Anterior ECG changes following iatrogenic dissection of the right coronary artery into the aortic root: Exclusion of left coronary obstruction with transoesophageal echocardiography




Abstract


One of the most troublesome complications of percutaneous coronary intervention (PCI) or angiography is retrograde dissection of the artery into the aortic root. We report a case involving the right coronary artery (RCA) which was treated with prompt deployment of stents. Recurrent chest pain and ST segment elevation in V 2–4 mimicked the ECG appearance of acute anterior infarction and prompted concern that the dissection had extended to impair flow in the left coronary artery (LCA). Transoesophageal echocardiography (TOE) demonstrated that the aortic root dissection had been contained and that the LCA was not compromised.


1


Case report


A 53 year old man presented with an acute inferior ST-elevation myocardial infarct ( Fig. 1 ). Coronary angiography showed no significant disease of the left system. The occluded RCA ( Fig. 2 ) was engaged with a 6 F JR4 guide and a guide wire 1


1 Guidant BMW.

passed to the distal vessel. The lesion was dilated with a 3.0 mm balloon 2

2 3.0 × 20 mm Guidant Cross-Sail to 10 bar.

to 10 bar. The subsequent angiogram disclosed retrograde dissection to the aortic root ( Fig. 3 ). Two bare-metal stents 3

3 3.5 × 23 mm Multi-Link Vision™ to 10 bar, 3.5 × 24 mm Medtronic AVE S7 to 14 bar.

were deployed across the lesion back to the ostium of the RCA to seal the entry ( Fig. 4 ). He was given heparin, abciximab, metoprolol, aspirin, and clopidogrel.


Fig. 1


ECG on admission — limb leads with ST-segment elevation in leads II, III and aVF.



Fig. 2


Initial L oblique image showing complete occlusion of mid-RCA beyond conus branch.



Fig. 3


L oblique image of RCA following PCI with contrast extravasation into RCA sinus.



Fig. 4


L oblique image of RCA following stent deployment — the conus branch is no longer filled.


Two hours later he developed recurrent chest pain. His ECG showed that the inferior ST elevation had resolved but displayed new anterior ST elevation to 4 mm in V 2 and V 3 ( Fig. 5 ). We were concerned that the dissection had extended to compromise flow in the LCA but TOE showed that the haematoma remained confined to the aortic root adjacent to the ostium of the RCA and that the LCA was patent ( Fig. 6 ). Left ventricular systolic function was well-preserved with no regional wall motion abnormalities.




Fig. 5


ECG showing resolution of inferior changes but fresh ST-segment elevation in leads V 2–4.



Fig. 6


TOE images showing haematoma in R coronary sinus (arrows) not impinging on L main ostium (LM).


We presumed that his recurrent pain and the transient ECG changes in the anterior precordial leads had reflected occlusion of a conus or right ventricular branch of the RCA, the origin of which had been compromised by our intervention. His anterior ECG changes improved and his pain settled promptly with analgesia, β-blockade and ramipril. He was discharged after six days.


Three months later he was admitted to another hospital with diffuse in-stent restenosis which was corrected with two drug-eluting stents.

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Nov 14, 2017 | Posted by in CARDIOLOGY | Comments Off on Anterior ECG changes following iatrogenic dissection of the right coronary artery into the aortic root: Exclusion of left coronary obstruction with transoesophageal echocardiography

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