Author + information
- Yuzo Akita1
Patient initials or identifier number
Relevant clinical history and physical exam
This 70-year-old gentleman known a history of hypertension, dyslipidemia and diabetes mellitus on medication. He felt out of sorts on August 6th, 2016. He felt the difficulty of breath and could not get up from his bed on August 8th, 2016. He was admitted to our hospital for acute myocardial infarction with complete AV block by ambulance on August 9th. His blood pressure was 131/62 mmHg, pulse was 35/min. His heart sounds no murmur, lung sounds moist rate at lower lungs.
Relevant test results prior to catheterization
His ECG showed complete AV block, complete right bundle block left axis deviation. His cardiac enzyme was elevated. So, we diagnosed him for acute myocardial infarction with complete AV block.
Relevant catheterization findings
He was inserted temporary pacemaker from right jugular vein then underwent for a coronary angiogram. It showed severe stenosis in proximal RCA, 99% with the TIMI-2 flow in #4 AV, severe stenosis in OM and PL, total occlusion in proximal LAD. Also, there is a good collateral channel from RV branch to LAD.
We performed PCI to LAD total occluded lesion first. We used EBU3.75 7F guiding catheter from the radial approach. The SION blue wire with Mogul microcatheter backup could not pass the lesion, so we changed the wire from the SION blue to SION black. It could pass to distal LAD. We opened LAD by 2.5 mm balloon and then implanted 2DES from Left Main Trunk (LM) to mid LAD. We performed kissing balloon technique between LM-LAD and LM-Cx. During the kissing balloon technique, his blood pressure was down so he was inserted IABP from his right femoral artery. His hemodynamics was stable and his LAD had got TIMI 3 flow. After this procedure, his ECG changed to Mobitz type II block. We performed PCI to RCA lesion because his ECG still remained Mobitz type II block. We opened #4 AV by 2.0 mm balloon and opened proximal RCA by 2.5 mm balloon. A slow flow phenomenon was occurred in RCA after ballooning to proximal RCA. We injected intracoronary Nitroprusside and Nicorandil to his RCA. His RCA blood flow was recovered to TIMI3 flow. Then we implanted 2DES to proximal RCA. We could get TIMI 3 flow. After these procedures, his ECG recovered to normal sinus rhythm.
We experienced an interesting case that progression of various ECG changes during primary PCI for AMI with complete AV block. RCA jeopardized collateral channel to LAD CTO was the culprit lesion of this case. The cause of complete AV block, in this case, was ischemia of LAD & RCA territory which distal of His bundle. Complete AV block was recovered to Mobitz type II after LAD reperfusion. Mobitz type II was recovered to normal sinus rhythm after RCA reperfusion.
In the case of AMI with complete bundle branch block, it is important of culprit coronary artery reperfusion of damaged heart conduction system.