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Acute Thrombotic Occlusion of Non-Dominant Right Coronary Artery Presenting as Acute Coronary Syndrome and Hemodynamic Instability

Gurkirat Singh, Hemant Khemani, Shakil Shaikh, Vikrant Deshmukh, Rahul Singla, Narender Omprakash Bansal

Gurkirat Singh, Assistant professor, Department of Cardiology, Grant Medical College and Sir J.J. group of hospitals, Mumbai, India
Hemant Khemani, Assistant Professor, Cardiology, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India
Shakil Shaikh, Senior resident in Cardiology, Cardiology department, Sir JJ group of Hospitals, Mumbai, India
Vikrant Deshmukh, Senior resident in cardiology, Cardiology department, Sir JJ group of Hospitals, Mumbai, India
Rahul Singla, Senior resident in cardiology, Cardiology department, Sir JJ group of Hospitals, Mumbai, India
Narender Omprakash Bansal, Professor and Head, Department of Cardiology, Sir JJ group of Hospitals, Mumbai, India

Conflict-of-interest statement: The author(s) declare(s) that there is no conflict of interest regarding the publication of this paper.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Correspondence to: Gurkirat Singh, Assistant professor, Department of Cardiology, Grant Medical College and Sir J.J. group of hospitals, Mumbai, India.
Email: singhgs269@yahoo.com
Telephone: +966-12-2266666, ext. 25797
Fax: +919833826672

Received: July 13, 2018
Revised: September 10, 2018
Accepted: September 17 2018
Published online: November 24, 2018

ABSTRACT

It is generally believed that the occlusion of a nondominant right coronary artery is not associated with significant consequences. Atherosclerotic disease of non-dominant right coronary in the absence of significant left coronary artery disease is rare, and the prevalence is substantially lower as compared to dominant Right Coronary Artery. We report a case of a young male presenting with acute coronary syndrome and hemodynamically significant atrial fibrillation. Coronary angiography showed thrombotic occlusion of the nondominant right coronary artery. After the stenting of this artery, the patient improved hemodynamically with complete resolution of ECG changes.

Key words: Non-dominant Right Coronary Artery; Occlusion; Acute coronary syndrome

© 2018 The Author(s). Published by ACT Publishing Group Ltd. All rights reserved.

Singh G, Khemani H, Shaikh S, Deshmukh V, Singla R, Bansal NO. Acute Thrombotic Occlusion of Non-Dominant Right Coronary Artery Presenting as Acute Coronary Syndrome and Hemodynamic Instability. Journal of Cardiology and Therapy 2018; 5(1): 751-755 Available from: URL: http://www.ghrnet.org/index.php/jct/article/view/2382

Introduction

It is usually presumed that the occlusion of a non-dominant Right coronary artery (NDRCA) is not associated with serious complications. Non-dominant RCA is small in diameter and supplies right atrium (RA), right ventricle (RV) and sino- atrial (SA) node. Although a significant atherosclerotic disease of NDRCA in the absence of significant left coronary artery disease is rare, isolated occlusion of NDRCA has been described in past. It can present as an acute coronary syndrome, hemodynamically significant arrhythmias, isolated right ventricle infarction and sudden cardiac death. Electrocardiography pattern can mimic inferior wall ischemia or anterior wall ischemia. We report a case of a young male presenting with acute coronary syndrome and hemodynamically significant atrial fibrillation. Electrocardiogram showed changes of inferior wall infarction. Coronary angiography showed thrombotic occlusion of the non dominant right coronary artery. After the stenting of this artery, the patient improved hemodynamically with complete resolution of ECG changes.

CASE REPORT

30-year-old male presented with chest pain since 2 hours. Not a known case of any major illness, nonsmoker / alcoholic. On examination pulse was 150/min irregularly irregular; blood pressure was 90/56 mmHg. ECG showed atrial fibrillation with fast ventricular rate, ST elevation in II, III and aVF (Figure 1). DC shock of 50 J was given. Sinus rhythm was restored (Figure 2). Again developed atrial fibrillation with a blood pressure of 90/60 mmHg, again DC of 100 J shock was given. Qualitative Troponin T was positive. 2d echo showed no regional wall motion abnormalities, Left ventricle ejection fraction of 60%. Right ventricle size was normal in four chamber view (Figure 3). Routine blood investigations and serum electrolyte levels were normal. In view of ongoing chest pain and recurrent atrial fibrillation, he was taken for coronary angiography. Coronary angiography showed a left dominant system with normal LAD and LCX (Figure 4). RCA was 100% occluded in the proximal segment (Figure 5).

