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CASE20191028_020
| CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS) | |
| Successful Urgent Three Vessel Primary Angioplasty in a Patient with Extensive Myocardial Infarction and Acute Pulmonary Edema | |
| Saurabh Goel | |
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[Clinical Information]
- Patient initials or identifier number:
V K
-Relevant clinical history and physical exam:
A 56 year old female , presented to Emergency Room with history of acute complaints of breathlessness and chest pain of two hours duration , She was rushed to hospital from physicians clinic with ECG showing acute Myocardial infarction.She had past history of NIDDM since 6 years with no history of hypertension or ischemic heart disease in past. Clinical examination revealed HR 96/min, BP 110/70,scattered bilateral basal crepitations bilaterally and Oxygen Saturation was 93% on room air.
-Relevant test results prior to catheterization:
ECG – showed extensive myocardial infarction with ST elevation in 2,3, AVF, V5 , V6and marked ST Depression in V1- V4
- Relevant catheterization findings:
Angiography was done from right femoral route and right venous and left femoral arterial sheaths were also placed.Left Main – normalLAD - showed ostial 80 % followed by 90 % proximal stenosisLCx - is non dominant and large good sized vessel with mid segment long 95 % stenosisRCA – dominant, proximal to mid 90% stenosis noted
 1 angio left.avi 2 left angio.avi 3 angio right.avi |
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[Interventional Management]
- Procedural step:
Patient had multivessel disease and in view of extensive ECG changes,it was difficult to identify which was the target vessel. It was decided totackle RCA and LCx first and then LADThe right coronary artery was cannulated using 6F JR 4 guiding catheter . the RCA lesion was crossed with Sion blue wire and predilated with 2.5 mm balloon. A 3 X 26 mm Resolute Integrity stent was deployed in Mid RCA, after which proximal residual lesion was noted hence another 3 X 18 Resolute Integrity stent was deployed overlapping the previous stent with good result . Thereafter PTCA of LCX was done, using long 3 X 38 mm Resolute Integrity stent.The proximal LAD lesion was dilated with 2.5 X 15 NC Apollo balloon. A 2.75X 30 mm Resolute Integrity stent was placed from LAD ostium and covering the proximal lesion. Minor plaque shift was noted to LCX ostium . There was TIMI 3 flow in all vessels and patient was getting stabilized with pulmonary edema resolving and good hemodynamics , hence it was decided to continue medical management in ICCU. The patient was covered with Bolus Tirofiban injection and intravenous infusion was continued.The patient made complete uneventful recovery with good preservation of LV function on 2 D echo ( ejection fraction 52 %) and resolution of all ECG changes.On follow up after 6 months the patient remained asymptomatic with good LV function on Echo and no significant areas on ischemia on Stress nuclear imaging.
5 ptca right final.avi lcx stenting done.avi 12 LAD final.avi- Case Summary:
This case demonstrates that in patients with extensive infarction complicated with pulmonary edema or cardiogenic shock with multivessel disease is often encountered and there is a dilemma as which vessel to tackle. In the present case, all three vessels supported large areas of myocardium and ECG changes were noted in all 3 territories. In such a case complete revascularization is important starting with the most important large vessel first . Complete revascularization of 3 vessels was done in this case of a acutely ill patient and the patient made a complete uneventful recovery.
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