A 67-year-old woman was referred to emergency room because of chest pain, lasting for approximately 11 h. The prehospital ECG showed ST-elevation in the leads characterising the anteroseptal and basolateral ventricle segments (). At admission, the patient was in cardiogenic shock. Coronary angiography revealed total thrombotic occlusion (thrombolysis in myocardial infarction (TIMI) flow grade 0) of the left main coronary artery (). Emergency angioplasty was successfully performed with stenting and final kissing-balloon dilation resulting in TIMI flow grade III (), followed by intensive care unit (ICU) treatment with mechanical ventilation, high-dose catecholamines and intra-aortic balloon pump. Antibiotic therapy due to hospital-acquired pneumonia, acute renal failure requiring haemodialysis and critical illness polyneuropathy complicated the mobilisation process.
Prehospital ECG with ST-elevation in the leads characterising the anteroseptal and basolateral ventricle segments (A). Angiography before and after PCI (B). Delayed enhancement MRI images after application of gadolinium-based contrast media (C).
After successful ICU treatment, MRI was performed, confirming echocardiographic findings of an extremely reduced left ventricular ejection fraction of 24% (). Delayed enhancement images after application of gadolinium-based contrast media visualised extensive mainly transmural contrast enhancement in the infarct regions (, arrows). Infarct size was 65% of total left ventricular mass.
Left ventricular ejection fraction did not recover substantially after 6 months. However, the patient survived fulminant myocardial infarction with total occlusion of left main stem – a disease with in-hospital mortality of 36–55%1 2
– after suffering from chest pain for 11 h. Left main stem occlusion need not be accompanied by pulmonary oedema, cardiogenic shock or cardiac arrest. Also worth mentioning is the alternative treatment option of emergent surgical revascularisation.