A 74 year old female patient had suffered from chest pain which was developed 6 hours ago. The pain was tearing and not subsided. So she visited nearby hospital. Since there was abnormal finding on 12-lead electrocardiogram (ECG), she was transferred to Chonnam National University Hospital. On 12-lead ECG at other hospital, ST-segment elevation was seen from V1 to V5 and lead II, III, aVF (Figure 1A), and 12-lead ECG at our hospital showed similar finding compared to that achieved at other hospital. (Figure 1B). She had history of cerebral infarction in basal ganglia and cerebellar infarction 1 year ago. Because she complained continuous chest pain and ECG showed simultaneous ST-segment elevation on anterior and inferior leads, we thought that the cause of ST-segment elevation myocardial infarction (STEMI) was vasospasm or thromboembolism. We also considered occlusion of wrapped left anterior descending artery (LAD). Coronary angiography (CAG) revealed critical stenosis in middle right coronary artery (RCA) and critical stenosis in proximal to mid LAD (Figure 2). Firstly, balloon angioplasty was done for proximal to middle LAD using 2.5 x 15 mm balloon catheter, then we examined intravascular ultrasound (IVUS) for LAD. It revealed large amount of plaque burden with plaque rupture in target lesion. Minimal lumen area (MLA) was about 2.4 mm2 and plaque burden was 83% at middle LAD. We implanted 2.5 x 30 mm Resolute Onyx for middle LAD and 3.0 x 22 mm Resolute Onyx for proximal LAD. We also performed additional balloon angioplasty using 3.25 x 12 mm non-compliant balloon for stent under-expansion. Follow-up IVUS showed good stent apposition and expansion, Stent area on proximal was 6.5 mm2 and minimal stent area (MSA) on stent distal part was 5.5 mm2 (Figure 3). Final CAG showed good distal flow without residual stenosis.

After that, we checked IVUS for RCA. It revealed plaque rupture in target lesion, and MLA was 2.7 mm2 and plaque burden was 80.3%. Balloon angioplasty was done for mid RCA using 2.0 x 15 mm balloon catheter, and we implanted 3.5 x 38 mm Resolute Onyx for this lesion. Follow-up IVUS showed good stent apposition and expansion. MSA was 7.7 mm2. Final CAG showed good distal flow without residual stenosis. (Figure 4). A 12-lead ECG after procedure showed ST-segment regression with Q-wave formation in precordial lead and inferior leads (Figure 5). Patient discharged at the seventh hospital day without any cardiovascular complications.

There were several conditions which make simultaneous ST-segment elevation in ECG. Firstly, these can be developed in simultaneous coronary vasospasm. Secondly, these also can be developed by occlusion of wrapped LAD. Wrapped LAD is an LAD from a post reperfusion coronary angiogram that perfuse at least one fourth of the inferior wall of the left ventricle in the right anterior oblique projection. The current case showed simultaneous ST-segment elevation in two culprit lesions with plaque ruptures. Although we could not know the exact timing of plaque ruptures in LAD and RCA, we should know that this rare case also can be a cause of simultaneous ST-segment elevation in 12-lead ECG.

 

Figure 1. Twelve-lead electrocardiogram (ECG) showed simultaneous anterior and inferior ST-segment elevation on ECG at other hospital (A) and our hospital (B)

Figure 2. Coronary angiography showed critical stenosis in middle right coronary artery (A) and critical stenosis in proximal to middle left anterior descending artery (B).

Figure 3. Intravascular ultrasound findings. (A) after percutaneous transluminal coronary angioplasty for LAD using 2.5 x 15 mm balloon catheter (B) after stent deployment: Resolute Onyx 3.0 x 22 mm for proximal LAD, Resolute Onyx 2.5 x 30 mm for mild LAD

Figure 4. Intravascular ultrasound finding before percutaneous transluminal coronary angioplasty (A) After stent deployment for mild RCA using Resolute Onyx 3.5 x 38mm (B)

Figure 5. Follow up 12-lead electrogradiogram showed regression of ST-segment elevation and Q-wave formation in precordial lead and inferior lead.