case_images: PMC9714305_01
case_images: Baseline ECG showed sinus rhythm with mild ST-T elevation in aVR and V1 leads and ST-T depression in I, aVL, and V2-V5 leads.
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case_images: PMC9714305_01_fcvm-09-1012916-g0001.jpg
case_images: F1
case_images: Baseline ECG displayed sinus rhythm (HR = 74 bpm) with likely "left main coronary artery lesion" (mild ST-T elevation in aVR and V1 leads and ST-T depression in other 6 leads) (Figure 1). On the eighth day of hospitalization, the patient underwent cardiac catheterization and trans-radial coronary angiography showed severe three-vessel coronary artery disease (CAD) with a severely diseased and calcified left circumflex artery (LCA, 80-90% stenosis) and left anterior descending artery (LAD, 90-95% stenosis) in multiple segments (Figures 2A,B and Supplementary Videos 1, 2).
case_images: Coronary angiography showed severe three-vessel coronary artery disease with severely diseased and calcified left circumflex artery (LCX) (A) and left anterior descending artery (LAD) involved in multiple segments (B). RCA angiography unveiled fluent stent and diffused lesions in distal segment, and subtotal occlusion close to post-trigeminal area (C), the distal lesion of RCA was treated with drug-coated balloon with satisfactory result (D).
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case_images: PMC9714305_01_fcvm-09-1012916-g0002.jpg
case_images: F2
case_images: On the eighth day of hospitalization, the patient underwent cardiac catheterization and trans-radial coronary angiography showed severe three-vessel coronary artery disease (CAD) with a severely diseased and calcified left circumflex artery (LCA, 80-90% stenosis) and left anterior descending artery (LAD, 90-95% stenosis) in multiple segments (Figures 2A,B and Supplementary Videos 1, 2). RCA angiography unveiled fluent stent in the second segment and diffuse lesions in the distal segment, with subtotal occlusion close to the post-trigeminal area (Figure 2C and Supplementary Video 3). The distal lesion of RCA was treated with a drug-coated balloon (Figure 2D and Supplementary Video 4).
case_images: ECG showing ST-elevation in V1 and ST-depression in I, aVL, and V1-V6 leads when the patient complained of severe chest pain (A). There is an ES attack during the reported chest pain (B). Coronary angiography demonstrated patency of RCA (TIMI flow grade II-III) (C). Three stents were implanted in the LAD with remarkable results (TIMI flow grade III) (D,E).
case_images: fcvm-09-1012916-g0003.jpg
case_images: PMC9714305_01_fcvm-09-1012916-g0003.jpg
case_images: F3
case_images: RCA angiography unveiled fluent stent in the second segment and diffuse lesions in the distal segment, with subtotal occlusion close to the post-trigeminal area (Figure 2C and Supplementary Video 3). ECG demonstrated diffuse ST-T changes in anterior leads (Figure 3A) and the patient suffered from an ES attack (repeated VF) soon after (Figure 3B). Coronary angiography demonstrated patency of RCA (TIMI flow grade II-III) (Figure 3C, Supplementary Video 5). Three stents were implanted in the LAD with remarkable results (TIMI flow grade III) (Figures 3D,E, Supplementary Video 6).
case_images: After stents implantation in LAD, patient still suffered from ES attack (A); A procedure of interatrial shunting was performed (B); The ES continues during procedure (C); but stopped immediately after the creation of shunting (D); TTE demonstrated s 9 mm interatrial shunting (E). Follow-up ECG showed sinus rhythm except for a slight ST elevation in II, II, and aVF leads (F).
case_images: fcvm-09-1012916-g0004.jpg
case_images: PMC9714305_01_fcvm-09-1012916-g0004.jpg
case_images: F4
case_images: The distal lesion of RCA was treated with a drug-coated balloon (Figure 2D and Supplementary Video 4). However, there was another recurrence of ES on the second day (Figure 4A) after LAD intervention that remained refractory to multiple antiarrhythmic medications. After dilation with an 18 x 30 mm balloon (Figure 4B, Supplementary Video 7), the LA pressure decreased from 33 to 13 mmHg. The ES that had been present during the procedure ceased immediately (Figures 4C,D). TTE showed a 9 mm interatrial shunting channel (Figure 4E). The patient had no further episodes of ES during hospitalization. ECG revealed near sinus rhythm except for slightly elevated ST segments at the inferior leads (Figure 4F).