Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 42-years old man presented with effort angina. He was a smoker, hypertensive and dyslipidemic. Cardiovascular and other system examination didn't reveal any significant abnormality. His blood pressure was 150/90 mm of Hg.
Relevant test results prior to catheterization
Electrocardiogram & echocardiogram normal. Treadmill test was positive at 8 METS.
Relevant catheterization findings
Coronary angiogram revealed significant lesion in proximal LAD and distal LCX. Percutaneous coronary intervention (PCI) & stenting of LAD and PCI with balloon angioplasty of distal LCX planned.
Chest pain noted 4 hours later after diagnostic CAG. ECG done which showed NSR and non-specific ST-T change. The echocardiography performed which showed adequate LV systolic function without wall motion abnormalities. No pericardial effusion found. NTG was given and the pain improved a lot. Echocardiography followed 2 hours later again which showed the same result. Severe chest pain with hypotension noted 1 hours later after the 2nd echocardiography. Dopamine given for hemodynamic support. CAG was performed again immediately. The LAD and LCX were similar to previous CAG result except more severe milking effect of the myocardial bridge. The RCA showed diffuse 70-80% stenosis from proximal to middle part. Spasm suspected initially. Isoket IC injection was done for several times but in vain. IVUS performed which showed homogeneous hyper-echoic, crescent-shaped area from p- to m- RCA. Intramural hematoma diagnosed. Two DES (Resolute Integrity 3.0 x 26) deployed directly from m-RCA to p-RCA. Optimal result noted after stenting. After reviewing the the 1st diagnostic angiography. Catheter related dissection with subsequent intramural hematoma was favored.
A 76 years old man admitted due to angina with positive thallium scan(LAD territory). CAG showed tortuous p-LAD and myocardial bridge at m-LAD. Significant stenosis was suspicious over p-LAD. Several view was taken but in vain. IVUS was done which showed no plaque over p-LAD. Chest pain noted 4 hours later after CAG. ECG and echo were within normal limit. The pain improved a lot after NTG use. However, chest pain with hypotension noted again hours later. Repeated CAG showed diffuse stenosis over p- to m-RCA. IVUS check-up showed intramural hematoma. Two stent deployed at RCA with optimal result. Catheter related dissection and IMH was favored.