Left main coronary artery occlusion with myocardial infarction in a cocaine user. Successful angioplasty with a drug-eluting stent

Abstract

T he present paper describes the case and management of a cocaine user with an occlusion of the left main coronary artery (LMCA) presenting with ST segment elevation myocardial infarction. To our knowledge, this is the second reported case of LMCA occlusion due to cocaine abuse (1) and the first to be associated with a favourable outcome. Acute LMCA stenting using a drug-eluting stent has been reported (2), although not in the context of cocaine abuse. Data show that primary percutaneous coronary intervention (PCI) in acute LMCA occlusion is feasible. Neri et al (3) reported a 91% initial success rate in patients who, for the most part, presented with cardiogenic shock. However, in-hospital (50%) and six-month (59%) mortality remained very high, as did angiographic restenosis (40%). CASE PRESENTATIONA 42-year-old man proceeded to a nearby community hospital after experiencing several hours of chest pain following heavy cocaine use. His electrocardiogram at admission showed diffuse ST segment depression. Despite administration of nitroglycerine and heparin, subsequent electrocardiograms showed anterolateral ST segment elevation. He was transferred to the Centre Hospitalier de l'Université de Montreal (Montreal, Quebec) for primary PCI approximately 6 h after the onset of symptoms. He received intravenous eptifibatide and a loading dose of clopidogrel before arrival in the catheterization laboratory. Emergent coronary angiography revealed acute LMCA occlusion ( Figure 1A). The patient quickly became hypotensive. Vasopressors were started and an intra-aortic balloon pump was inserted. Balloon angioplasty was performed, restoring Thrombolysis In Myocardial Infarction (TIMI) grade 2 flow in the left coronary artery and revealing a severe plaque burden at the distal bifurcation of the LMCA ( Figure 1B) with a distal embolized thrombus and residual vasospasm. Thrombectomy was achieved with an aspiration catheter (Export; Medtronic, USA). A 4.5 mm × 20 mm paclitaxel-eluting stent (TAXUS; Boston Scientific, USA) was deployed in the LMCA across the circumflex artery. TIMI grade 3 flow was shown to be restored in the left coronary artery on final angiography ( Figure 1C). Endotracheal intubation was required during the procedure. His stay in the coronary care unit was complicated by nosocomial pneumonia. At discharge, he had a left ventricular ejection fraction of 35%. Two CASE REPORT ©2008 Pulsus Group Inc. All rights reserved A patient presented with acute ST segment elevation myocardial infarction following cocaine abuse. He was transferred for primary angioplasty. The emergent coronary angiography revealed acute left main coronary artery occlusion. Recanalization with balloon angioplasty was performed, followed by thrombectomy and stenting of the left main coronary artery with a paclitaxel-eluting stent. The patient recovered with a left ventricular ejection fraction of 35% at discharge. The pathophysiology of cocaineinduced myocardial infarction includes vasospasm, thrombosis and increased myocardial oxygen demand. Pr...

Differential diagnosis of non-atherosclerotic left main coronary artery stenosis

“…CABG, coronary artery bypass grafting; CBC, complete blood count; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; LMCA, left main coronary artery.For example:* idiopathic,2 catheter-induced,3 cocaine-induced;4 †spontaneous,5 traumatic 6

Reference numbers for reported cases are given in the first column.

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“…LMCA spasms have been described as idiopathic,2 catheter-induced3 and cocaine-induced 4. In most cases LMCA stenosis can be diagnosed by intracoronary application of nitroglycerine, leading to reduction of luminal narrowing 2.…”