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 A 52-year-old man with type II diabetes and hypertension, visited our emergency department because of angina for 2 hours. On examination the blood pressure was 89/54 mmHg.,the heart rate was 114 beats perminute, the respiratory rate was 24 per minute and the oxygen saturation was 99%.

A 12-leads ECG demonstrated sinus tachycardia at a rate of 110 beats per minute. There was ST segment elevation in leads V1-V3, aVL and aVR with reciprocal changed in leads II,III,aVF, V5 and V6.

6Fr. vascular sheath was inserted into right femoral artery.Coronary angiogram (CAG) revealed left main coronary artery (LMCA) had 70%stenosis at distal part. There was 90% stenosis at ostial left anterior descending (LAD) artery with total occlusion at proximal LAD. There was 95%total occlusion at proximal left circumflex (LCX) artery with total occlusion at mid LCX. There was 80% diffuse stenosis at co-dominant proximal right coronary artery(RCA).
1_pre.avi

-7Fr Extra-backup guide catheter (Medtronic Inc., USA) wasengaged to ostial LMCA. - Intra-aortic balloon pump was inserted into left femoralartery.- 0.014 inch coronary guide wire was successfullymanipulated to distal LAD artery.- 0.014 inch Runthrough NS Hypercoat (Terumo, Japan) guidewire and then, 0.009 inch Fielder XT guide wire (Asahi intecc, Japan) was unableto cross the proximal LCX lesion. - Successfully crossed the proximal LCX lesion using 0.014inch Gaia First guide wire (Asahi intecc., Japan). - 2.5x16 mm. drug eluting stent (DES)was deployed toproximal to mid LCX.- 2.5x15 mm non-compliance (NC) balloon was inflated at leftmain to mid LAD.- 2.5x33 mm, 3.5x16 mm and 4.0x23 mm DES was deployed frommid LAD to ostial LM, overlapped with retrograde fashion.- Kissing balloon inflation (KBI) was done at LM bifurcationusing 3.5x15 mm NC balloon for LM to LAD and 2.5x12 mm. NC balloon for LM toLCX.- Proximal optimization technique (POT) was performed at LMusing 4.0x6 mm NC balloon.- Immediate angiogram revealed ostial LCX was jailed.- 3.0x16 mm DES was deployed to ostial LCX using T andprotrusion (TAP) technique.- KBI was done at LM bifurcation using 3.5x15 mm NC balloonfor LM to LAD and 3.0x12 mm. NC balloon for LM to LCX.- 2.25x12 DES was deployed covered linear dissection at distalstent edge of mid LAD stent.- Intravascular ultrasound revealed good stent expansion andapposition.- Final angiogram demonstrated good result. - Patient was discharged on Day10 after admission.
2_Final.avi

- Cardiogenic shock complicating ST-segment elevation myocardial infarction (STEMI) has a high mortality rate. This situation required emergent revascularization of culprit vessel, vasopressor drugs, mechanical circulatory support, and intensive care post catheterization. - We demonstrated STEMI patient with cardiogenic shock treated with primary PCI for LMCA bifurcation including PCI of chronic total occlusion (CTO) co-dominant LCX.