A rare case of double infarction treated with primary percutaneous coronary intervention

Introduction

Coronary artery disease is the leading cause of mortality and morbidity in developing as well as developed countries, and the acute presentation occurs in the form of ST-elevation myocardial infarction (STEMI) or unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI). The process of acute myocardial infarction begins with an anatomic or functional obstruction in the coronary vascular bed, which results in regional myocardial ischemia and, if the ischemia persists, in infarction. Depending on the involved vessels, e.g., left anterior descending (LAD), left circumflex (LCx) or right coronary artery (RCA), it results in anterior wall myocardial infarction (AWMI), inferior wall myocardial infarction (IWMI), or right ventricular myocardial infarction (RVMI), etc.
Acute myocardial infarction (AMI) involving two or more culprit lesions at the same time, known as double or combined infarction, is an extremely rare event with a grave prognosis [1, 2]. Here, we describe a case of a patient with acute myocardial infarction due to total occlusion of the left anterior descending and right coronary artery who presented with cardiogenic shock.

Case report

A 34-year-old young male smoker presented with sudden onset severe retro-sternal chest pain lasting for 2 h with radiation to the left arm. On examination the pulse was 110/min and blood pressure was 70 mm Hg (systolic); bilateral basal crackles were present along with left ventricular third heart sound. ECG showed ST elevation in anterior leads (V1–V6) and also in inferior leads (II, III, aVF) (Figure 1), and troponin T was elevated. The patient also had several episodes of ventricular tachycardia alternating with complete heart block. Based on history and clinical examination, we made a diagnosis of acute anterior wall myocardial infarction, probably due to occlusion of the left anterior descending coronary artery, which had also wrapped around the inferior wall. The patient was loaded with 350 mg of aspirin and 600 mg of clopidogrel and was immediately shifted to the cath lab for coronary angiography with the intention to do primary percutaneous coronary intervention (PCI). A temporary pacemaker lead was inserted as he developed persistent complete heart block.
But, after performing coronary angiography, we were surprised to find that both the LAD (Figure 2 A) and the RCA (Figure 3 A) were totally occluded, which seemed to be acute as there was absence of...


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