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Images in cardiovascular medicine

Massive left ventricular ischemia in a patient with anterior ST elevation myocardial infarction and anomalous origin of the circumflex artery Laura Lenattia, Luigi Piattia, Luca A. Ferria, Andrea Farinaa, Pietro Deliseb and Stefano Savonittoa a

Division of Cardiology, A. Manzoni Hospital, Lecco, bDivision of Cardiology, A. Manzoni Hospital, Lecco and bDivision of Cardiology, Pieve di Soligo, Italy

Correspondence to Dr Stefano Savonitto, MD, Division of Cardiology, Ospedale A. Manzoni Hospital, via dell’ Eremo, 9 - 23900 Lecco, Italy Tel: +39 335 6056565; fax: +39 0341 489489; e-mail: [email protected] Received 29 August 2014 Revised 22 October 2014 Accepted 22 October 2014

A 41-year-old man with no risk factors for coronary disease presented with chest pain for 90 min. His ECG showed a wide QRS with ST elevation in leads V1–4, aVR, aVL and inferior ST depression (Fig. 1). Echocardiography showed severe left ventricular dysfunction with akinesia of anterior wall, apex and interventricular septum and severe lateral hypokinesia. Before angiography, ventricular fibrillation occurred that required six Direct Current (DC) shocks for defibrillation. Angiography revealed an isolated left anterior descending artery (LAD) with proximal subocclusive stenosis (Fig. 2a). The anomalous circumflex artery was hypoplasic and originated from the distal part of the retroventricular branch of the right coronary artery (RCA) (Fig. 2b). Primary angioplasty by thrombus aspiration and stent implantation restored Thrombolysis In Myocardial Infarction (TIMI) III flow (Fig. 2c). The ECG after Percutaneous Coronary Intervention (PCI) showed com-

plete resolution of the ST elevation (Fig. 3), with subsequent normalization of left ventricular function. Congenital coronary anomalies have been described in 0.6–1.3% of the patients,1 and are being found more frequently with the growing use of computed tomography (CT) angiography. Rare cases with absent left circumflex artery have been described as occasional findings, with the posterolateral and lateral walls supplied by a superdominant RCA.2,3 In the present case, the circumflex artery was hypoplasic and originated as a continuum from the distal part of the RCA, encircling the whole atrioventricular groove. The marginal branches were ill represented, and the vast majority of the left ventricle was supplied by the LAD. However, during acute occlusion, the presenting ECG was typical of a very proximal occlusion of the LAD. The ST elevation vector was directed anteriorly in the horizontal plane (as indicated by precordial leads) and superiorly in the frontal plane (as indicated by periferal leads). In other words, the same vector suggested a transmural ischemia of anteriorseptal, superior and high lateral left ventricle. As shown in Fig. 4, the ECG of a functionally similar left main occlusion (with a normal left circumflex artery) would

Fig. 1

The ECG at admission shows ST segment elevation in leads V1–4, aVR, aVL and depression in inferior leads. The frontal ST segment vector points towards the base of the heart.

1558-2027 ß 2014 Italian Federation of Cardiology

DOI:10.2459/JCM.0000000000000243

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2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00

Fig. 2

(a)

(b)

(c)

Coronary angiography after 6 DC shocks and thrombus aspiration. (a) Subocclusion of the proximal LAD and first diagonal branch. There is diffuse vasoconstriction of the septal and diagonal branches. (b) Coronary angiogram showing the RCA with the anomalous circumflex artery originating from the distal part of the vessel and ascending into the atrioventricular groove. (c) Left anterior descending artery after primary angioplasty and restoration of TIMI III flow.

Fig. 3

The ECG after PCI shows complete resolution of the ischemic changes. Fig. 4

Typical ECG presentation of acute myocardial ischemia due to critical stenosis of the left main coronary artery with normal left circumflex artery. There is profound ST segment depression in the anterior and lateral leads and the frontal ST deviation vector pointing towards aVR.

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Lenatti, acute myocardial ischemia and anomalous circumflex artery Lenatti et al. 3

have been quite different, showing rather profound ST depression in leads V3–5 and the frontal ST deviation vector pointing towards aVR.4

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References

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1

Page HL, Engel HJ, Campbell WB, Thomas CS. Anomalous origin of the left circumflex coronary artery. Recognition, angiographic, demonstration and clinical significance. Circulation 1974; 50:768–773.

3

Mittal SR, Maheshwari M. Absent left circumflex artery and unusual dominant right coronary artery. J Assoc Phys India 2008; 56:711. Majid Y, Warade M, Sinha J, Kalyanpur A, Gupta T. Superdominant right coronary artery with absent left circumflex artery. Biomed Imaging Interv J 2011; 7:e2. Sclarowski S, Davidson E, Strasberg B, et al. Unstable angina: the significance of ST segment elevation or depression in patients without evidence of increased myocardial oxygen demand. Am Heart J 1986; 112:463–467.

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Massive left ventricular ischemia in a patient with anterior ST elevation myocardial infarction and anomalous origin of the circumflex artery.

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