Spontaneous multivessel coronary artery spasm diagnosed with intravascular ultrasound imaging:A case report

BACKGROUND Coronary artery spasm is a major cause of myocardial ischemia.Although coronary artery spasm has been known for a long time,its mechanism has not yet been identified.Many clinicians,especially young clinicians pay less attention to coronary artery spasm,which may lead to some patients not being appropriately diagnosed and treated in time.We report a patient with spontaneous multivessel coronary artery spasm for more than 30 years diagnosed with intravascular ultrasound(IVUS)imaging.CASE SUMMARY A 66-year-old Chinese male patient had chest squeezing at rest for more than 30 years.He had a history of cigarette smoking for more than 40 years and hypertension for 10 years.Before presenting at our institution,the patient had undergone coronary angiography 4 times and percutaneous transluminal coronary angioplasty procedures twice at other hospitals without a diagnosis of coronary artery spasm.However,his chest symptoms worsened.Spontaneous multivessel coronary artery spasm occurred during IVUS without provocation testing,and the IVUS image was recorded.Thus,the diagnosis of multifocal spontaneous coronary artery spasm was confirmed.The patient was placed on oral diltiazem,isosorbide mononitrate,and nicorandil to suppress coronary artery spasms.All medications were given at the maximum dosages tolerated by the patient.He was discharged after 5 d without complications.During the six-month follow-up period,the patient was symptom-free.CONCLUSION Coronary artery spasm is still prevalent in Eastern countries.It is essential for clinicians to be aware of coronary artery spasm,which may be hard to detect and can be lethal,in order to diagnose and treat patients appropriately.

Pheochromocytoma in a 49-year-old woman presenting with acute myocardial infarction:A case report

BACKGROUND Pheochromocytoma is a rare endocrine tumor arising from chromaffin cells and having extensive and profound effects on the cardiovascular system by continuously or intermittently releasing catecholamines.The clinical manifestations of pheochromocytoma are diverse,and the typical triad,including episodic headache,palpitations,and sweating,only occurs in 24%of pheochromocytoma patients,which often misleads clinicians into making an incorrect diagnosis.We herein report the case of a patient with intermittent chest pain and elevated myocardial enzymes for 2 years who was diagnosed with pheochromocytoma.CASE SUMMARY A 49-year-old woman presented with intermittent chest pain for 2 years.Two years ago,the patient experienced chest pain and was diagnosed with acute myocardial infarction,with 25%stenosis in the left circumflex.The patient still had intermittent chest pain after discharge.Two hours before admission to our hospital,the patient experienced chest pain with nausea and vomiting,lasting for 20 min.Troponin I and urinary norepinephrine and catecholamine levels were elevated.An electrocardiogram indicated QT prolongation and ST-segment depression in leads II,III,aVF,and V3-V6.A coronary computed tomography angiogram revealed no evidence of coronary artery disease.Echocardiography showed left ventricular enlargement and a decreased posterior inferior wall motion amplitude.Contrast-enhanced computed tomography demonstrated an inhomogeneous right adrenal mass.The patient successfully underwent laparoscopic right adrenalectomy,and histopathology confirmed adrenal pheochromocytoma.During the first-year follow-up visits,the patient was asymptomatic.The abnormal changes on echocardiography and electro-cardiogram disappeared.CONCLUSION Clinicians should be aware of pheochromocytoma.A timely and accurate diagnosis of pheochromocytoma is essential for alleviating serious cardiac complications.

Chest pain showing precordial ST-segment elevation in a 96-year-old woman with right coronary artery occlusion:A case report

BACKGROUND Typically,right coronary artery(RCA)occlusion causes ST-segment elevation in inferior leads.However,it is rarely observed that RCA occlusion causes STsegment elevation only in precordial leads.In general,an electrocardiogram is considered to be the most important method for determining the infarct-related artery,and recognizing this is helpful for timely discrimination of the culprit artery for reperfusion therapy.In this case,an elderly woman presented with chest pain showing dynamic changes in precordial ST-segment elevation with RCA occlusion.CASE SUMMARY A 96-year-old woman presented with acute chest pain showing precordial STsegment elevation with dynamic changes.Myocardial injury markers became positive.Coronary angiography indicated acute total occlusion of the proximal nondominant RCA,mild atherosclerosis of left anterior descending artery and 75%stenosis in the left circumflex coronary artery.Percutaneous coronary intervention was conducted for the RCA.Repeated manual thrombus aspiration was performed,and fresh thrombus was aspirated.A 2 mm×15 mm balloon was used to dilate the RCA with an acceptable angiographic result.The patient’s chest pain was relieved immediately.A postprocedural electrocardiogram showed alleviation of precordial ST-segment elevation.The diagnosis of acute isolated right ventricular infarction caused by proximal nondominant RCA occlusion was confirmed.Echocardiography indicated normal motion of the left ventricular anterior wall and interventricular septum(ejection fraction of 54%),and the right ventricle was slightly dilated.The patient was asymptomatic during the 9-mo follow-up period.CONCLUSION Cardiologists should be conscious that precordial ST-segment elevation may be caused by occlusion of the nondominant RCA.

