Case study: A case of thromboembolic left anterior descending artery occlusion following electrical cardioversion for atrial fibrillation is described. A 66-year-old female patient presenting with exertional angina pectoris and atrial fibrillation was subjected to coronary angiography, ventriculography and transesophageal echocardiography. No significant coronary stenoses were found, left ventricular systolic function and regional wall motion were normal, and she had no intracardiac thrombi. Direct-current cardioversion was complicated by asystole which was managed by cardiac massage and 1 mg atropine and 1 mg adrenaline intravenously. Shortly afterwards, the patient regained a normal sinus rhythm. She remained hypotensive and developed ST segment elevation over the chest leads. Angiography was repeated and showed apical ballooning and thromboembolic subtotal occlusion of the proximal LAD, which migrated to the periphery and subsequently disappeared with regain of TIMI 3 flow by the end of angiography. 4 months later, a normal left ventricular global and regional function was seen in echocardiography.
Hypothesis: At least part of the apical ballooning syndrome patients are a sequel of transient thromboembolic occlusions.
Methods: Therefore, all patients with the diagnosis of coronary embolism in the period from September 2004 to September 2005 were analyzed retrospectively.
Results: Further three patients had coronary artery embolism (two females, one male; age 69-76 years). Two patients had apical ballooning, and one showed global hypokinesia (known dilated cardiomyopathy). Cardiac markers were slightly elevated. ST segment elevation was seen in two patients and T-wave inversion in one. All had risk factors for embolization and two had an additional triggering factor. Both cases with apical ballooning had regained a normal ejection fraction at follow-up.
Conclusion: This case series probably bridges the gap between two as yet separate disease entities, namely the apical ballooning syndrome and coronary emboli. The time factor probably plays the pivotal role in determining whether the apical ballooning alone or also an embolus is seen. It seems possible that some patients presenting with apical ballooning are unrecognized coronary thromboembolic cases.