CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS)
Late Presentation of Acute Coronary Syndrome with Double Acute Total Occlusion - A Challenging Case
Diyana Farouk1, Hamat Hamdi Che Hassan1, Shawal Faizal Mohamad1, Patrick WJ Tiau1, SHATHISKUMAR GOVINDARAJU2
Pusat Perubatan Universiti Kebangsaan Malaysia, Malaysia1, PPUKM, Malaysia2,
Patient initials or Identifier Number
Relevant Clinical History and Physical Exam
A 60-year-old female presented with a 3-day history of non-specific epigastric discomfort. She has underlying hypertension but does not attend regular follow-up. Upon arrival to the Emergency Department, she was alert but hypotensive (89/65mmHg) and tachycardic (134bpm). Soon after arrival, she developed ventricular fibrillation and required CPR with defibrillation shocks 3 times and Amiodarone before the return of spontaneous circulation. Her ECG showed inferior STEMI with right-sided involvement.
Relevant Test Results Prior to Catheterization
There was ST segment elevation in the inferior leads II, III, and aVF with reciprocal ST depression in the lateral leads V4-V6 and I and aVL. There was no posterior segment involvement but her right-sided ECG revealed ST elevation as well. A portable, bedside echocardiogram done in the emergency department showed hypokinesia of the inferior, posterior, anterior and septal walls.
Relevant Catheterization Findings
As soon as she was stable enough for transfer, she was brought up to the cath lab for emergency angiography. We found her to have double, acute total occlusions of both the RCA and the LAD, as well as severe disease in the distal LCx. AP CAU.mov LAO.mov
The RCA was treated first with Tirofiban and a thrombus extraction catheter (Thrombuster). Several pieces of thrombi were aspirated successfully and reflow was achieved. There was quite significant diffuse disease throughout the artery distal to the occlusion. The vessel was stented with a 3.0-2.5x60mm Sirolimus Eluting Stent (Biomime Morph) from mid to distal vessel and a 3.5x14mm Biolimus eluting stent (Biomatrix alpha) from the ostium to the proximal vessel.Following the deployment of the second stent, the patient again went into cardiac arrest and the attending team performed cardiopulmonary resuscitation. Her rhythm on the monitor ranged from ventricular tachycardia to slow idioventricular rhythm and pulseless electrical activity. She was on high dose triple inotropes at the time. Her rhythm persisted in slow idioventricular rhythm at a rate of about 20-30bpm despite a total of 5mg of adrenaline and 2mg of atropine administered over 25 minutes of CPR. A decision was made to administer dual current cardioversion despite the presence of a pulse. The patient returned to sinus rhythm at a rate of 90bpm and the procedure was resumed.
The acute total occlusion in the LAD was predilated with a 2.0x20mm semi-compliant balloon to high pressure before stenting with a 3.5-3.0x50mm Sirolimus Eluting Stent (Biomime Morph). After post-dilation, TIMI 3 flow was established with good final angiographic result. She was then transferred to the Coronary Care Unit for after care. LAD balloon.mov LAD.mov RCA.mov
This lady was very unfortunate. Her late presentation of acute coronary syndrome with double acute total occlusions meant that although we were able to salvage the coronaries, she developed worsening metabolic acidosis and eventually succumbed a week later as she was unable to tolerate continuous veno-venous haemofiltration. Her echocardiogram post-intervention showed poor left ventricular function with akinetic septal, inferior, and anterior walls. This case highlights how the awareness to seek early medical attention needs to be better instilled in the general public to allow for better outcome in similar cases in the future.