A 56-year-old female patient with hypertension, obesity and chronic intermittent cauda equina compression suffered an acute myocardial infarction five days after a lumbar hernia operation. The electrocardiogram (ECG) showed ST-segment elevation in multiple leads, consistent with an extensive acute apical and lateral myocardial infarction (figure 1, panel A). Acute coronary angiography revealed occlusion of the end-arteries of the left coronary artery in the absence of significant atherosclerotic disease (figure 1, panel B). Neither thrombosuction nor balloon dilatation were successful. Due to the recent operation, only acetylsalicylic acid, low-molecular-weight heparin and clopidogrel were given. The electrocardiogram 24 hours later showed signs of extensive myocardial damage, with loss of R waves, the occurrence of Q waves in multiple leads and incomplete ST-segment recovery, consistent with low or absent myocardial perfusion (figure 1, panel C). Cardiac magnetic resonance imaging five days later revealed pericardial effusion and akinesia of the mid anterolateral and inferolateral segments (movie).
Figure 1
Panel A. Electrocardiogram showing an acute apical and lateral myocardial infarction. Panel B. Coronary angiogram: occlusion of circumflex (Cx), obtuse margin (OM) artery (white arrows), left anterior descending (LAD) and first diagonal (D1) artery (black arrows). Panel C. Follow-up ECG: Q waves and R-wave loss in multiple leads and in addition showing incomplete ST-segment recovery (persistent ST-segment elevation). Panel D. T1-weighted inversion recovery short-axis image, 10 minutes after injection of 0.2 mmol/kg gadolinium showing transmural hyperenhancement of the mid anterolateral and inferolateral segments (white arrows), with a subendocardial hypoenhanced core consistent with microvascular obstruction (black arrow).
