Author + information
- Satoshi Yamamoto1
Patient initials or identifier number
Relevant clinical history and physical exam
She had been living in group homes for the senile elderly. An assistant of the home found her lying in a rest room. Her systolic blood pressure was 90mmHg and heart rate was 50bpm. An affiliated physician transferred her to our hospital because she complained chest pain.
Blood Pressure: 148/62mmHg, Heart Rate: 68bpm, regular
O2 Saturation: 98% (room air)
Body Temperature: 35.9°C
Lung: clear, no rale
Heart: S1→, S2→, S3-, S4-, no murmur
Leg edema: -
Relevant test results prior to catheterization
12 Leads electrocardiogram
Heart Rate: 70bpm, Sinus Rhythm, I° Atrioventricular Block
ST elevation in II III aVF, depression in I aVL V1.2
Cardio-thoracic Rate: 56%
Inferior wall asynergy
Relevant catheterization findings
Right Coronary Artery(RCA) #2: 100%
Left Anterior Descending Artery(LAD) #7: 100%
Left Circumflex Artery(LCX)#13: 90%
Diagonal Artery(D) to LAD: fair with flow competition
First Major Septal to #4 Posterior Descending Artery(#4PD): fair
D and LCX to #4 Post-lateral Artery(#4PL): fair
RCA to LAD: not definite
Thrombectomy with EXPORT Advance (6Fr.): no visible thrombus aspiration
Pre-dilatation with Hiryu Plus 3.0*12mm
TIMI III flow was restored at this point.
We could see collateral flow to LAD through some septal branches and conus branch clearly.
We decided to take Intra vascular Ultrasound (IVUS), but electrocardiogram (ECG) came to show complete atrio ventricular block and ST elevation in left precordial lead.
Because his hemodynamic collapsed, temporally pacemaker and Intra-aortic balloon pumping were inducted.
Resolute Integrity 3.0*38mm stent was implanted in #2 without distal protection.
Although distal embolization was occurred in #4AV, the septal collateral channels were still visible at this point.
But hemodynamical instability and ST elevation in left precordial leads were still sustained.
Xience Xpedition stent 2.5*28mm in #3 to #4AV with kissing balloon technique at #4PD.
After this stenting, #4PD flow was diminished and septal collateral channels disappeared.
His hemodynamics still unstable and ventricular tachycardia came to occur frequently.
Intracoronary infusion of Nicorandil and Sodium Nitroprusside was effective to improve RCA flow but not sufficient to restore collateral flow.
Because of persistent ST elevation and collapsed hemodyanamics, we tried LAD revascularization.But we could not cross the wire either antegradely or retrogradely.
Since his family refuses the further treatment including extra corporeal membrane oxygenation and bypass surgery, we gave up the procedure.
Unfortunately, we could not save the patient.,
In retrospect, the following strategies might produce better result.
Induction of intra-aortic balloon pumping precedential to coronary intervention.
Use of distal protection device.
We have to apply this experience to our future daily clinical practice.