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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 119-121

Simultaneous acute occlusion of right and anterior descending coronary arteries in acute myocardial infarction in a young man


Department of Cardiac Rehabilitation, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong, China

Date of Web Publication17-Jul-2018

Correspondence Address:
Dr. Lan Guo
Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 102, Zhongshan Road, Guangzhou, Guangdong
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_12_17

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  Abstract 

We report a case of a 36-year-old male presented with symptoms of chest pain and the electrocardiographic evidence of ST-segment elevation in inferior and anterior leads. An emergent coronary angiogram showed that both the distal right and mid left descending coronary arteries were totally occluded. Both arteries were successfully ballooned and stented. Multiple cases of simultaneous coronary occlusion have been reported, but the mechanism was still not well understood. In this case, the man had neither coronary risk factors nor positive family history. The laboratory studies revealed a decreased serum-free protein S.

Keywords: Angiography, myocardial infarction, protein S


How to cite this article:
Ma H, Guo L. Simultaneous acute occlusion of right and anterior descending coronary arteries in acute myocardial infarction in a young man. Heart Mind 2017;1:119-21

How to cite this URL:
Ma H, Guo L. Simultaneous acute occlusion of right and anterior descending coronary arteries in acute myocardial infarction in a young man. Heart Mind [serial online] 2017 [cited 2022 Dec 4];1:119-21. Available from: http://www.heartmindjournal.org/text.asp?2017/1/3/119/236927


  Introduction Top


Simultaneous acute occlusion of two coronary arteries is very rare. In this article we report a case of a 36-year-old male presented with symptoms of chest pain and the electrocardiographic evidence of ST-segment elevation in inferior and anterior leads. An emergent coronary angiogram showed that both the distal right and mid left descending coronary arteries were totally occluded. What happened to this patient and the mechanism under it is need to check.


  Case Report Top


A 36-year-old man was transferred to our hospital in the late evening on October 8, 2014, because of persistent chest pain for 24 h and came to our emergency department. He had begun to experience resting angina about 1 year before this event. He had no coronary risk factors including diabetes, hypercholesterolemia, hypertension, obesity, smoking, or positive family history. An electrocardiogram (ECG) on arrival showed ST-segment elevation in leads II, III, aVF, and V3 to V6 and Q wave in leads II, III, and aVF [Figure 1]. On arrival, his blood pressure was 102/65 mmHg, and heart rate was 64 beats/min. The laboratory examination on admission showed that white blood cell was 14.96 × 109/L, C-reaction protein was 105.81 mg/L, creatine kinase (CK) was 2001 U/L, CK-muscle/brain was 88 U/L, troponin I (TnI) was more than 50 ug/L, and the protein S (PS) was 35.6%. The PS was 35.6%, lower than the normal level, which usually was 59%–118%.
Figure 1: The electrocardiogram on arrive at the hospital

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An emergency coronary angiogram (CAG) demonstrated the presence of thrombus in the mid left anterior descending coronary artery (LAD) with thrombolysis in myocardial infarction (TIMI) Grade 1 flow patency [Figure 2]a. In addition, there was a total occlusion of the distal right coronary artery (RCA)-posterior left ventricle artery [Figure 2]b. Moreover, the left circumflex artery (LCX) was not occluded. We performed emergency percutaneous coronary intervention (PCI) for LAD lesion. A 6 Fr EBU 3.75 guiding catheter was used. The LAD lesion was crossed with a guidewire. After the balloon inflations (SPRINTER), subsequent CAG showed 70% stenosis left and the drug-eluting stent (2.75 mm × 18 mm Endeavor) was placed at the site. Subsequent CAG showed no residual stenosis, no thrombus, and TIMI Grade 3 flow in the LAD [Figure 2]c. However, his chest pain persisted. CAG revealed that the RCA was still totally occluded. PCI for the RCA was therefore performed. A 6 Fr JR 4.0 GUIDING catheter was used. The RCA lesion was crossed with the same guidewire, and balloon inflation with the same balloon catheter resulted in an intimal dissection and significant residual stenosis. The drug-eluting stent (2.75 mm × 18 mm Endeavor) was placed at the site. Moreover, no residual stenosis was observed [Figure 2]d. His chest pain was improved, and ECG showed near-complete resolution of the anterior and inferior ST elevations. The TnI was >50ug/L for 2 days and the minimum value was 7.774 ug/L when he discharged from our hospital 5 days later. The PS was 35.6%, lower than the normal level, which usually was 59%–118%. The left ventricular ejection fraction was 32% 5 days after reperfusion. Moreover, the subsequent course was uneventful.
Figure 2: (a-d) The coronary angiogram of the patient

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  Discussion Top


Although intracoronary thrombus is usual finding in acute MI (AMI), simultaneous formation of the thrombi in two different coronary arteries is very rare. In this case, we observed thrombi in two different arteries 24 h after the onset of AMI.

From earlier published report, simultaneous occlusion coronary arteries mostly involved the LAD and RCA.[1],[2],[3],[4],[5],[6] Only a small fraction was related to LCX and RCA.[7],[8] To the best of our knowledge, none available article has reported that the concurrent occluded arteries were involved LAD and LCX. This probably as a result of the coronary artery anatomy that both the LAD and LCX originate from one artery – the left main artery (LM), also, numerous acute LM occlusion was reported before,[9] and lots of clinical researchers have conducted to explore the most suitable treatment manner to improve the surviving rate during acute stage [10] and delay late adverse ventricular remodeling process.[11] However, due to the low incidence of two coronary artery simultaneous occlusion, the mechanisms were not clear.

