting in ST-segment–elevation myocardial infarction. We suspect that the patient had chronic angina secondary to progressive compression of the left anterior descending coronary artery with superimposed acute occlusion on the day of presentation. The patient remained clinically stable. A pericardial window was performed, and salvage chemotherapy was initiated. As of this writing, she has elected to focus on comfort measures. Her life expectancy is now estimated at
