E-Case

JACC

Lots of interesting abstracts and cases were submitted for TCTAP 2023. Below are the accepted ones after a thorough review by our official reviewers. Don¡¯t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

TCTAP C-013

Acute Coronary Syndrome With Huge Thrombus Successfully Managed With Deferred Stenting in a Patient With Essential Thrombocythemia

By Chi Tung Chen

Presenter

Chi Tung Chen

Authors

Chi Tung Chen1

Affiliation

China Medical University Hospital, Taiwan, Taiwan1,
View Study Report
TCTAP C-013
CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS)

Acute Coronary Syndrome With Huge Thrombus Successfully Managed With Deferred Stenting in a Patient With Essential Thrombocythemia

Chi Tung Chen1

China Medical University Hospital, Taiwan, Taiwan1,

Clinical Information

Patient initials or Identifier Number

Mr. Jian

Relevant Clinical History and Physical Exam

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.

Relevant Test Results Prior to Catheterization

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)

Relevant Catheterization Findings

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.

Interventional Management

Procedural Step

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)


Case Summary

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.