Case presentation
This is a 61-year-old patient, an active smoker at 20 pack-years, in
full professional activity during the period of total confinement, has
presented a presyncope in the morning around 09.50 am without chest
pain, or loss of consciousness or fall with notion of chills a few hours
earlier. She was transported by the firefighters at 10:30 am for the
Montluçon Hospital Center. Patient was received around 11.40 am and
referred to its sector hospital (Gueret Hospital Center) in accordance
with the COVID-19 Plan from the Regional Health Agency for screening as
suspected of Coronavirus infection 19. On arrival at the emergency room
of this health facility, an electrocardiogram carried out revealed an
apicolateral and inferior persistent ST segment elevation with mirror
image on anterior area (figure 1). Then, patient has been transported to
the initial center for emergency coronary angiography where she arrived
at 3:30 p.m. Coronary angiography was performed and revealed the
presence of a thrombus in the distal anterior interventricular artery
with the appearance of ”stick insect”, a thrombus on the dominant
circumflex artery obstructing the second marginal with a ”radish tail”
aspect and a right network free from any atheromatous lesion (Figures
2). Transthoracic cardiac ultrasound found good biventricular
systolo-diastolic function with a left ventricular ejection fraction of
69%, no abnormalities in segmental and global kinetics of the left
ventricle. Troponin I was 2465pg / ml, Creatine phosphokinase at 1874pg
/ ml, C-reactive protein 1.1mg / l, leukocytes at
13,81.109 /l. The medical treatment included
glycoprotein IIb / IIIa inhibitor, double anti-aggregation platelet and
anticoagulant (unfractionated heparin), beta-blocker (bisoprolol) on Day
1 hospitalization. Bisoprolol has been changed to ivabradine because the
patient remained tachycardic with low blood pressure. We noted on the
Day 3 electrocardiogram, presence of a Q wave of apico-lateral and
inferior necrosis with persistence of the elevation from the same
territory. Treatment with acetylsalicylic acid, clopidogrel, ivabradine,
inhibitor of the proton pump was given as an exit treatment. Magnetic
resonance imaging (MRI) was performed on an outpatient basis at one
month and found: a sequelae of infero-latero-moderate,
infero-septo-average, latero-apical, infero-apical and septo-apical with
thinning of the middle and apical walls measuring respectively 3mm and
4mm; a left ventricular ejection fraction of 47%.
Coronarography control with optical coherence tomography (OCT) performed
two months later allowed to highlight a complete healing of the lesions
(Figure 3). OCT does not highlighted the intimal breach (figure 4).