Unusual Case of Three Total Occlusions

J INVASIVE CARDIOL 2018;30(2):E20.

Key words: cardiac imaging, chronic total occlusion

A 65-year-old male presented with cardiac sounding chest pain and elevated troponin level and was diagnosed with non-ST elevation myocardial infarction (NSTEMI). He was a smoker and had a positive family history of ischemic heart disease. His resting heart rate was 64 beats/min and blood pressure was 124/76 mm Hg on admission. He had a previous history of three myocardial infarctions in 1992, 1998, and 2004, which had all been medically managed. Coronary angiography revealed severe triple-vessel disease, with three chronic total occlusions (CTOs) involving the left anterior descending (LAD) artery, right coronary artery, and circumflex (CX) artery (Figures 1A-1C; Videos 1-3), with extensive collaterals (Rentrop grade 3 and collateral connection grade 2). Cardiac magnetic resonance imaging was requested to look for myocardial viability. This demonstrated a severely impaired left ventricular systolic function (ejection fraction, 17%), small subendocardial infarctions in the LAD (Figure 1D) and CX territories, but extensive viability in all myocardial segments (Figures 1E, 1F). He was referred for a coronary artery bypass graft and received three grafts. Echocardiography was performed 2 weeks post surgery and showed an improvement in the systolic function (ejection fraction, 37%). 

This case highlights the value of extensive coronary collaterals in maintaining myocardial viability in severe coronary artery disease, and the role of cardiac magnetic resonance imaging in guiding revascularization decisions. Usually, CTOs affect one or two vessels, but it is very rare to see a patient with three major vessels occluded, and remain relatively symptom free until his recent presentation. Collaterals are sometimes overlooked, but in many cases they act as natural bypass grafts and can save the patient’s life.

From the ¹Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, United Kingdom; and ²Department of Cardiology, Suez Canal University, Ismailia, Egypt. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted June 12, 2017. 

Address for correspondence: Dr Ahmed Mohamed Salah Eldin Khedr Abdelaty, MRCP(UK), MSc, Postgraduate Research Fellow, Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Groby Road, Leicester, United Kingdom, LE3 9QF. Email: amsek1@le.ac.uk