59 years old gentleman, actively smoking, with no previous medical illness, presented with left sided chest pain.He was diagnosed with acute infero-posterior myocardial infarction Killips I and was transferred to our centre for primary percutaneous coronary intervention.He had stable vital signs upon arrival and had no signs of acute heart failure.

Electrocardiogram showed ST segment elevation in leads II, III, aVF, and ST segment depression in V1 and V2. There were occasional premature ventricular complexes seen.Hemoglobin 13.9 g/dL.Creatinine 90 umol/L.HbA1c 7.7%.Bedside echocardiography showed inferior hypokinesia with mildly depressed left ventricular function.

Acute total occlusion of right coronary artery (RCA) detected, after the sino-atrial branch.Left circumflex artery (LCx) had subtotal occlusion at the proximal segment with TIMI 2 flow.Left main stem had no significant disease.The left anterior descending artery (LAD) wrapped around the left ventricular apex, with tandem lesions of 70-80% stenosis after the main diagonal branch.The main diagonal branch had mild disease.

Right coronary artery (RCA), engaged with JR 3.5 and crossed with guidewire Sion Blue.Dottering with Ryurei 2.0 x 15mm balloon done, followed by serial thrombo-aspiration with Export Advance aspiration catheter.TIMI 2 flow established in RCA, and was further prepared with Ryurei 2.0 x 15mm balloon.Significant recoil was noted, decision to deploy Synergy 3.0 x 48mm. DES post-dilated with Sapphire NC 24 3.5 x 15mm balloon at 18 atmospheric pressure (atm).Patient developed several episodes unstable ventricular tachycardia, requiring synchronised cardioversion.We then proceeded to treat the left circumflex (LCx) artery, engaged with EBU 3.0. LCx crossed with Sion Blue, and pre-dilated with Ryurei 2.0 x15mm balloon.Synergy 2.75 x 20mm was deployed, and post-dilated with Accuforce 3.0 x 15mm balloon at 14 atm.Patient, however had incessant VT, and required further synchronised cardioversion, bolus amiodarone 150mg, and inotropic support for hypotension.In view of multiple episodes of VT,  decision was then made to treat the LAD.LAD lesions crossed with Sion Blue and pre-dilated with Accuforce 3.0 x 15mm balloon. Further preparation of lesions with Scoreflex NC 4.0 x 15mm was done prior to Synergy 3.5 x 48mm deployment. DES was post-dilated with stent balloon at 20 atm. There were no slow flow, perforation or dissection in the treated coronary arteries.VT resolved and inotropes were weaned off in the coronary care unit.