• cardiac magnetic resonance
• ischaemic cardiomiopathy
• percutaneous coronary intervention

A 45-year-old man was admitted to hospital for an acute coronary syndrome. A coronary angiography was performed showing heavily calcified stenosis of the left anterior descending artery (LAD); a dedicated stent covered with biolimus (Xstent) (3×44 mm) was deployed in the LAD lesion with an optimal result as assessed by intravascular ultrasound. During the next few hours the patient started to complain of thoracic pain associated with ischaemic T waves in lateral leads; an emergency new coronary angiography was performed.

An occlusion of the first septal branch of the LAD was confirmed as well as patency of the stent (panels A and B). Owing to the small diameter of the artery (<2 mm) no further procedure was considered. In the following days the patient remained asymptomatic; the highest troponine I level reached 12.94 μg/l.

Stress cardiac magnetic resonance imaging was performed showing a significant akynesia in the mid-portion of the septum in the cine sequences (arrow, panel C). A limited area of subendocardium infarction was confirmed in the contrasted enhanced sequences as a brilliant white area (arrow, panel D).

This case illustrates the well-known fact that the occlusion of side coronary branches during percutaneous coronary intervention and even a small increase in troponine and creatine phosphokinase levels implies a poor prognosis in the short and mid-term. In this case occlusion of a small septal branch caused segmentary contractility alterations and an area of scar tissue, which might be a source of myocardial remodelling or a focus of arrhythmias.

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