Marchi Enrico, Muraca Iacopo, Cesarini Daniel, Pennesi Matteo, Valenti Renato
Interventional Cardiology Unit, Careggi University Hospital, Largo G.A. Brambilla 3, 50141 Florence, Italy.
Eur Heart J Case Rep. 2024 Aug 5;8(8):ytae394. doi: 10.1093/ehjcr/ytae394. eCollection 2024 Aug.
ST elevation myocardial infarctions are usually a consequence of the occlusion of a single coronary artery, but in 2.5% of the cases, two or more culprit lesions are found. Simultaneous coronary artery occlusion is a potentially life-threatening condition that leads to cardiogenic shock or ventricular arrhythmias.
We presented the case of a 74-year-old man presenting with chest pain and ST segment elevation (STE) in inferior leads and evidence of alternating STE in anterior leads in a pattern like Wellens syndrome type A in subsequent electrocardiogram (ECGs). Emergency coronary angiography (CA) revealed thrombotic occlusion of the proximal right coronary artery (RCA) and sub-occlusion of mid left anterior descending artery (LAD). During the CA, he became haemodynamically unstable requiring intravenous inotropes and vasopressors, and he underwent primary percutaneous coronary intervention of both RCA and LAD culprit lesions. His subsequent hospital stay was uneventful, and he was discharged 5 days later.
ST elevation myocardial infarction with more than one culprit coronary artery is a rare but at high risk of haemodynamic decompensation. The causes of occlusion of multiple coronary arteries may be several: coronary embolism, coronary ectasia, simultaneous plaque disruption, coronary vasospasm, hypercoagulability states, smoking, and illicit drug abuse. The presumed mechanism behind the presented case may be a combination of release of pro-thrombotic cytokines due to the thrombotic occlusion of the first coronary and low output state secondary to myocardial dysfunction leading to impaired flow in a severe stenotic coronary artery with subsequent thrombosis.
ST段抬高型心肌梗死通常是单一冠状动脉闭塞的结果，但在2.5%的病例中，可发现两个或更多罪犯病变。同时发生的冠状动脉闭塞是一种潜在的危及生命的情况，可导致心源性休克或室性心律失常。
我们报告了一例74岁男性病例，该患者出现胸痛，下壁导联ST段抬高（STE），随后心电图（ECG）显示前壁导联STE呈A 型Wellens综合征样交替变化。急诊冠状动脉造影（CA）显示右冠状动脉（RCA）近端血栓性闭塞，左前降支动脉（LAD）中段次全闭塞。在冠状动脉造影期间，他出现血流动力学不稳定，需要静脉注射血管活性药物，随后对RCA和LAD罪犯病变均进行了直接经皮冠状动脉介入治疗。他随后的住院过程顺利，5天后出院。
存在多个罪犯冠状动脉的ST段抬高型心肌梗死罕见，但血流动力学失代偿风险高。多条冠状动脉闭塞的原因可能有多种：冠状动脉栓塞、冠状动脉扩张、同时发生的斑块破裂、冠状动脉痉挛、高凝状态、吸烟和非法药物滥用。本病例背后的推测机制可能是由于第一支冠状动脉血栓性闭塞导致促血栓形成细胞因子释放，以及继发于心肌功能障碍的低心排血量状态，导致严重狭窄冠状动脉内血流受损，随后形成血栓。
