• Images in cardiology

A 76 year old man presented with chest pain; he had a personal history of hypertension, diabetes mellitus, and pneumoconiosis. He was hospitalised because of an inferior myocardial infarction. On the fifth day of his clinical follow up in the coronary intensive care unit, the patient experienced chest discomfort and palpitation, and an ECG revealed atrial fibrillation and ST segment depression. Afterwards, coronary angiographic examination revealed a thrombus that was narrowing the lumen to 80% at the bifurcation of the left anterior descending coronary artery (LAD) and the left circumflex coronary artery (LCx) distal to the left main coronary artery (panel A). TIMI II flow was present at the distal LAD and LCx. The patient was treated with tissue plasminogen activator (tPA) because of intracoronary thrombus. One hour after the onset of treatment, the angina pectoris ceased and a normal sinus rhythm returned. ST segment depressions and T wave inversions on anterior derivatives returned to normal. Cardiac troponin I concentration increased to 2 ng/dl (normal limits 0.01–0.1 ng/dl). The patient was diagnosed with non-ST elevation myocardial infarction. Coronary angiography was repeated two days later. The large thrombus in the distal left mean coronary artery was found to have resolved (panel B).

Several pathogenic processes, besides atherosclerosis, are known to involve the coronary arteries and to be responsible for severe acute coronary syndromes. Coronary embolism is included among non-atherosclerotic entities causing acute myocardial infarction and should be suspected in the presence of atrial fibrillation, and left atrial or ventricular thrombus. We report a case of distal left main coronary artery thrombus which was detected by coronary angiography and treated by tissue plasminogen activator.