In this case, we testified the free PS level in the plasma and found that the value was below the normal range. As we know, the free form of PS is functionally active as a cofactor in mediating the anticoagulant effects of activated PC, deficiencies of PS, or PC predispose to venous thrombosis, and nowadays, researchers revealed that PS deficiency probably associated with coronary thrombosis.[12],[13],[14] Till now, only one published report describes specifically a case of coronary thrombosis involving two arteries resulting from PS deficiency. The authors report the case of a 27-year-old patient by thrombosis in both the left anterior descending and RCA in an otherwise angiographically normal coronary circulation.[15] All above indicated that PS probably related to coronary thrombosis no matter totally occluded the whole artery or secondary to obstructive atherosclerotic disease. In this case, we found the low level of circulating-free PS, which may contribute to the simultaneous occlusion of two coronary arteries.

We agree that this concurrent thrombosis is uncommon, but it may represent important pathophysiologic syndrome related to hypercoagulability or perhaps coincident plaque events such as fissuring or rupture.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

The study was supported by the grant (20172072) from Guangdong Provicial Bureau of Traditional Chinese Medicine and the grant (81602848) from The National Natural Science Fund, People's Republic of China.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Nishiyama O, Iwasaki K, Hina K, Tominaga H, Kanai H, Ueda M, et al. Acase of acute myocardial infarction due to simultaneous occlusion of the right coronary artery and left anterior descending coronary artery. Kokyu To Junkan 1991;39:287-90.  Back to cited text no. 1
    
2.
Suzuki N, Hiasa Y, Miyazaki S, Tomokane T, Ogura R, Miyajima H, et al. Acute myocardial infarction caused by simultaneous occlusion of the right coronary artery and the left anterior descending coronary artery probably due to coronary spasm: A case report. J Cardiol 2005;45:213-7.  Back to cited text no. 2
    
3.
Sia SK, Huang CN, Ueng KC, Wu YL, Chan KC. Double vessel acute myocardial infarction showing simultaneous total occlusion of left anterior descending artery and right coronary artery. Circ J 2008;72:1034-6.  Back to cited text no. 3
    
4.
Zurek P, Dębiński M, Czerwiński W, Kondys M, Buszman P. Acute myocardial infarction with simultaneous occlusions of two coronary arteries in a 44 year-old man. Kardiol Pol 2013;71:279-82.  Back to cited text no. 4
    
5.
Ahmed M, Abdul A. Simultaneous double coronary thrombosis in a 47-year-old male patient with acute myocardial infarction. Am J Case Rep 2013;14:430-4.  Back to cited text no. 5
    
6.
Tiberti G, Farina A, Piatti L, Achilli F. Simultaneous acute occlusion of right and anterior descending coronary arteries in acute myocardial infarction. J Cardiovasc Med (Hagerstown) 2012;13:614-8.  Back to cited text no. 6
    
7.
Derian W, Hertsberg A. Acute myocardial infarction from simultaneous total occlusion of the left circumflex and right coronary artery. A case report. Int J Cardiol 2007;119:e65-7.  Back to cited text no. 7
    
8.
Benjelloun Bennani H, Boukili Makhoukhi Y, Champagne S, Dubois-Randé JL. A case report of an acute myocardial infarction with simultaneous occlusion of circumflex and right coronary artery. Ann Cardiol Angeiol (Paris) 2010;59:238-42.  Back to cited text no. 8
    
9.
Burgazli KM, Bilgin M, Soydan N, Chasan R, Erdogan A. Acute left main coronary artery occlusion. Pak J Med Sci 2013;29:216-7.  Back to cited text no. 9
    
10.
Lee MS, Dahodwala MQ. Percutaneous coronary intervention for acute myocardial infarction due to unprotected left main coronary artery occlusion: Status update 2014. Catheter Cardiovasc Interv 2015;85:416-20.  Back to cited text no. 10
    
11.
van Gaal WJ, Jennings BR, Banning AP. Late adverse ventricular remodelling as a consequence of acute left main coronary artery occlusion. BMJ Case Rep 2009;2009:bcr2006102095.  Back to cited text no. 11
    
12.
Sayin MR. Left main coronary artery thrombus resulting from combined protein C and S deficiency. Intern Med 2013;52:697.  Back to cited text no. 12
    
13.
Oo TH. The timing of thrombophilia testing is important: Comment on “left main coronary artery thrombus resulting from combined protein C and S deficiency”. Intern Med 2013;52:695.  Back to cited text no. 13
    
14.
Hisatomi K, Yamada T, Odate T, Yamashita K. Intermittent coronary artery occlusion caused by a floating thrombus in the left coronary sinus of valsalva of a patient with a normal aorta and protein C deficiency. Ann Thorac Surg 2011;92:1508-10.  Back to cited text no. 14
    
15.
Carrié D, Béard T, Sié P, Boudjemaa B, Delay M, Bernadet P, et al. Simultaneous thrombosis of the left anterior interventricular and right coronary arteries in a 27 year-old patient with protein S deficiency. Arch Mal Coeur Vaiss 1993;86:921-4.  Back to cited text no. 15
    


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