Spontaneous recanalization following subtotal proximal LAD occlusion: a case report.

Abstract

Introduction: Owing to the activation of the endogenous fibrinolytic system, spontaneous restoration of coronary blood flow in the infarcted artery may seldom occur without thrombolysis or primary coronary intervention. Spontaneous reperfusion is associated with less myocardial damage, a tremendous in-hospital outcome, and a better overall prognosis compared with patients requiring reperfusion therapy to achieve a thrombolysis in myocardial infarction grade 3 patency. We present an intriguing case of spontaneous recanalization succeeding a subtotal left anterior descending occlusion in a 46-year-old male from Tanzania with neither positive history of cardiovascular disease nor apparent coronary artery disease risk.

Case presentation: A 46-year-old man of African origin was referred from central Tanzania for revascularization. He had presented with a 2-day history of ongoing central chest pain, crushing in nature and radiating to the left arm. His past medical history was unremarkable and had no apparent risk factors for coronary artery disease. Cardiac markers were found to be elevated, while electrocardiographic and echocardiographic evaluation revealed features in keeping with anterior wall myocardial infarction. He was prescribed the standard precatheterization medications and subsequently underwent an urgent coronary angiography. Catheterization revealed a 99% occlusion of the proximal left anterior descending with a thrombolysis in myocardial infarction grade 1 flow. Due to an intraprocedural machine fault and a lack of technical support, percutaneous coronary intervention could not be done in the same setting, and the patient was referred to Dar es Salaam for revascularization. The patient continued to be symptomatic for 5 days postcatheterization but came to Jakaya Kikwete Cardiac Institute (JKCI) free from symptoms on the ninth day since the onset of chest pain. He had stable hemodynamics and was in Killip class I. Cardioselective enzymes, a 12-lead electrocardiogram, and two-dimensional echocardiography done at this point revealed essentially normal findings, but the patient underwent a second catheterization for revascularization of a tight proximal left anterior descending lesion. Unexpectedly, coronary angiography revealed a patent left anterior descending vessel. Based on the clinical presentation, cardiac markers, and electrocardiographic and angiographic evolution, a diagnosis of spontaneous recanalization following subtotal proximal left anterior descending occlusion was entertained.

Conclusion: Spontaneous recanalization in patients with significant coronary lesions may seldom occur and portend a favorable prognosis. In light of the increasing incidence of acute coronary syndrome in Sub-Saharan Africa, it is crucial for primary physicians to recognize this potentially fatal entity timely and offer or refer for appropriate reperfusion therapy promptly. Parallel to this, efforts to raise public awareness, improve health-seeking behaviors, and strengthen emergency services are of utmost importance.