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Acute Lateral Wall M.I.

Sat, 09/21/2013 - 22:45 -- Dawn

This week's ECG for your collection was kindly donated by Dr. Stasinos Theodorou, interventional cardiologist with the Limassol Cardiology Practice in Cyprus. It offers a wonderful teaching opportunity, and illustrates how valuable an ECG can be in locating a lesion during an M.I.   Dr. Theodorou previously posted this ECG and the angiograms from the same patient on FaceBook, and he has offered them to the users of the ECG Guru website  free of copyright.

Dr. Theodorou reports that the culprit lesion in this M.I. was initially very difficult to find on angiogram.  In this case the culprit was an ostially occluded second diagonal artery which, due to the anatomy, was almost impossible to spot from the initial diagnostic images.  There was no "stump" because the occlusion was in the ostium - the beginning of the artery.  The patient also had a significant right coronary artery lesion, but it was not the cause of the M.I. because the RCA perfuses the right ventricle and inferior/posterior wall of the left ventricle.  The ST elevation in this ECG is in I and aVL - the area of the high lateral wall.  Because the  ECG appeared to be inconsistent with the angiogram, Dr. Theodorou obtained further projections, allowing him to identify and treat the offending lesion.  This illustrates the importance of the ECG in locating coronary artery lesions, even in this age of high technology and cath labs.  The interventional cardiologist's proficiency in ECG interpretation enabled him to find this "invisible" lesion.

We are grateful to Dr. Theodorou for sharing this valuable learning experience with us.  You can find more from Dr. Theodorou on his website, FaceBook page, and here, on our "Ask the Expert" page.


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     Great teaching case - with our gratitude to Dr. Stasinos Theodorou for posting the ECG and cath films on the ECG Guru (and for allowing us copyright-free use of this material! ).

  • Dawn has described the case fully. The ECG shows sinus rhythm with marked ST elevation limited to leads I and aVL - with "mirror-image" ST depression in the inferior leads.
  • NOTE - there is also ST segment straightening in lead V2, with slight-but-real elevation of the J-point takeoff in this lead. This picture in lead V2 is all the more remarkable (assuming it is NOT due to lead misplacement - which I do not think is the case) - because ST elevation is ISOLATED in the precordial leads to V2. 
I've made a web page to assist in the localization of the "culprit" artery with acute STEMI. Schematic pictures are included of the major coronary vessels and principal anatomic variants. Please CLICK HERE - for basic anatomy of the LAD (Left Anterior Descending) artery.
  • Now check out what to expect with LAD Occlusion - Please CLICK HERE - 
  • Note the 2nd bullet down - where I describe results of a study by Birnbaum et al - in which a group of patients with ST elevation in lead aVL were studied.
  • Note this case fits perfectly to the group with ST levation in aVL and in V2 - but in no other precordial leads. Usually this suggests acute occlusion of the 1st Diagonal branch of the LAD - but in this case it was the 2nd Diagonal branch. This is NOT a common lesion - but as per Dawn, in this case awareness of this pattern was invaluable for suggesting the anatomic lesion that initially was NOT evident on cath.
Great illustrative case - so THANK YOU Dr. Theodorou!
  • Please check out other facets of my web page on localizing the culprit artery with acute stemi - CLICK HERE.

Ken Grauer, MD   [email protected] 

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