The patient was having ongoing chest pain and recurrent hemodynamically significant atrial Fibrillation. Hence it was decided to open RCA. The lesion was crossed with FIELDER FC wire with the support of 1.5 × 6 mm balloon followed by dilatation with 2 × 12 mm balloon. As the flow was TIMI II in RCA after balloon dilatation and patient was developing intermittent atrial fibrillation, it was decided to stent the diseased segment. The lesion was stented with 2.5 × 18 mm Everolimus-eluting stent (Figure 6). After the procedure patient's hemodynamics stabilized and sinus rhythm was restored. There was complete resolution of ST segments in II, III, aVF (Figure 7). Patient was kept in ICCU for 24 hours; there was no episode of atrial fibrillation. Patient was discharged after 72 hours. Patient is asymptomatic at 2-month follow-up.

Figure 1 ECG on admission showing Atrial Fibrillation with rapid Ventricular rate.

Figure 2 ECG after DC shock showing Sinus rhythm with ST elevation in II, III, and aVF.

Figure 2 2D echocardiography apical four chamber view showing normal chamber size.

Figure 4 LAO cranial view showing Left dominant system and normal LAD and LCX arteries.

Figure 5 Left lateral view showing Proximal RCA total occlusion.

Figure 6 Left lateral view after stenting of Non-dominant Right coronary Artery showing good result.

Figure 7 ECG immediately after PCI of non - dominant RCA showing sinus rhythm and complete resolution of ST-segment changes in II, III and aVF.

DISCUSSION

The term coronary dominance is base on the origin of posterior descending Artery (PDA) and postero-lateral left ventricle (PLV) branches from right coronary artery or left circumflex artery. In Left dominant coronary artery system PDA and PLV branches arise from left circumflex artery. Left ventricle is supplied by left coronary system with no contribution from RCA. Left dominant system has a prevalence of about 7% to 8% in the general population. Right coronary artery in left dominant system is small in diameter, short in length and supplies mainly right atrium, right ventricle and SA node. Isolated atherosclerotic disease of this artery in left dominant system is rare. Even if the NDRCA is small, its thrombotic occlusion can cause serious complications. Acute thrombotic occlusion of NDRCA can present as an acute coronary syndrome, isolated right ventricular infarction, ventricular tachycardia or sudden cardiac death.

Isolated right ventricular infarction is a most common presentation of acute thrombotic occlusion of NDRCA. Moreyra et al reported a case of total occlusion of NDRCA resulting in isolated RV infarction and ventricular fibrillation[1]. Rao et al reported a case of recurrent ventricular fibrillation due to subtotal occlusion on NDRCA[2]. Vural et al reported a case of isolated RV infarction and severe tricuspid regurgitation due to occlusion of nondominant RCA[3]. Karim et al reported a case of a patient who presented with sudden cardiac death secondary to a subtotal occlusion of a small non-dominant right coronary system[4].

Electrocardiogram can mimic Inferior wall or anterior wall ischemia and infarction. Anterior ST elevation mimicking anterior wall MI has been described in thrombotic occlusion of NDRCA by vural et al[3], Carrol et al[5], Franco et al[6], Collins et al[7] and Ilia et al[8]. Moreyra et al reported ST elevation in both anterior and inferior leads[1]. Rao et al reported ST elevation in inferior leads associated with occlusion of NDRCA[2]. Our patient also had ST elevation in inferior leads. These ECG patterns are the consequence of proximal obstruction of NDRCA and not necessarily of isolated RV infarction. These ECG changes lead to misdiagnosis.

