Successful Treatment of Ischemic Dysfunction of the Sinus Node with Thrombolytic Therapy: A Case Report
A 56-year-old male was admitted to the hospital with resting chest pain that developed three days before admission. He had effort-induced chest pain for three years, but did not take any medications and had no prior cardiac evaluations. Physical examination findings, blood pressure and heart rate were all normal. An echocardiography showed normal left ventricular wall motion and a normal ejection fraction. The electrocardiogram showed T wave inversions in lead aVL. The coronary angiography revealed a 50% discrete stenosis at the ostium of the left anterior descending artery (LAD), an 80% tubular stenosis at the intermedius branch, and a 90% tubular stenosis at the distal LCX (). A ramus intermedius angioplasty was successfully performed with placement of a sirolimus-eluting stent (Cypher, Johnson & Johnson). We performed a balloon dilatation with a balloon, 2.25 mm in diameter (Aqua, Johnson & Johnson). A coronary angiography immediately after balloon removal from the LCX demonstrated a patent distal LCX but total occlusion of the sinus node branch (). About 1 minute later, the patient complained of dyspnea and chest pain and the ECG showed a junctional rhythm with a heart rate of 40/min and the blood pressure dropped to 90/60 mmHg (). A temporary pacemaker was inserted through the right subclavian vein and dopamine was continuously infused (10 µg/kg/min) to increase the heart rate and blood pressure. The patient also received nitroglycerin (200 µg) and abciximab (0.25 mg/kg) bolus through a guiding catheter; the abciximab was infused intravenously (10 µg/min) for 12 hours. Then, an infusion catheter (Microferret, Cook) was placed in the SN artery where nitroglycerin 100 ug and nicorandil 1 mg were infused to rule out coronary spasm. Distal flow was not established; then urokinase 100,000 IU for 5 minutes through the catheter () was infused. A coronary angiogram performed shortly after the urokinase infusion showed thrombolysis in acute myocardial infarction (TIMI).