occlusion

A previously healthy 31-year-old man with a history of smoking presented with severe prolonged chest pain for more than one hour duration. ECG taken on admis-sion revealed slightly widened QRS complexes, and ST segment elevations in leads aVR, aVL, V 1 and V2 in con-trast to up-sloping ST-segment depressions in leads DII, DIII, aVF and V 3–6 at the J point (Figure 1 A), which is called de Winter sign. Subsequent urgent coronary angiography revealed almost total occlusion of the left main coronary artery (LMCA) with severe thrombus formation (Figure 2) and poor distal filling of both the left anterior descend-ing (LAD) and circumflex (CX). The patient underwent a successful coronary artery bypass grafting (CABG) op-eration with the bilateral internal mammary arteries to the LAD and CX. His post-op. ECG substantially improved, as shown in Figure 1 B. He was discharged 10 days later with optimal medical therapy. Although the underlying mechanism remains elusive, de Winter sign is generally ascribed to occlusions in the proximal segment of the LAD artery and is not mentioned among the ECG patterns representing acute left main coronary artery (LMCA) occlusion [1, 2]. Unfortunately, there is no single type of ECG pattern indicating sudden total occlusion of the LMCA [3]. Various factors such as individual differences in coronary anatomy, recruitment of collateral channels and repeated episodes of ischemia with preconditioning, the size of the jeopardized myo-cardium, timing of the ECG recording, partial obstruction causing some residual flow and different phases of the thrombotic cascade may all be responsible for the differ