Coronary vasospasm, ventricular fibrillation arrest, exercise induced ST segment elevation, atheroma, intravascular image study
Figure 1: A. Coronary angiogram of the right coronary artery (RCA) showed severe spasm of proximal part (white arrow). B. After administration of nitroglycerine, vasospasm disappeared.
The smooth, enlarged RCA angiogram suggested no significant plaque burden.
Figure 2: ST segment elevation in leads V1-3, aVL , aVR and ST depression in leads II, III, aVF, V4-6 were documented during chest pain after exercise for 3 minutes. The maximal heart rate was only 105 bpm.
His angina and ST deviation disappeared within 4 minutes.
Figure 3: A: The left coronary angiogram revealed a moderate lesion localized in the mid LAD segment (white arrow, A-C), close to the origin of an unobstructed diagonal branch (DG). The mid LAD segment had diffuse severe stenosis (black arrow).
B-C: After administration of intra-coronary nitroglycerine, the whole LAD diameter was enlarged but the mid LAD lesion (black arrow) remained in 50-60% diameter stenosis (white arrow B,C). FFR, performed after intracoronary administration of adenosine 60 cc and 400 microgram of NTG, was in the normal range, 0.89-0.95, indicative of a non-hemodynamic significant lesion, so coronary intervention was deferred.
Figure 4: Intravascular ultrasound imaging showed an angiographic silent atheroma from 2 to 12 o’clock in the left main, (A) and proximal LAD artery (B).
At the mid LAD segment, the lumen (arrow sign) shape was elliptical since it was surrounded by an eccentric fibro-lipid atheroma, causing an area stenosis of 55.6% and 60% (C &D). Similar lesion was observed along the vaso-spastic segment (E). However, there was no significant plaque burden in the distal LAD (F).
Figure 5: After administration of slow release verapamil 240 mg for two weeks, the repeat exercise stress test showed no reproducible chest pain after walking 9 minutes on Bruce protocol (10 mets achieved).
There was mild STE in aVR and J point ST depression in leads V4-6 and II, aVF but the patient had no symptoms.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission
from the publisher.