Author + information
- Sanjat Shankar Chiwane1
Patient initials or identifier number
Relevant clinical history and physical exam
A 34-year-old, male.
Chronic smoker, non-diabetic, non-hypertensive.
c/o left sided chest pain and backache since 12 hours. The patient was managed as a case of ACS at a primary health facility and subsequently referred to us.
Ecg: s/o st elevation v1-v6, i and avl, st depression ii, iii and avf, st elevation in Avr
echo: Global lv hypokinesia, lvef ∼10-15%, mild mrcardiac enzymes: troponin t and ck mb positive
The patient remained hemodynamically stable with sinus tachycardia and map ∼75 mm of hg.
Relevant test results prior to catheterization
Ecg: s/o ST elevation v1-v6, I and AVL, ST depression ii, iii and AVF, ST elevation in AVR
Echo: Global lv Hypokinesia, lvef ∼10-15%, mild MR
Cardiac enzymes: trop and CK MB positive
Relevant catheterization findings
After premedicating the patient, he was shifted to cath lab.
Bilateral arterial and right venous access obtained.
RCA: Dominant, normal
LMCA: Distal 100% thrombotic occlusion
- LCO engaged with 7FR XB 3.0 guiding catheter. Lesion in lad crossed with whisper ES wire. Multiple thrombus aspirations done using export 6 FR thrombectomy catheter. Red thrombus aspirated. In view of poor distal flow, intracoronary nitroprusside, nicorandil, and adrenaline cocktail was given. LCX crossed with BMW wire and lx balloon dilated with 2.5 x 12 NC balloon at 6-8 atm. A patient had a cardiac arrest during the procedure and 1 cycle of CPR done as per ACLS protocol. Lesion in lmca-lad stented with xience 4.0 x 23 at 14 atm. Post-dilatation done using 4.0 x 9 NC balloon. Check angiogram: Timi iii flow, poor myocardial blush grades.
- The patient was shifted to icu on iv gp-iib/iia inhibitors and other ancillary treatment.
- After 12 hours he developed intermittent CHB. Immediate tpi was inserted and check angiogram showed patent stent in left main. In view of deteriorating hemodynamics, he was intubated and inotropes were started. After 72 hours, he was extubated, tpi removed and intrpestapered. He was discharged after 10 days of hospitalization.
- After 1 year, his check angiogram revealed patent stent in left main and his lvef improved ∼35-40%.
Left main coronary artery thrombosis with acute myocardial infarction is an uncommon condition with an extremely high mortality. The small number of reported cases prevents the development of an evidence-based approach. Hence there are no clear-cut guidelines describing the best management approach for this condition. I have described my experience with 1 patient who presented with LMCA thrombosis and discussed etiology and management options available for this high-risk subgroup.