A 68-year-old woman was admitted to her local emergency department with central chest pain radiating to both shoulders. The initial 12-lead ECG showed ST segment depression in the lateral leads and she was commenced on standard therapy for an acute coronary syndrome. She continued to have chest pain and serials ECGs progressed to show ST segment elevation in lead aVR with global depression in all other leads (). She then sustained a ventricular fibrillation (VF) arrest from which she was successfully resuscitated with a single DC shock following which she was urgently transferred to our centre for emergency coronary angiography.
12 Lead ECG showing ST segment elevation in aVR with global ST depression suggestive of possible left main stem occlusion.
On arrival at our centre she was haemodynamically stable but still had ongoing chest pain with persistent ECG changes. She therefore underwent urgent coronary angiography which showed acute total occlusion of the distal LMS with no anterograde flow (). The right coronary artery (RCA) was seen to have an anomalous origin from the left coronary sinus () and appeared a dominant vessel and unobstructed thus explaining why the patient was haemodynamically stable.
Diagnostic angiogram of the left coronary artery showing acute occlusion of the left main stem (LMS).
Diagnostic angiogram of the right coronary artery which is seen to arise from the left coronary sinus.
Given the patient's ongoing symptoms we proceeded to emergency percutaneous coronary intervention to the distal LMS occlusion. This was successfully performed with two drug eluting stents deployed from the distal LMS into the left anterior descending artery (LAD) and also the circumflex artery with adjuvant pharmacological therapy with abciximab. Follow-up angiography a week later showed a good result with a patent left coronary system ().
Angiogram after percutaneous coronary intervention to the left main stem (LMS) showing a good angiographic result with now patent left anterior descending (LAD) and circumflex coronary arteries.
The patient was pain-free post procedure but required treatment for acute left ventricular failure but did not require invasive ventilation. A transthoracic echocardiogram showed significant regional wall motion abnormalities in the LAD territory and overall moderately impaired left ventricular systolic function.
She was commenced on secondary prevention medications as well as therapy for her heart failure and made a gradual recovery. She was discharged home 7 days after her admission and will be followed up in the cardiology and heart failure clinics and will be considered for a primary prevention implantable defibrillator in the future.