Recurrent Takotsubo cardiomyopathy triggered by emotionally stressful events: A case report

BACKGROUND Takotsubo cardiomyopathy(TCM)is characterized by reversible left ventricular dysfunction triggered by emotional or physical stress.Only 1%-2%of patients with acute coronary syndrome are diagnosed with TCM.Although obstructive coronary artery disease is frequently considered to be the cause of chest pain,TCM should be considered in some clinical settings.In this case,clinicians did not make a timely and accurate diagnosis for TCM due to a lack of knowledge until the third hospitalization with a left ventriculogram.CASE SUMMARY A 55-year-old postmenopausal woman had intermittent chest pain following emotionally stressful events three times in the past 3 years.Cardiac troponin levels increased after each instance of symptom onset.A transthoracic echocardiogram showed reversible left ventricular dysfunction.The patient underwent three coronary angiograms without evidence of coronary artery disease.A left ventriculogram was first performed at the third hospitalization and revealed apical akinesia with ballooning of the apical region and consistent hypercontractile basal segments.The diagnosis of TCM was confirmed.The patient was treated with an angiotensin-converting-enzyme inhibitor(perindopril)and aβ-blocker(metoprolol).No complications occurred during the patient’s hospitalization.The patient was told to avoid stressful events.During the 9-mo follow-up visit,the patient was asymptomatic with an ejection fraction of 55%.CONCLUSION Clinicians should be conscious of the possibility of TCM,especially in postmenopausal women presenting with clinical manifestations similar to acute coronary syndrome without coronary occlusion.

Arrhythmogenic right ventricular cardiomyopathy characterized by recurrent syncope during exercise:A case report

BACKGROUND Arrhythmogenic right ventricular(RV)cardiomyopathy is a rare and currently underrecognized cardiomyopathy characterized by the replacement of RV myocardium by fibrofatty tissue.It may be asymptomatic or symptomatic(palpitations or syncope)and may induce sudden cardiac death,especially during exercise.To prevent adverse events such as sudden cardiac death and heart failure,early diagnosis and treatment of arrhythmogenic RV cardiomyopathy(ARVC)are crucial.We report a patient with ARVC characterized by recurrent syncope during exercise who was successfully treated with combined endocardial and epicardial catheter ablation.CASE SUMMARY A 43-year-old man was referred for an episode of syncope during exercise.Previously,the patient experienced two episodes of syncope without a firm etiological diagnosis.An electrocardiogram obtained at admission indicated ventricular tachycardia originating from the inferior wall of the right ventricle.The ventricular tachycardia was terminated with intravenous propafenone.A repeat electrocardiogram showed a regular sinus rhythm with negative T waves and a delayed S-wave upstroke from leads V1 to V4.Cardiac magnetic resonance imaging showed RV free wall thinning,regional RV akinesia,RV dilatation and fibrofatty infiltration(RV ejection fraction of 38%).An electrophysiological study showed multiple inducible ventricular tachycardia as of a focal mechanism from the right ventricle.Endocardial and epicardial voltage mapping demonstrated scar tissue in the anterior wall,free wall and posterior wall of the right ventricle.Late potentials were also recorded.The patient was diagnosed with ARVC and treated with combined endocardial and epicardial catheter ablation with a very satisfactory follow-up result.CONCLUSION Clinicians should be aware of ARVC,and further workup,including imaging with multiple modalities,should be pursued.The combination of epicardial and endocardial catheter ablation can lead to a good outcome.

Atypical double right coronary artery:a case report and literature review

Coronary artery anomalies are a kind of rare congenital coronary disease most of which are nonmalignant and asymptomatic,while some could lead to severe clinical manifestations and even sudden cardiac death.Here,we reported an atypical anomaly of a double right coronary artery with no obvious atherosclerosis on angiograms,in a 51-year-old woman who showed mild symptoms and had ischemic signs on electrocardiogram.This anomaly is neither similar to the typical appearances of a split right coronary artery nor a large right ventricle branch,is probably account for the potential risk of myocardial ischemia and highly likely to be missed during coronary angiography.