2024 Scientific Sessions

STEMI Resulting from Flush Occlusion of the Ostial Left Anterior Descending Artery in a Dual Ostia Coronary Artery System

Introduction

A 62-year-old man with a Dual Ostia Coronary Artery System presented with ST-elevation myocardial infarction (STEMI) and underwent a successful percutaneous coronary intervention (PCI) procedure to recanalize the flush occlusion of the left anterior descending (LAD) artery.

Clinical Case

A 62 year-old man with a history of diabetes mellitus and hypertension presented to the emergency department with a complaint of stabbing substernal chest pain radiating to the back, off and on for several hours. Initial EKG showed sinus tachycardia and ST segment elevations in the leads V2,V3,V4. En route to the cardiac catheterization laboratory (CCL), the patient underwent a chest CT angiography to investigate the possibility of aortic dissection. This imaging was performed due to the patient's medical history and chest pain radiating to the back, with the aim of excluding or confirming the presence of aortic dissection as a potential cause. The troponin level was elevated to 38.60 ng/ml. In the CCL the patient underwent left heart catheterization with left ventriculography. The Left circumflex (LCX) and the right coronary arteries were patent while ventriculography revealed severe hypokinesis of anterolateral wall and akinesis of the apex. The Left anterior descending (LAD) coronary artery could not be visualized. The EKG changes and left ventriculogram both indicated the LAD as the culprit artery, prompting suspicion of an anomaly in its origin. Using a 6 French EBU 3.5 guide and Runthrough guide wires, exploration in the left coronary sinus revealed a dual ostia system. The LCX artery was engaged and anchored, allowing probing of the aortic wall near LCX ostium. Successful identification of the ostium led to advancing a wire to the LAD artery. Stenting addressed a thrombotic 100% lesion in the ostial LAD and a diffuse 75% lesion in the mid-LAD, utilizing Resolute Onyx drug-eluting stents. Despite improved ejection fraction, a left ventricular thrombus was discovered, likely due to the thrombotic ostial LAD lesion and delayed presentation. The patient was discharged on aspirin, clopidogrel, and rivaroxaban, remaining stable on follow-up.

Discussion

Primary percutaneous coronary intervention (PCI) requires prompt recanalization of the culprit artery. However, coronary anomalies can pose challenges for the operator, particularly in cases where the lesion is located in the aorto-ostial region and the anatomical position is unknown. In such scenarios, the use of ancillary techniques like CT angiography of the coronary arteries may not be feasible or available, further complicating the procedure. The operator must navigate these challenges with expertise and rely on alternative strategies to ensure successful recanalization and optimal patient outcome.