Echocardiographic and Morphological Correlation of Winking Coronary Sign on Coronary Angiography

A BSTRACT Background: A serious complication of acute myocardial infarction is a ventricular septal rupture (VSR), which is lethal if untreated. Hemodynamic and mechanical theories have been proposed for the Winking coronary sign (WCS) of the infarct-related culprit artery on coronary angiography (CAG) in VSR patients. However, whether other structural (aneurysm) or hemodynamic changes (raised left ventricular end-diastolic pressure [LVEDP]) alone can cause WCS is not evaluated. We aimed to evaluate echocardiographic and angiographic findings in patients with WCS on CAG. Methods: The study was observational single centre study enrolling 251 patients which comprised of 132 consecutive VSR cases (Group A) and age and gender matched 51 LV Aneurysm/Dyskinetic/Akinetic segments (Group B) and 68 raised LVEDP (Group C) patients as control arms. Results: The baseline characteristics were matched between all three groups. Among 132 patients with VSR, WCS was observed in 40.15% of patients, while Group B and C had no WCS. A significantly higher number of patients with time in myocardial infarction (TIMI) flow 0 with VSR had absent WCS, while patients with TIMI 1–3 flow were significantly higher to have WCS in Group A. As compared to Group A ( n = 1; 1.9%), a significantly higher number of patients had left circumflex artery (left circumflex involvement) involvement in Group B ( n = 2; 3.9%) and Group C ( n = 6; 8.8%) without WCS. There was no significant correlation between the size and location of VSR to the occurrence of WCS. Conclusions: WCS is only observed in VSR patients and not seen in patients with LV aneurysm/dyskinetic or akinetic segment or in patients with raised LVEDP, suggesting Venturi effect and mechanical instability of inter ventricular septum as the primary mechanism behind WCS.