Acute myocardial infarction without angiographic luminal narrowing

- Operator : Bon-Kwon Koo

Acute myocardial infarction without angiographic luminal narrowing

- Operator: Bon-Kwon Koo, MD, PhD
Case Presentation

A sixty-one year old man was referred to the emergency room due to the sudden chest pain and ST segment elevation that occurred during right coronary artery angiography at the other hospital. His coronary risk factors were diabetes mellitus and hypertension. At the emergency room, the patient still had severe chest pain. Baseline electrocardiogram showed ST segment elevation in leads II, III and aVF and ST depression in leads V1-3 (Figure 1). Initial CK-MB was 219 U/L (normal range: < 16). Under the impression of acute inferior wall infarction, urgent coronary angiography was conducted.

Angiography and Procedure

Left coronary angiogram revealed no significant narrowing (Figure 2). Right coronary angiogram showed no demonstrable luminal narrowing (Figure 3). For further investigation, intravascular ultrasound (IVUS) was performed and then it showed an intimal detachment along the entire right coronary artery (RCA), suggesting iatrogenic dissection during diagnostic coronary angiography in the referred hospital (Movie 1) . We intended to treat this lesion with spot stenting at the entry site of long dissection. Thus, a cypher stent (3.5x18mm) was deployed at 8 atm and adjunctive balloon inflation with Quatum 5.0x8mm was performed at the proximal part of the stent (Figure 4). After stent implantation, chest pain was relieved and ST segment elevation was resolved. Post-intervention IVUS showed a good apposition at the proximal part of stent with residual dissection (Figure 5, Figure 6). However, we finished the procedure because the entry site was successfully covered by the stent. The patient discharged without any complication. Six-month follow-up angiogram showed a patent right coronary lumen without neointimal growth in the stented segment (Figure 7) . IVUS showed a resolution of the dissection and a inappostion at the stented segment (Movie 2; middle RCA, Figure 8; distal part of stent, Figure 9; proximal part of stent). No further procedure was performed.

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