41 years old vet presented to ER at 12 PM in an unconscious state since 5 mins. He had chest pain since 6 AM which worsened by 11 AM. His FMC was at 11.15 AM in a nearby hospital where ECG was done and diagnosed as Acute STEMI AWMI. In ER he is in cardiac arrest VF . ROSC attained after 10 mins of CPCR and multiple DC shocks. He is started on noradrenaline, adrenaline and intubated. After stabilizing his BP he was thrombolysed with inj.Reteplase 10 +10 units over 30 and admitted in ICU.
In ICU he was initiated on TTM of 34- 36 c for 24 hours. Post lysis ECG shows ST resolution with T inversion. His ABG showed metabolic acidosis with Lactate of 16.16 mol/L. He had mild hepatitis with elevated renal parameters. He was treated with DAPT, statin and inotropes in ICU along with ventilator management. After 16 hours he regained consciousness and maintained 100/60 mmHg on Dual inotropes with elevated lactate and renal parameters. ECHO shows Global Hypokinesia Severe LVD, EF-15%.
He underwent Coronary angiography via Right Radial approach which showed Left main Bifurcation lesion Medina 1,1,1 with Triple vessel disease. Distal Left main 80% lesion, ostial LAD 90% lesion, Ostial LCX 60-70% lesion and mid RCA 90% lesion.
VA ECMO initiated via Right Femoral vein 27 F , Left Femoral Artery 17 F, Left SFA antegrade perfusion via 5 F and hemodynamics stabilized.
Right Femoral artery 7 F sheath inserted and Bifurcation PCI (Minicrush ) done with 2 DES. LCX stented with 3.5X12 Ultimaster Naomi and LM- LAD scented with 3.5X24 Ultimaster Nagomi. SKD done with 3.5X10 to LAD and 3.5 X10 to LCX. PrePOT and POT done with 4.5X8 at 20 atm. TIMI 3 flow in LAD and LCX.
PCI to proximal to mid RCA done with 2.75X44 Ultimaster Nagomi. TIMI 3 flow in RCA .
He was stable on ECMO and EF improved to 25-30% after 24 hours. Adrenaline stopped and Noradrenaline continued. His lactates decreasing, urine output is adequate and he is started on empirical antibiotics. His vitals remained stable on ECMO after 48 hours and ECMO decannulated, Left femoral artery repaired.
His CXR showed right lower zone opacity and he was continued on ventilator support. He developed sudden onset hypoxia on day 3 requiring high ventilator support and prone ventilation. Bronchoscopy done and multiple blood clots along with mucous plus removed. Antibiotics escalated and he was extubated to NIV on day 4. He continued to improve and shifted to ward on day 7 , ambulated in ward and discharged on day 15 with EF of 35% .
We here in report a unique case of Acute STEMI AWMI post Cardiac arrest revived after 15 mins and thrombolysed with reteplase. Targeted temperature management with inotrope support were crucial for regaining his GCS back to normal. Complete revascularisation with Complex Left main PCI was done with ECMO support. The course is further complicated by bronchial obstruction requiring bronchoscopic removal of blood clots.
