Wrap-Around Left Anterior Descending Coronary Artery Occlusion Presenting With the de Winter Pattern and Inferior ST-Segment Elevation Myocardial Infarction (STEMI) - A Case Report and Comprehensive Literature Review

Sep 29, 2026

Uploaded by Marglet

The left anterior descending (LAD) coronary artery can present a “wrap-around” anatomical variant in which the distal vessel continues beyond the left ventricular apex to supply the inferior wall. Acute occlusion may produce simultaneous anterior and inferior electrocardiographic changes, including ST-segment elevation with a de Winter pattern. A patient in his 60s with recurrent myocardial infarction developed inferior STEMI and an anterior de Winter pattern, confirmed by coronary angiography and treated with angioplasty. Despite timely revascularization, ischemic HFmrEF developed, emphasizing the need for rapid ECG recognition to limit damage and prevent death.

LanguageEnglish

CategoryHealthcare

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Pages9

Reading Time23 min

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Abstract

Case Report

Coronary Anatomy and ECG Rationale

ECG Variants of LAD

Review began 11/07/2025 Review ended 12/01/2025 Published 12/04/2025 © Copyright 2025 Granata et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98496 Open Access Case Report Wrap-Around Left Anterior Descending Coronary Artery Occlusion Presenting With the de Winter Pattern and Inferior ST-Segment Elevation Myocardial Infarction (STEMI): A Case Report and Comprehensive Literature Review Lucio Giuseppe Granata 1 , Francesco Amico 1, Marcello Marchetta 2, Francesca Campanella 1, Simona Giubilato 1 1. Cardiology, Cannizzaro Hospital, Catania, ITA 2. Cardiology, Policlinico Tor Vergata, Rome, ITA Corresponding author: Lucio Giuseppe Granata, [lucio.granata87@gmail.com](lucio.granata87@gmail.com) Abstract The left anterior descending (LAD) coronary artery originates from the left main coronary artery and runs along the interventricular groove, terminating before the apex of the left ventricle. A “wrap-around” LAD is a normal anatomical variant in which the distal portion of the vessel continues beyond the apex to supply part of the inferior wall. Its acute occlusion can frequently produce characteristic electrocardiographic changes, with ST-segment elevation in both the anterior and inferior leads. These diffuse repolarization abnormalities can make it difficult to identify the culprit artery and may even be mistaken for non-ischemic alterations, thus delaying appropriate treatment. We report a case of wrap-around LAD occlusion presenting with unusual and distinctive ECG findings. Aman in his 60s with multiple cardiovascular risk factors and recurrent myocardial infarction presented with acute chest pain. The ECG showed ST-segment elevation myocardial infarction (STEMI) in the inferior leads, associated with a de Winter pattern in the anterior leads, characterized by 1-3 mm upsloping ST-segment depression at the J point that continued into tall, symmetrical T-waves, indicative of proximal LAD occlusion or severe obstruction. Coronary angiography revealed both proximal and distal subocclusions of a wrap-around LAD, successfully treated with angioplasty without procedural complications; However, despite the good angiographic result and an optimal first medical contact-to-balloon time, the patient subsequently developed an infarction-related complication, manifesting as ischemic heart failure with mildly reduced ejection fraction (HFmrEF) . This case represents a unique demonstration of how this LAD variant can produce the simultaneous coexistence of a de Winter pattern and inferior ST-segment elevation. Although rare, the ECG signs of wraparound LAD occlusion are distinctive and must be promptly recognized, as immediate reperfusion is indicated to prevent poor prognosis, extensive myocardial damage, heart failure, and death. In our case, despite early and successful revascularization, the patient developed ischemic HFmrEF, underscoring the severity of the consequences associated with wrap-around LAD occlusion and highlighting the potentially serious damage that may result from delayed or missed diagnosis. Categories: Cardiology Keywords: acute coronary syndrome, coronary angiography, de winter pattern, electrocardiography, heart failure with reduced ejection fraction, myocardial infarction, percutaneous coronary intervention, stemi, st-segment elevation, wrap-around left anterior descending artery Introduction The left anterior descending (LAD) coronary artery is typically 10-13 cm long, originates from the left main coronary artery, and courses through the interventricular groove, usually terminating before reaching the apex of the left ventricle. Along its course, it gives rise to septal perforators and diagonal branches that supply the anterior and anterolateral walls o

FAQs

What is the “wrap-around” LAD and why does it matter clinically?

A wrap-around LAD is an anatomical variant where the distal LAD continues beyond the left ventricular apex and supplies part of the inferior wall. Its occlusion can cause characteristic ECG patterns that can obscure the culprit artery and delay treatment.

Which ECG findings were key in this case?

The ECG showed inferior ST-segment elevation myocardial infarction (STEMI) together with an anterior de Winter pattern. The de Winter pattern included J-point upsloping ST-segment depression that continued into tall, symmetrical T-waves, suggesting proximal LAD occlusion or severe obstruction.

How was the patient treated and what outcome occurred afterward?

Coronary angiography revealed proximal and distal subocclusions of the wrap-around LAD, treated successfully with angioplasty. Despite an optimal first medical contact-to-balloon time and a good angiographic result, the patient later developed ischemic heart failure with mildly reduced ejection fraction (HFmrEF).

Sep 29, 2026

Uploaded by Marglet