JB

A 71-year-old gentleman was brought to the emergency room with complaints of retrosternal chest pain and uneasiness for the last 14 hours and one episode of fainting followed by severe shortness of breath for two hours. On examination, he was dyspneic, his pulse rate was 36 bpm, BP was 160/100 mmHg, and SPO2 was 87% at room air. The JVP was raised and had bilateral crepitations on chest examination. The other systemic examination was unremarkable.

  The ECG showed CHB with ST Elevation Inferior Wall MI.  The echocardiogram suggested multi segments RWMA with LVEF 35%. His haemoglobin was 12.0 gm/dL, Creatinine 2.83 mg/dL, Potassium 6.3 mmol/L and NT pro-BNP was 8374 pg/mL. He was intubated and put on a ventilator. Other than the symptomatic treatment, loading doses of Ticagrelor 180 mg, Disprin 325 mg and Atorvastatin 80 mg were given. After taking written high-risk-informed consent, the patient was shifted to the catheterization laboratory.

The balloon-tipped temporary pacemaker implantation, through the right femoral vein, was done with satisfactory lead parameters. The coronary angiogram was done through the right femoral artery, which revealed 100% occlusion of proximal RCA with high thrombus load. The LAD was having a critical bifurcation lesion proximally. The LCx was non-dominant and had mild plaquing. Hence primary PCI to RCA and staged PCI to LAD was Planned

For primary PCI to RCA, the Left main was hooked with JR 3.5, 7F’ guiding catheter. The lesion was crossed with the Sion blue guidewire. Considering the very high thrombus load, multiple attempts of thrombosuction were done with the help of Export 7F’ (Medtronic), and Eliminate 7F’ (Terumo) thrombus extraction catheters. Multiple pre-dilatations were done with 2 x 10 mm semi-compliant and 3 x 12 mm non-compliant balloons. Intracoronary abciximab, nicorandil, diltiazem and sodium nitroprusside were given at the distal coronary bed. Even after such exhaustive effort, the TIMI 3 flow could not be achieved and the thrombus burden was still very high. Hence the intracoronary thrombolysis was planned and it was done with the help of a “Fine Cross” microcatheter using streptokinase 5 lacs IU over half an hour. After that, the pre-dilatation was done with a 3.0 x 12 mm non-compliant balloon and then two overlapping drug-eluting stents (4 x 40 mm and 4 x 28 mm) were deployed. The post-dilatation was done with 4 x 28 mm same stent balloon at 18 atmospheric pressure with good end results and distal TIMI 3 flow. The patient was shifted to the coronary care unit for further management. His further hospital stay was uneventful and we could wean off the ventilator after 24 hours and was discharged after 4 days in stable condition.

High thrombus burden is always a cause of concern during primary PCI and affects the prognosis. If the thrombus burden still remains very high despite adequate pharmacological measures, multiple attempts of thrombosuctions and balloon dilatations, then the intra coronary thrombolysis can be done with great success.