E-Science Station

CKS

56/ M. Mr. CKS had history of HT, DM, IBD and hepatitis B. He experienced central chest pain for 10 days, which was non-exertional and was associated with dyspnea. On arrival to emergency department, his GCS was 15 / 15; BP 132 / 93mmHg; P 69 bpm; RR 26 / min; SpO2 86 % on 10 L / min O2. General physical examination showed cold peripheries and raised JVP. Chest auscultation noted bilateral basal crepitations, no audible heart murmur was heard. No lower limb edema was noted. 

Blood capillary glucose 15 mmol / L and blood gas analysis showed type II respiratory failure. CXR: congested lung fields. ECG: sinus tachycardia 140 bpm, Q wave over anteroseptal leads with ST elevation. Bedside echo: Severe hypokinetic anterior and anteroseptal wall with LVEF 35%, mild MR and engorged IVC. Blood result revealed raised Troponin T level 871 ng / L; SCr 86 umol / L; ALT 111 U /L; Hb 14 g / dL; WBC 13 x10^9 / L.  Clinical diagnosis was recent anterior myocardial infarction.

After initial stabilization in ICU, urgent coronary angiogram was done.  Coro: LM 100% occlusion, with collateral from RCA to LAD & LCX. Mid RCA 70% stenosis. IABP was inserted and CTS was consulted for CABG. CTS reviewed patient’s condition and commented that CABG and general anesthesia might cause more harm than benefit and advise against operation. After discussion with patient and relatives for option of multivessel PCI as surgical turn-down case, they agreed to proceed.

PCI was performed with femoral approach under IABP support. 6F JL4 guide was used. LMS occlusion crossed by Runthrough wire and placed in LAD. LMS pre-dilated by 2.0 x 15 mm and 2.5 x 15 mm balloon. Then another Runthrough wire to LCX. IVUS interrogation to LM & LAD. PTCS to ostial LM to pLAD by EES 3.5 x 18 mm. POBA from dLAD back to pLAD with 2.0 x 15 mm balloon. PTCS to m / dLAD with EES 2.25 x 33 mm and p / mLAD with EES 2.75 x 38 mm. Post dilated m / dLAD stent with 2.5 x 15 mm and then 3.0 x 15 mm NC balloon. POBA to LMS / pLAD stent by 3.5 x 8 mm NC balloon. Recross LCX by another Runthrough wire, then POBA to ostial LCX by 2.0 x 15 mm balloon. IVUS to LCX. Culotte stenting to LMS / LCX with EES 3.0 x 15 mm. Kissing inflation to LM / LAD and LMS / LCX by two 3.0 x 12 mm NC balloons. Final POT to LMS by 4.0 x 8 mm NC balloon. Left system achieved good angiographic and IVUS result Then proceed to PCI to RCA lesion with 6F JR4 guide. Runthrough wire crossed mRCA lesion and IVUS performed. Direct stenting to mRCA with EES 4.0 x 15 mm and then post-dilated by 4.0 x 8 mm NC balloon. Good angiographic and IVUS result.

Patient eventually weaned off IABP support post PCI and heart failure medication was titrated. Cardiac rehabilitation was given post procedure and discharged home 10 days after PCI. Repeated Echo 3 months later showed improved LVEF 53% without regional wall motion abnormality.  ConclusionSuccessful percutaneous coronary intervention to occluded left main plus triple vessel disease under intra-aortic balloon pump support was performed in patient presented as recent anterior myocardial infarction with acute pulmonary edema.