The prevalence, clinical characteristics, and treatment of the severe isolated NDRCA disease in a cohort of 35 catheterized patients have been described by Ilia et al[9]. The incidence of isolated NDRCA disease was 0.08%, with only 35 cases described over 18 years[9]. The most common indication of coronary angiography was acute coronary syndrome[9]. Our patient presented with the acute coronary syndrome and atrial fibrillation. Atrial fibrillation associated with occlusion of NDRCA has not been described in the above cases. The right ventricular function was good, which was mainly due to the early presentation. Atrial fibrillation in our case may be attributed to right atrial ischemia or infarction. Early cardiac catheterization followed by stenting of the non-dominant right coronary artery lead to resolution of arrhythmia and abolition of chest pain.

CONCLUSION

In a patient with the left dominant system, RCA is a small artery supplying the right ventricle and right atrium. Although NDRCA appears relatively small, its acute thrombotic occlusion may have significant clinical and hemodynamic impact. The above case showed the importance of non-dominant RCA. Even if RCA is not supplying the left ventricle, it may present with acute coronary syndrome. Associated arrhythmias (Atrial fibrillation and fast ventricular rate) may lead to hemodynamically unstable patient. However, the above procedure on the RCA helped to stabilize the patient symptomatically with the abolition of recurrent AF and resolution of the ST segment changes.

Acknowledgment

We are grateful to Dr. Narendra Omprakash Bansal, Professor, and Head of Department of Cardiology, Grant Medical College and Sir JJ Group of Hospitals, Mumbai for allowing us to publish this case report.

REFERENCES

1. Moreyra AE, Wajnberg A, Byra W, Kostis JB. Nondominant right coronary artery occlusion presenting with isolated right ventricular infarction and ventricular fibrillation. Am J Med. 1986; 81(1): 146-148. [PMID: 3728542]; [DOI: 10.1016/0002-9343(86)90199-3].

2. Rao J, Mascarenhas D, Schiavone J. Nondominant right coronary artery occlusion and ventricular tachyarrythmias. Cathet. Cardiovasc. Intervent. 2002; 56: 53-57. [PMID: 11979534]; [DOI: 10.1002/ccd.10157].

3. Vural M, Uslu A, Bulbul S. An isolated right ventricular myocardial infarction and severe tricuspid regurgitation due to occlusion of a non-dominant right coronary artery: the role of delayed revascularization. Anadolu Kardiyol Derg. 2010; 10(4): 376-377. [PMID: 20693136]; [DOI: 10.5152/akd.2010.099].

4. Karim MA, Wong C, Armbruster R, Windle J, Deligonul U. Importance of a non-dominant right coronary artery occlusion presenting as sudden cardiac death with prolonged right ventricular dysfunction and malignant arrhythmias. Cathet Cardiovasc Diagn. 1995; 35(3): 257-261. [PMID: 7553836]; [DOI: 10.1002/ccd.23482].

5. Carroll R, Sharma N, Butt A, Hussain KM. Unusual electrocardiographic presentation of an isolated right ventricular myocardial infarction secondary to thrombotic occlusion of a non-dominant right coronary artery–a case report and brief review of the literature. Angiology. 2003; 54(1): 119-124. [PMID: 12593505]; [DOI: 10.1177/000331970305400116].

6. Franco JJ, Brown M, Bashir R, O'Murchu B. Acute Anterior ST-Elevation Myocardial Infarction and Electrical Storm Secondary to Nondominant Right Coronary Artery Occlusion. Texas Heart Institute Journal. 2014; 41(3): 335-337. [PMID: 24955058]; [DOI: 10.14503/THIJ-13-3338].

7. Collins N, Elliott V, Seidelin P. True isolated right ventricular infarction with tombstone anterior ST elevation. Heart. 2007; 93: 374. [PMID: 17322517]; [DOI: 10.1136/BCR.2006.092890].

8. Ilia R, Margulis G, Goldfarb B. ST elevation in leads V1 to V4 caused by isolated right ventricular ischemia and infarction. Cardiology 1987; 74: 396-399. [PMID: 3652081]; [DOI: 10.1159/000174228].

9. Ilia R, Cafri C, Wolak A, Weinstein JM. Isolated Nondominant Right Coronary Stenosis: Clinical Presentation and Management. Angiology. 2012; 64(7): 512-514. [DOI: 10.1177/0003319712465486].

Peer Reviewer: Shih-Tai Chang

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