A 75-year-old female patient was referred to the department of cardiology on account of dyspnea at rest of several days duration. Past medical history revealed an episode of tako-tsubo with non-obstructive, tortuous coronary arteries 11 years ago (Figures 1 A, C), complicated by an episode of acute decompensated heart failure. Following the acute event, the patient was asymptomatic and received merely antihypertensive medications. On admission the patient presented with an irregular heart rate of 110 bpm, blood pressure of 110/70 mm Hg, peripheral edema and pulmonary congestion. The ECG showed atrial fibrillation without significant ST-segment abnormalities. Transthoracic echocardiography revealed left ventricle ejection fraction (LVEF) of 20% with dyskinesia of the apical segments of the left ventricle and normal chamber dimensions without left ventricular hypertrophy or right ventricular overload. Laboratory tests showed elevated and stable troponin T level, elevated N-terminal-pro-B-type natriuretic peptide (2456 pg/ml) and features of stage III chronic kidney disease. Invasive coronary angiography disclosed tortuous left coronary artery without significant coronary stenoses within epicardial coronary vessels and prominent Thebesian veins draining blood directly to the left ventricle (Figures 1 B, D), which were not visible during the initial study 11 years previously. Following intensive heart failure pharmacotherapy, including disease-modifying drugs and intravenous loop diuretics, relief of heart failure symptoms and significant improvement of LVEF to 50% were achieved. The likely cause of the cardiovascular decompensation episodes was identified as tako-tsubo-like syndrome. Following successful management, the patient was discharged with a referral for electrical cardioversion of atrial fibrillation, which was successfully performed 4 weeks following initial hospitalization.
Figure 1
Prominent Thebesian vein system developing within ten-year period reflected by invasive coronary angiography. A – coronary angiography; left anterior oblique (LAO) 30°; caudal (CAU) 15°; tortuous course of left coronary artery without significant lesions; no visible Thebesian veins on coronary angiography in 2012; B – coronary angiography; LAO 30°; CAU 15°; prominent Thebesian veins on coronary angiography in 2023; C, D – coronary angiography; LAO 45°; stable image of right coronary angiography without visible anomaly
The Thebesian veins may serve as a minor, alternative pathway for venous drainage of the myocardium with the direct emptying of blood into the heart chambers, which contributes to the physiological right-to-left shunting of circulation. With their enlargement or increased quantity, pathological left-to-left shunting becomes possible, creating a loop-like pathway that redirects blood from the aorta to the coronary arteries, then back into the left ventricle, and once again into the aorta. This represents a form of coronary stealing, leading to reduced myocardial perfusion and the manifestation of anginal symptoms or even acute coronary syndrome [1]. The present case is a unique tako-tsubo-like presentation of Thebesian veins-related myocardial steal phenomenon. Primary tako-tsubo syndrome is characterized by dominant acute cardiac symptoms leading to hospitalization, potentially triggered by emotional or physical stress, which may be undisclosed upon admission, while secondary tako-tsubo affects hospitalized patients on top of the existing medical or surgical condition [2]. Although a surge in catecholamine levels plays a crucial role in tako-tsubo pathogenesis, microvascular dysfunction or myocardial steal phenomenon may also trigger tako-tsubo-like syndrome [3]. The present case highlights the possible dynamic nature of Thebesian veins anomaly, which was present in the index coronary angiography, but was absent in the former study.
