PMC8380411_01
Transesophageal echocardiography. (a, b) Severe hypokinesis of the anteroseptal wall was observed at a 130  angle in a (diastole) and b (systole). Left ventricular ejection fraction was measured as 20%. LA: left atrium; LV: left ventricle; Ao: aorta; RV: right ventricle. (c) Severe mitral regurgitation at a 0  angle (arrow).
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The ECG showed ST depression in lead II, and a transesophageal echocardiogram (TEE) revealed severe hypokinesia of the anteroseptal and lateral wall, left ventricular ejection fraction (LVEF) of 20%, and severe mitral regurgitation (Figures 1(a)-1(c); see video 1 and 2 in Supplementary Material available online at https://drive.google.com/file/d/1RdC-7s-jwodX6bldxCBS1Kba2cS1DIjS/view and https://drive.google.com/file/d/1KsyF4WTUgB0X9wdrhtMetjzbgzYSdaSC/view, respectively).
(a) Emergent coronary angiography. Right anterior oblique caudal view showing a severe stenosis of mid LMCA (arrow). LMCA: left main coronary artery; LAD: left anterior descending artery; LCX: left circumflex artery. (b) Intravascular ultrasound study. The section at the white line showing low attenuation plaque around the entire circumference of the vessel with ulceration (arrows) in the mid LMCA. LMCA: left main coronary artery; LAD: left anterior descending artery; LCX: left circumflex artery. (c) Final coronary angiography. Right anterior oblique caudal view showing no significant LMCA stenosis with grade 3 TIMI flow after stent implantation (arrow). LMCA: left main coronary artery; LAD: left anterior descending artery; LCX: left circumflex artery.
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Coronary angiography (CAG) revealed severe stenosis of the left main coronary artery (LMCA) with a thrombolysis in myocardial infarction (TIMI) flow of grade II and moderate stenosis of the proximal segment of the left circumflex artery and ramus intermediate branch (Figure 2(a); see video 3 in Supplementary Material available online at https://drive.google.com/file/d/1LO67IkfRkyN1SEi9XlvNDTMhEjtHeG75/view). An intravascular ultrasound study (IVUS) of the LMCA revealed the presence of an attenuation plaque around the entire circumference of the mid portion of the LMCA (Figure 2(b); see video 4 in Supplementary Material available online at https://drive.google.com/file/d/1Iwo7m03maLjClM5FUgyT8rMfzQH3xj8o/view). The final CAG showed optimal dilatation of the LMCA stent and a TIMI flow of grade III (Figure 2(c)).
Chest roentgenogram. Chest X-ray showed a severe pulmonary edema.
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Extracorporeal membrane oxygenation (ECMO) was initiated to improve hypooxygenation due to severe pulmonary edema demonstrated by a chest roentgenogram (Figure 3).