A dissection of the right coronary artery with ST segment elevation in lead V1 to V5

To the editor: A 60-year-old male was admitted with complaints of chest distress occurring over four months. His ECG displayed QS in leads V1 and V2 (Figure 1A). A diagnosis of old anteroseptal wall and anterior wall myocardial infarction was made. Coronary angiography (CAG) revealed that the middle portion of the left anterior descending artery (LAD) was completely occluded (Figure 1C), the first diagonal branch (D1) opening presented with approximately 90% stenosis (Figure 1C), and the proximal portion of the left circumflex (LCX) disclosed approximately 70% stenosis (Figure 1C). The right coronary artery (RCA) presented a 70% stenosis in the middle portion of its body (Figure 1F). Extensive collateral circulation was established from the distal portion of the RCA to the distal portion of the LAD. We performed percutaneous coronary intervention (PCI) on the RCA, the LCX, the LAD and the D1. After the failure of opening the LAD, a drug eluting stent (DES) was implanted into the D1 (Figure 1D); a DES into the LCX; two DES into the RCA (Figure 1G). However, the patient experienced severe chest pain after 30 minutes of PCI. The ECG revealed an ST segment elevation in leads V1 through V5 (Figure 1B). Emergency CAG revealed a dissection of the proximal RCA with TIMI 1 flow (Figure 1H), but stents in the D1 and LCX were normal (Figure 1E). Direct stenting was implanted into the RCA opening after predilatated (Figure 1I).Figure 1. A:: The pre-percutaneous coronary intervention (PCI) electrocardiography displayed QS in leads V1 and V2, qrS in lead V3 and qR in lead V4. B: Electrocardiography after the first PCI displayed a ST segment elevation in leads V1 through V5 and ST segment depression in leads I and aVL. C: Pre-PCI of the middle portion of the left anterior descending artery (LAD) was completely occluded (TIMI 0 level). The first diagonal branch (D1) opening presented with approximately 90% stenosis (arrow). D: The appearance of the same segment of the D1 after direct coronary stenting (arrow), showing an improved coronary blood flow. E: The appearance of the same segment of the D1 after the first PCI was normal without acute occlusion. F: The right coronary artery (RCA) before PCI presented a significant stenosis of about 70% in the middle portion of its body (arrow). G: The appearance of the same segment of the RCA after direct coronary stenting (arrow). H: Dissection of the proximal RCA was established (TIMI 1 level) after the first PCI. I: The appearance of the same segment of the proximal RCA after the second coronary stenting (arrow), showing improved coronary blood flow.Currently, there is no standard treatment for dissection of RCA. If the dissection is localized and a guide can pass through the true coronary lumen, PCI is the first option.1 If the dissection is longer with less effect on the distal coronary flow, we recommend a follow-up. If the dissection is wide, leading the closure of the RCA flow, and the wire cannot access the true lumen of RCA, coronary artery bypass grafting (CABG) is the best option.