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

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. A man 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 wrap-around 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.