Altmann, David R.

Buser, Peter

Sticherling, Christian

RERO DOC Digital Library

32. Hindorff LA, Rice KM, Lange LA, Diehr P, Halder I, Walston J, Kwok P, Ziv E,Nievergelt C, Cummings SR, Newman AB, Tracy RP, Psaty BM, Reiner AP.Common variants in theCRP gene in relation to longevity and cause-specificmortalityin older adults: the Cardiovascular Health Study. Atherosclerosis 2008;197:922–930.33. Hazzard WR. Depressed albumin and high-density lipoprotein cholesterol: sign-posts along the final common pathway of frailty. J Am Geriatr Soc 2001;49:1253–1254.34. Ridker PM, Danielson E, Fonseca FA, Genest J, Gotto AM Jr, Kastelein JJ,Koenig W, Libby P, Lorenzatti AJ, MacFadyen JG, Nordestgaard BG, Shepherd J,Willerson JT, Glynn RJ. Reduction in C-reactive protein and LDL cholesteroland cardiovascular event rates after initiation of rosuvastatin: a prospectivestudy of the JUPITER trial. Lancet 2009;373:1175–1182.35. Smith GD, Ebrahim S. ‘Mendelian randomization’: can genetic epidemiologycontribute to understanding environmental determinants of disease? Int J Epide-miol 2003;32:1–22.36. Nitsch D, Molokhia M, Smeeth L, DeStavola BL, Whittaker JC, Leon DA. Limits tocausal inference based on Mendelian randomization: a comparison with random-ized controlled trials. Am J Epidemiol 2006;163:397–403.CARDIOVASCULAR FLASHLIGHT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/ehq048Online publish-ahead-of-print 19 February 2010An unusual cause of cardiogenic shockDavid R. Altmann, Peter Buser , and Christian Sticherling*Division of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 Basel, Switzerland* Corresponding author. Tel: +41 61 265214, Fax: +41 61 2654598, Email: csticherling@uhbs.chA 76-year-old man with a history of coronary arterybypass grafting presented with acute onset of chestpain and cardiogenic shock. The ECG showed atrialfibrillation (AF) and severe ST-segment depressionin the anterolateral leads. Cardiac angiographyrevealed an occluded native right coronary artery(RCA) and left anterior descending artery (LAD)and stenosis of the proximal circumflex artery(Panel A). The left subclavian artery was occludedby a large thrombus (Panel B, asterix; note the ste-nosis of the vertebral artery, arrow). Thrombusaspiration failed and balloon dilatation was not per-formed in order to avoid dislocation of thromboticmaterial into the left internal mammary artery(LIMA) graft. We therefore started localintra-arterial thrombolysis (alteplase 10 mg bolus)followed by systemic thrombolysis (alteplase90 mg over 60 min) resulting in rapid improvementof clinical symptoms and normalization of the ECG.A control angiography showed a patent subclavianand LIMA (Panel C), which supplied the LAD. Theright internal mammary artery was used as a freegraft from the LIMA to the marginal branches andthe RCA (Panel D).Mechanistically, the thrombus may have formedlocally over a ruptured subclavian atherosclerotic plaque (Panel C, arrow) or may have originated from the left atrium since thepatient was in AF and off anticoagulant therapy.In summary, this case demonstrates the successful treatment of cardiogenic shock secondary to thrombotic occlusion of the sub-clavian artery proximal to a single LIMA bypass supplying six coronary branches by local and systemic thrombolysis.Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org.J. Zacho et al.1632

An unusual cause of cardiogenic shock

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