CYVH 2021-001

This 47-year-old man has a history of hyperlipidemia. However, he suffered from sudden onset of chest pain since around 5-6 pm while he was driving on the highway. He described the pain as oppressive, severe and constant. He has been experiencing palpitation, diaphoresis and heartburn. So he called 119 and pre-hospital ECG showed inferior STEMI. The ECG signal was transmitted to hospital via 4G network. While he arrived ER, the heart team was ready.His consciousness was clear.
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ECG: inferior wall STEMIOther lab data: all normal.CPK, CPK-MB, cardiac troponin-I: all within normal range.

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Bil. CAG:  right dominant.  LM: 10-20% stenosis.  LAD: Mild AS change & -D myocardial bridge, -D1 & -D2 ostium 80% stenosis.  LCX: -M angioectasia with aneurysm formation, -D 90% stenosis.  RCA: Diffuse angioectasia and aneurysm formation, -P to -M acute totally occluded.  *Vessels to be treated: RCA.
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For RCA lesion, a JR 4/6 guiding catheter was used first. Due to poor support, a Sion blue guide wire was used for better support, but the support was poor. So a SAL 1/6 GC was used later. A temporary pacing wire was inserted from RFV. Fielder FC guide wire was managed to distal RCA. An Export Advance aspiration catheter (6Fr) was used for thrombosuction & some small thrombi was taken out. After thrombosuction several times, TIMI 0-1 flow was gained & RCA-D was pre-dilated with a Spriner BC (2.5x15mm) with 14. TIMI 1 flow was gained and angiography showed a very heavy thrombus burden. An EagleEye IVUS catheter was used for lesion evaluation and heavy thrombus burden and large vessel size (6-7mm) were impressed. Then an Angioject Spiroflex catheter was used for thrombosuction. Coronary flow increased but the patient had progressive angina. For hemodynamic support, an IABP was inserted from RFA. Then Angiojet was used for thrombosuction again. But the coronary flow was still 1-2. Then RCA-D was pre-dilated with an NC Euphora BC (5.0x15mm) with 12 atm But TIMI flow decreased to 0-1 after POBA. The Export Advance Aspiration catheter was used again but no any thrombus was taken out. Angiography and IVUS catheter both showed dissection. So an Energy stent (5.0x40mm) was deployed later with 12 atm pressure. Post-diltation was done with an NC Emerge BC (6.0x12mm) with 18 atm pressure. Final result was TIMI flow 2. F/U CAG 3 days later showed TIMI 3 flow.
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Pre-hospital wireless transfer ECG system helps to identify STEMI patients.Manual aspiration thrombectomy has it’s limitation.Although Angiojet thrombectomy is not recommended routine use, it is helpful in high thrombus burden ACS patients.DAPT with anti-coagulation and aggrastat is effective pharmacological thrombectomy.IABP is also helpful to improve perfusion in high thrombus burden ACS case.