A 67-year-old man, heavy smoker, presented to the emergency department with 2 days' history of stuttering chest pain, that aggravated about one hour ago. On arrival, he was anxious, diaphoretic, and in distress. Clinical examination revealed a pulse of 80 bpm, blood pressures of 136/86 mmHg, SPO2 90%. Lungs were full of crackles and heart examination revealed an S3 gallop. A 12-lead electrocardiogram revealed ST elevation in leads V3 to V6, as shown in figure 1. 

Initial blood work revealed normal blood counts and chemistry. A chest X-ray revealed signs of congestion.  In view of the ST elevation myocardial infarction, patient was taken to cardiac catheterization laboratory with the intent of primary angioplasty. 

Coronary angiogram revealed an acutely occluded left main coronary artery, and a non-obstructive right coronary, as shown in figure. An occluded LAD from the mid was anticipated based on the ECG findings, but seeing the left main occlusion in the setting of acute STEMI, ignited urgency in the angioplasty, where every ticking second would count. 

A 6Fr EBU 3.5 guide was engaged to the left main, and a BMW wire was parked down the distal LAD. The lesion in the LM was quickly predilated with a 2.0x15 mm SC balloon to restore flow down the left system. Next, first a 3.5x26 mm Sirolimus-eluting stent was deployed in the LM into the LAD at 16 ATM, which was overlapped distally with another 3.0x35 mm sirolimus-eluting stent deployed at 10 ATM into the mid LAD. This stent was postdilated with stent balloon at 16 ATM. After postdilation with the stent balloon only, the flow went down (as shown in figure and video) hence it was decided to defer further postdilation at that moment and bring back later for the same.  However, to counteract no-reflow, large doses of adenosine and nitrprusside were given via Export catheter. A bolus of tirofiban was given and infusion started. The patient was brought back after 48 hours. The angiogram revealed TIMI 3 flow, hence decided to postdilate. A JL 3.5 guide was used to engage the LM this time, and then LM stent was postdilated first with 4.0x6mm NC balloon upto 28 ATM, while the LAD stent was postdilated with 3.5x15 mm NC balloon upto 26 ATM. Final result was TIMI 3 flow. The patient was discharged after 48 hours on aspirin, clopidogrel, statins, beta blockers and ACE inhibitors. Echocardiogram revealed an ejection fraction of 30-35%, with mild mitral regurgitation. He was initially followed up at two weeks, and is doing very well until a year down the line. 

Acute ST elevation myocardial infarction that involves occlusion of left main is rare and fatal, if not intervened timely. Urgency to wire, and restoring flow down the system is pivotal and lifesaving. Postdilation after STEMI can be deferred in the setting of no-reflow. A stent, in time, saves nine, indeed.  Speed, does have an advantage while dealing with cases like this, as life hangs in a balance, and the seconds count.