PMC8379640_01
ECG on admission and LHC findings. (a) ECG showing ST elevations in anterior leads. (b) Initial coronary angiography. (c) Coronary angiography after PCI. Arrows indicate the course of LAD.
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Hospitalization was complicated by acute chest pain on hospital day five with ECG showing anterior wall STEMI (Figure 1(a)). He was intubated and left heart catheterization (LHC) revealed 40% stenosis of distal left main artery (LM), 100% stenosis of midleft anterior descending artery (LAD), normal left circumflex (LCx), 80% stenosis of proximal right coronary artery (RCA), and proximal posterior descending artery (Figure 1(b)). The procedure was complicated by heavy thrombus burden in LAD and "no-reflow" phenomenon despite the use of rescue thrombectomy, multiple intracoronary vasodilators, and 3 drug-eluting stent (DES) placement; flow was not reestablished to the apex (Figure 1(c)), which was concerning for stent thrombosis.
PMC8379640_02
ECG on admission and LHC findings. (a) ECG showing ST elevations in anterolateral leads. (b) Initial coronary angiography with arrow showing occluded LAD. (c) Coronary angiography after PCI with arrow showing coronary vasospasm in distal LM.
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ECG demonstrated ST-elevation over anterolateral wall distribution (Figure 2(a)). LHC revealed late presenting anterior wall MI with 30% stenosis of distal LM, 100% stenosis of LAD, normal LCx, and normal RCA. Left ventricular (LV) filling pressures were moderately elevated at 18 mmHg (Figure 2(b)). Two DES were placed in the proximal and distal LAD, but no reflow was observed with noteworthy thrombus burden likely from stent thrombosis (Figure 2(c)).
PMC8379640_03
ECG on admission and LHC findings. (a) ECG showing ST elevations in inferolateral leads. (b) Initial coronary angiography with arrow showing RCA ostium. (c) Coronary angiography after PCI.
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Repeat ECG in the ED demonstrated inferolateral ST-elevation (Figure 3(a)). Coronary angiography revealed 99% ostial stenosis of the RCA with TIMI-2 flow, mid-RCA 40% stenosis, distal RCA 60% stenosis, 40% proximal lesion in LAD, and LCX without obstruction (Figure 3(b)). DES was placed to ostial RCA with good flow (Figure 3(c)).