Complicated acute myocardial infarction with simultaneous occlusion of two coronary arteries

Dual Coronary Artery Thrombosis: An Unforeseen Angiographic Encounter

Acute myocardial infarction (AMI) frequently involves single-vessel coronary artery disease, but simultaneous thrombosis in multiple coronary arteries is a rare and challenging clinical scenario. We report the case of a 42-year-old Southeast Asian male with a six-month history of hypertension controlled by a single antihypertensive agent, presenting to the emergency department with central chest pain radiating to the back. The initial electrocardiography (ECG) showed ST elevation in the inferior leads. Primary percutaneous coronary intervention (PCI) via the right femoral approach revealed complete thrombotic occlusions in the left anterior descending (LAD) and right coronary artery (RCA). Drug-eluting stents (DES) were deployed, restoring thrombolysis in myocardial infarction (TIMI) III flow. Despite initial hemodynamic stability, the patient experienced cardiogenic shock (CS), necessitating a relook angiogram that confirmed patent stents and identified an additional stenosis in the first diagonal branch (D1). An intra-aortic balloon pump (IABP) was inserted. The patient's course was complicated by recurrent CS, septic shock secondary to Fusobacterium periodonticum bacteremia, acute kidney injury, multiple supraventricular arrhythmias (SVTs), and partial thrombosis of the right radial artery leading to dry gangrene of the right index and thumb fingers. He was eventually discharged on oral warfarin for radial artery thrombosis and paroxysmal atrial fibrillation with follow-up care with vascular surgery.

Acute myocardial infarction with simultaneous total occlusion of the left anterior descending artery and right coronary artery successfully treated with percutaneous coronary intervention

BACKGROUND

Simultaneous thrombosis in more than one coronary artery is an uncommon angiographic finding in patients with acute ST-segment elevation myocardial infarction. It is difficult to identify using 12-lead electrocardiography and usually leads to cardiogenic shock and fatal outcomes, including sudden cardiac death. Therefore, immediate revascularization and adequate mechanical circulatory support are required.

CASE PRESENTATION

We report the case of a 58-year-old man who presented with vomiting and chest pain complicated by cardiogenic shock and complete atrioventricular block. Electrocardiography revealed ST-segment elevation in leads II, III, aVF, and V1-V6. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery and right coronary artery. The patient successfully underwent primary percutaneous coronary intervention with ballooning and stenting for both arteries. An Impella CP was inserted during the procedure. Fifty-seven days after admission, he had New York Heart Association class II heart failure and was transferred to a rehabilitation hospital.

CONCLUSIONS

Acute double-vessel coronary thrombosis, a serious event with a high mortality rate, requires prompt diagnosis and management to prevent complications such as cardiogenic shock and ventricular arrhythmias. A combination of judicious medical treatment, efficient primary percutaneous coronary intervention, and early mechanical support device insertion is crucial to improve the survival rate of patients with this disease.