Multiple Culprit Arteries in Patients With ST Segment Elevation Myocardial Infarction Referred for Primary Percutaneous Coronary Intervention

Abstract

In most cases of acute ST-segment elevation myocardial infarction, only 1 epicardial artery contains an occluding thrombus, commonly referred to as the "culprit" artery. Rarely, however, patients present with >1 acutely thrombosed coronary artery (i.e., "multiple culprits"). The investigators present their experience with 18 patients presenting with ST-segment elevation myocardial infarctions and angiographically documented multiple culprit arteries, provide a detailed review of an additional 29 patients previously reported, and summarize baseline characteristics, pertinent electrocardiographic and angiographic findings, laboratory values, and clinical outcomes for all 47 patients. In this case series, most patients were men (85%) with histories of tobacco use (49%). Although nearly 1/3 of the patients had isolated inferior ST-segment elevation on initial 12-lead electrocardiography, 50% of them had simultaneous thrombotic occlusions of the right coronary and the left anterior descending coronary arteries documented on coronary angiography. These patients were hemodynamically unstable on presentation, with >1/3 in cardiogenic shock. In most cases, no other potential predisposing factors were identified. In conclusion, patients with multiple culprit arteries in the setting of ST-segment elevation myocardial infarctions represent a unique population with high rates of cardiogenic shock and no clear cause.We present our own case series of 18 patients with ST-segment elevation myocardial infarctions (STEMIs) who were referred for primary percutaneous coronary intervention (PCI) in whom multiple culprit arteries were identified angiographically. In addition, we provide a detailed review of an additional 29 patients previously reported, report summary data for all 47 patients, and discuss possible causative factors. MethodsWith investigational review board approval, we searched the primary PCI database at the University of Texas South-western Medical Center and the University of Virginia for all patients presenting with STEMIs referred for primary PCI who had evidence of ST-segment elevation on admission 12-lead electrocardiography and >1 acutely occluded coronary artery documented on coronary angiography. All angiograms were reviewed by an interventional

Acute Simultaneous Thrombotic Occlusion of Multiple Coronary Arteries in Acute Myocardial Infarction: A Case Report

“…Multiple coronary thrombosis was demonstrated in 10% of the patients who died from acute myocardial infarction (17). Multiple simultaneous coronary occlusions in acute myocardial infarction always lead to very serious illness (1). In previous reports, more than 50% of patients presented with cardiogenic shock with poor prognosis, and had a high mortality rate.…”

Congenital Absence of the Left Circumflex Artery Associated with Inferior Myocardial Infarction

“…This pattern of ECG can be explained by the following reasons: (a) Conventional ECG findings used to distinguish infarctrelated artery are less useful in patients with simultaneous occlusion of RCA and LCx. Pollak et al described ECG characteristics of simultaneous occlusions of the RCA and LCx, two-thirds of the patients had isolated inferior STsegment elevation (6). (b) Good collateral from LAD to the territory of LCx may explain the absence of ST-segment elevation in leads V5 and V6.…”

Acute Myocardial Infarction due to Multiple Thrombosis without Cardiogenic Shock

“…In one case series, its frequency was reported as 2.5% [3]. The main pathophysiological mechanism is thrombotic occlusion due to atherosclerotic plaques in acute myocardial infarction.…”

“…This is one of the most severe clinical situations a patient can suffer. Approximately a third of the patients present with cardiogenic shock and nearly a fourth of the patients have life-threatening ventricular arrhythmias [1-3]. Herein, we report the case of a 43-year-old woman suffering from simultaneous anterior and inferior myocardial infarctions due to total thrombotic occlusion in both left anterior descending artery (LAD) and right coronary artery (RCA).…”