A 33 year old man , non smoker,with a history of of spinal surgery presented with sudden chest pain at rest with diaphoresis for 1 hour PTA. He went to emergency department. ECG Showed sinus rhythm with ST elevation in II, III, avF. Acute inferior wall STEMI was diagnosed, and he was emergency brought into cath lab. 

Left main : No significant stenosisLAD : total occlusion at distal segmentLcx : total occlusion at distal OM branchRCA : No significant stenosis
Baseline angiogram RAO caudal.mpg
Baseline angiogram RAO cranial.mpg
Baseline angiogram RCA1.mpg

We access right radial artery using 5/6 F sheath, IL 3.5 catheter.Angiogram showed total occlusion at distal segment of OM1 branch and distal LAD. Then we injected RCA  which no significant stenosis. We thought the culprit lesion was distal OM branch then we planned to engage Left coronary again. Just a seconds after we prepared to engaged left system again, patient suddenly developed hypotension and then cardiac arrest. Simultaneous CPR and left coronary system injection were performed. At this time, the left system showed the total occlusion of left main coronary artery!! With TIMI 0 flow. We advanced the Runthrough wire to cross the left main into LAD. 2.0 x 15 mm balloon was predilated at distal left main lesion. After predilate the balloon, slow flow was demonstrated to LAD but there was No flow to Lcx.Wiring to Lcx with Sion blue wire was done.  Then we deployed 3.0 x 21 mm DES to Left main-LAD.Angiogram after stent deployment showed TIMI II flow to LAD but Lcx still TIMI 0 flow. We performed POT in the Left main stent with 4.0 x 8 mm NC balloon -> after POT , flow to Lcx was restored but there was new total occlusion at distal Lcx.IABP was inserted. IVUS confirm wire was in false lumen. we placed 2.5 x 18mm DES to distal Lcx after rewiring.We also search for etiology of MI in the young. Echo showed high risk PFO -> successful PFO device closure.Final diagnosis was coronary emboli cause STEMI + guide-induce left main dissection and wire-induced Lcx dissection.


angiogram1.mov
procedure2.mov
final angiogram.mov

We also search for the etiology of MI the young patient with non-smoking. All hypercoagulable state were negative. Echocardiogram showed good LVEF but the agitated saline bubble test was positive with > 30 microbubbles during Valsalva’s maneuver. High risk PFO was diagnosed. An 25/18 mm PFO device closure was done.  So, the final diagnosis is coronary emboli causing acute inferior wall STEMI with the guiding-induced left main dissection during coronary angiogram.