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A 75 year old man was admitted to our coronary care unit with anterolateral ST elevation myocardial infarction (STEMI). After intravenous treatment with aspirin and nitrates, the patient underwent urgent coronary angiography that documented occlusion of the proximal left anterior descending coronary artery (LAD), with TIMI 0 flow (panel A). After crossing the lesion with the guidewires, a large thrombus became evident (panel B). During the procedure “dual LAD” anatomy was documented with a bifurcation of the LAD into a large septal branch (with intramyocardial course) and a large diagonal branch (panel C). A two dimensional echocardiogram documented a slightly hypertrophied and dilated left ventricle, with akinesia of the apex, mid anterior wall, lateral wall, and interventricular septum, and hypokinesia of relative basal segments with an ejection fraction of 35%. Twelve hours after percutaneous coronary intervention, a myocardial contrast echo study was performed using a Sequoia ultrasound machine (Siemens) and intravenous SonoVue (Bracco) 5 ml at 2 ml/min. A novel contrast detection method, called contrast pulse sequencing (CPS), was applied to visualise the coronary microcirculation. This method is able to selectively detect in real time the non-linear, fundamental ultrasound frequency, that, being particularly strong and peculiar to microbubbles, gives a high intensity signal with excellent signal-to-noise ratio. The patient had a large area of microvascular obstruction (no reflow) at the level of the apex, septum, and posterolateral wall (panels D and E). Within this no reflow area, septal and apical branches likely originated from the intramural septal branch of the dual LAD and were visible as yellow lines crossing the wall from the epicardium to the endocardium (panels D and E).
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