PMC9871765_01
A 18-lead electrocardiogram of the patient showing ST elevation in V2-V4 leads with widespread inverted T-waves in inferior, posterior, and right ventricular leads.
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F1
The first electrocardiography showed obvious ST elevation in V2-V4 (Figure 1), and his troponin I level was > 80 pg/ml, which exceeded the laboratory's testing limit.
Emergency coronary angiography at the onset of acute myocardial infarction. The results showed that the proximal left anterior descending artery (LAD) was completely occluded (A). Balloon dilatation was performed on the occlusive site (B). TIMI grade 3 flow was restored in LAD and right coronary artery (RCA) (C). The second coronary angiography at 4 months after myocardial infarction. The results showed high-grade lesion at the proximal LAD, as well as at LAD/RCA bifurcation and LAD/diagonal bifurcation (D). Drug-eluting balloons were used to dilate the diagonal branch (E) and the RCA (F). A drug-eluting stent in LAD and 2 balloons in D1 and RCA were dilated simultaneously for kissing balloon inflation (G). Final imaging results after procedure (H).
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F2
Selective left coronary angiography demonstrated a normal left main coronary artery, ostial LAD occlusion, and 40% ostial left circumflex artery (LCX) lesions (Figure 2A). We found that the left circumflex is the dominant artery and RCA originated from the middle of the LAD (Figures 2B, C). Four months after discharge, the patient was advised again to undergo coronary angiography, and the results showed complex and severe triple bifurcated lesions, with 90% ostial LAD lesions, 80% ostial D1 lesions, and 70% ostial RCA lesions (Figure 2D). Two Sion blue wires were passed down the LAD, D1, and anomalous RCA, and two 2.5 x 20 mm drug-coated balloons were deployed in the D1 and RCA (Figures 2E, F). Then, the LAD/RCA/D1 bifurcation was treated with a 3.0 x 36 mm (10 atm) drug-eluting stent (DES) placed in the LAD and two Maverick 2.0 x 20 mm (6 atm) balloons placed in the D1 and RCA (Figure 2G), which were dilated simultaneously for kissing balloon inflation. With no symptoms of discomfort, PCI was completed, and the outcomes were satisfactory (Figure 2H).
Coronary computed tomography angiography (CTA) was re-examined one month after PCI and resulting images (A-D) confirmed the anomalous origin of the right coronary artery.
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F3
Through CTA, we confirmed that the anomalous RCA originated from the middle of the LAD (Figure 3).