E-Science Station

A 45-year-old male patient presented herewith H/O Pain in both upper limbs, suffocation, sweating, associated with generalized weakness for last 1 day prior to admission.ECG: ST-T elevation in inferolateral leads.ECHO: CAD/RWMA-Inferoposterior Territory Hypokinetic. Mild LV systolic dysfunction (LVEF=40-45%). Mild MR.CAG- Triple Vessel Disease: LAD: Ostio proximal to mid 60-70% disease, distal diffuse disease, D1& D2: Diseased. Ramus: Proximal 80-90% disease. LCX: Proximal 100%occlusion. OM1: Ostial 90% disease. RCA: Dominant, Proximal 90% disease, mid70-80% disease.Chest X-RAY: Bronchovascular markings are prominent. 

PTCA TO LCX & OM : Left Coronary Artery was engaged with EBU 3.5, 6F guide catheter. A 0.014” SION BLUE wire was used to cross the LCX& OM lesion. Pre dilatation done with SC sapphire balloon 2.0  10 mm @ 16 atmospheres. Drug Eluting Stent RESOLUTEONYX 2.75  18 mm was deployed in LCX @ 16 atmosphere& another Drug Eluting Stent PROMUS ELEMENT 2.5  24 mm was deployed in OM @ 16 atmosphere. Post-dilatation done with NC sapphire balloon 3.5  10 mm @ 18 atmospheres. GP IIb IIIa inhibito rwas used during the procedure. Excellent result with TIMI III flow. PTCA TO RCA: Right Coronary Artery was engaged with JR 3.5, 6F guide catheter. A 0.014” SION BLUE wire was used to cross the RCA lesion. Direct stenting was done with Drug Eluting Stent PROMUS ELEMENT 3.5  38 mm was deployed in RCA @ 12 atmosphere.Post-dilatation done with NC sapphire balloon 3.5  10 mm @ 20 atmospheres.PTCA TO RAMUS: In same sitting, Left Coronary Artery was engaged with EBU 3.5, 6F guide catheter. A 0.014” SION BLUE wire was used to cross the RAMUS lesion. Direct stenting was done with Drug Eluting Stent RESOLUTE ONYX2.75  22 mm was deployed in RAMUS @ 12 atmospheres.Post-dilatation done with NC sapphire balloon 3.5  10 mm @ 12 atmosphere.
GP IIb IIIa inhibitor was used during the procedure. Excellent result with TIMI III flow. Successful PTCA with stenting to RCA & RAMUS.  

During hospitalization patient was taken for urgent Coronary Angiography which revealed Triple Vessel Disease and PTCATO LCX TO OM (02.12.2018)- (RESOLUTE ONYX 2.75  18 mm in LCX & PROMUS ELEMENT 2.5 24 mm in OM) was done. Here patient put on Inj. Heparin infusion, anticoagulant, antiplatelet, antibiotics, PPI & other supportive treatment. Post PTCA period patient had been fever with chilled, ongoing fever patient seen by physician and managed conservatively. Now the patient showed clinical improvement & being discharged in stable condition.NEXT SESSION: During hospitalization patient was taken for urgent Coronary Angiography which revealed Triple Vessel Disease with Patent Stent and PTCA TO RCA & RAMUS (10.01.2019)-(PROMUS ELEMENT 3.5 x 38 mm & RESOLUTE ONYX 2.75 x 22 mm) was done. Here patient put on Inj. Heparin infusion, anticoagulant, antiplatelet, antibiotics, PPI & other supportive treatment. Post procedure patient developed syncope attack & patient shift to Cath Lab for emergent TPI placed & check Angiography done which revealed patent stent. After stabilization, patient was taken for Permanent Pacemaker Implantation- MICRA-MCIVR01 in RV (14.01.2019) was done. Now the patient showed clinical improvement & being discharged in stable condition.

We present a case of symptomatic and profound AV node dysfunction in a patient treated with ticagrelor post-PCI for Inferior Wall MI. This was observed in our patient even in the absence of baseline conduction disease or concurrent confounding medications, unlike most cases in the published literature and highlights the need for broader awareness of ticagrelor’s not-insignificant brady-arrhythmic potential.