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A 72 year old woman presented with troponin positive acute coronary syndrome and was transferred to a tertiary centre a week later. Her admission ECG showed minimal ST depression in V2–V6 (maximum 1 mm) with a sinus bradycardia of 38 beats/min. There was resolution of symptoms and ECG changes on optimised medical treatment which included low molecular weight heparin. Cardiac enzymes were not raised throughout the admission.
Coronary angiography showed a giant thrombus in the distal left main stem. Ostial disease was present in the left anterior descending, circumflex, and obtuse marginal vessels. The right coronary artery was a non-dominant vessel with moderate proximal disease. Left ventricular angiography showed only mild dysfunction. In view of the precarious proximity of the coronary thrombus, she underwent urgent three vessel coronary bypass grafting. She made an uneventful recovery but had a dual chamber pacemaker implantation before discharge because of persistent sinus node disease.
This case illustrates that despite a giant distal left main thrombus in a dominant coronary system, the patient was relatively stable on medical treatment and had no significant myocardial damage. Percutaneous intervention was considered a high risk procedure because of the increased risk of distal embolisation of the thrombus. Urgent bypass surgery led to a favourable clinical outcome.