Electrocardiographic Recognition of Unprotected Left Main ST-Segment Elevation Myocardial Infarction

Figures

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  Figure 1. Electrocardiograms There are diffuse ST-segment elevations (red arrows) in the high-lateral (aVL, I) and anterior leads (case 1: V2 to V6; case 2: V2 to V4) plus reciprocal ST-segment depressions (blue arrows) in the inferior leads (II, III, aVF) and apico-lateral leads V5 and V6 (case 2), consistent with anterolateral ST-segment elevation myocardial infarction. ECG = electrocardiogram.

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  Figure 2. Coronary Angiographies Case 1: (A) unprotected left main (LM) (arrow) acute total occlusion (Video 1); (B,C) severe obstructive atherothrombosis (arrow) was visualized (Video 2) after guidewire advancement; (D) normal dominant right coronary artery; (E,F) LM post-successful intra-aortic balloon pump–supported percutaneous coronary intervention (PCI) (arrow) (Video 3). Case 2: (G) LM acute total occlusion (arrow) (Video 4); (H) after guidewire advancement, severe atherothrombotic disease was observed (Video 5) involving the distal-LM (arrow), proximal left anterior descending coronary artery, and the proximal circumflex coronary artery; (I) intra-aortic balloon pump–supported PCI was performed using simultaneous kissing stents technique (arrow). (J) Post-PCI of LM (arrow) into the proximal left anterior descending coronary artery and proximal circumflex coronary artery (Video 6); (K, L) mid–right coronary artery 80% stenosis (arrows) pre- and post-PCI, respectively.

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  Figure 3. Electrocardiographic Findings Favoring a Left Main Coronary Artery Occlusion from a Proximal Left Anterior Descending Coronary Artery Electrocardiographic findings favoring a left main coronary artery occlusion from a proximal left anterior descending coronary artery: 1) coexistence of left axis deviation (LADEV) and left anterior fascicular block (LAFB); 2) concomitant right bundle branch block (RBBB) with LADEV (case 2); 3) V5 to V6 ST-segment depressions (case 2); 4) ST-segment deviation in V6 > V1 (V6/V1 ≥1) (white arrows); 5) absence of aVR and V1 ST-segment elevations (green arrows).