Mr. Jian

A 30-year-old young male smoker without systemic disease was referred from a peripheral hospital to our catheterization laboratory for a primary percutaneous coronary intervention. He presented with retrosternal burning chest pain and cold sweating. He was hemodynamically stable.  ECG showed acute inferior ST-elevation myocardial infarction. His vital signs showed a regular heart rate of 91 beats/min, blood pressure of 123/83 mmHg. There was no audible heart murmur.

Theelectrocardiography on arrival revealed sinus rhythm and ST- segment elevationin leads II, III, and aVF. (Figure.A)The TroponinT high sensitivity showed 1.05 ng/mL (< 0.0875)The routine complete blood count (CBC) showed platelet count > 680 × 103/µL (Figure B)

His angiogram showed triple-vessle CAD.  LAD seems to be chronic total occlusion with vague collateral flow from RCA (Figure C / Video C). The RCA was critical lesion occluded at thejunction of the proximal and mid-third with a heavythrombus burden. Patient's current vital sign is regular heart rate of 78 beats/min, blood pressure of 112/75 mmHg.

Day1: 6Fr JR4 GC was engaged and Sion Blue wire was passed to dista PLA under Quickcross microcatheter support. After thrombosuction and POBA with sprinter 2.5*20mm, Sion wire was passed to PLA and Sion blue wire was shifed to PDA. We repeated manual thrombosuction for 20 times with 7Fr Eliminate catheter and  which much red thrombus removed. In addition, serial POBA with sprinter 4.0*20mm, NC-Emerge 5.0*15mm, and NC-Emerge 6.0*12mm were done. RCA flow returned to TIMI 3 flow intermittently. However, due to remaining much thrombus left in RCA with repeated no-flow during thrombosuction and POBA procedures, IC/IV aggrastat and IABP were given for better coronary flow support and for the huge RCA thrombus. Patient was in ICU care with heparinization treatment instead of stenting. We chosed deferred stent strategy with heparinization for totally 96 hours (Figure E/Video E)Day 6: 7Fr JR4 GC was engaged to RCA and Filter wire/Sion Blue wire were passed to distal PLA and PDA. Thrombosuction was done with 5Fr Angioget catheter, but severe vasovagal reflex with asystole and hypotension was noted while thrombosuction. Therefore, TPM lead was replaced to RV for HR support. Then repeated thrombosuction with 5Fr Angioget for totally 43 times (around 500+secs), and there is still a residual thrombus noted over distal RCA. Finally TIMI 3 flow  of RCA was noted(Figure F/Video F). We can even note that the used to LAD CTO lesion which showed weak bloodflow after heparinization.(Figure G/Video G)

We survey the the possible etiology/risk of such young man with ACS. He is a light smokers  (less than 5cig/day) and LDL/HDL in normal range. However, we noticed that platelet count always over > 400000/µL in past few months. We found a mutation in the JAK2 kinase (V617F) after serial test. Primary throbocythemia was diagnosed and received medical control in hematology OPD (Hydroxyurea for cytoredutive agent) And we administrate triple therapy with Aspirin/Plavix /rivaroxaban for the residual coronary thrombus. We Shift to aspirin / ticagrelor 9 months later, and then shifted to ticagrelor for one year. He was in a good condition with regular cytoreductive therapy + antiplatele agnet.