PMC4927217_01
A 12-lead electrocardiogram at admission shows acute anterior ischemia with marked ST-segment elevations in leads I, aVL, and V2-6.
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There were marked ST-segment elevations in the anterior electrocardiographic leads (Figure 1).
(a) Left coronary angiogram in the right anterior oblique view at admission. Note a tight, thrombotic lesion (black arrow) of the proximal left anterior descending artery. (b) At repeat angiography, the previous lesion has completely disappeared.
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The emergent coronary angiography showed a tight thrombotic lesion in the proximal left anterior descending artery (LAD) with a Thrombolysis in Myocardial Infarction (TIMI) grade 2 epicardial flow (Figure 2(a)). The angiography was repeated 12 days later; the TIMI 3 flow was confirmed without any significant obstruction of the LAD (Figure 2(b)).
(a) Optical coherence tomographic pullback throughout the left coronary artery is shown in the longitudinal view. All the numbers are indicating a millimeter scale. Note the tip of the guiding catheter (55) and the left main (LM) bifurcation (43); left circumflex artery is hidden in this lateral view. A largely fibrotic plaque is extending from the distal LM (46) to the proximal left anterior descending artery (16). The arterial tear (green insert) appears distal to the minimal obstruction area (yellow arrow). (b) The eccentric, crescent-shaped fibrous plaque is spreading from four to nine o'clock. The junction with the three-layered normal arterial wall (white arrow) seems to be intact. (c) The same plaque with a small intimal tear at the junction. (d) The same plaque with a large tear penetrating the medial layer resulting in a ~0.5-mm-thick flap (white arrow).
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The culprit lesion was recognized as a long, eccentric plaque extending from the distal left main artery to the proximal LAD (Figure 3(a)). Distal to the MLA, a 3-mm-long intimal tear appeared penetrating the medial layer (Figure 3(b)-(d)).