Author + information
- Zulfikri Mukhtar1,
- Teuku Bob Haykal1,
- Andika Sitepu1,
- Cut Aryfa Andra1,
- Nizam Zikri Akbar2,
- Sutomo Kasiman1,
- Amran Lubis1 and
- Tawanita Brahmana3
Patient initials or identifier number
Mr M, male, 56 years old
Relevant clinical history and physical exam
Acute myocardial infarction patient suffered chest pain 4 hours before hospital admission.
Risk factors were smoking and hypertension.
BP 110 / 70 mmhg. HR 70 bpm
Heart, normal heart sound.
Lung, there were no rales
Relevant test results prior to catheterization
Electrocardiography showed sinus rhythm, ST segment elevation V1 - V5, T wave inversion V2 - V6.
Laboratory findings : Troponin T: 899 ng/L, CKMB : 1.44 ng/ml
Relevant catheterization findings
Left main was normal
Left Circumflexa and Right Coronary Artery were normal
Left Anterior Descending ( Infarct Related Artery ) with occlusive thrombus was already spontaneously re perfused withTIMI flow grade 2.
Guiding XB 3/6F, Rinato (moderate) wire did not pass lesion. Using back-up balloon 1.5 x 15 mm Rinato wire penetrated plaque or small branch (?). Wire reposition enters to true lumen, followed by balloon predilatation. Further, angiogram showed lesion dissection and perforation of the two diagonal branches at distal vessel. We also see dye trapping in pericardial space. We deferred stent for 3 days until perforated vessel closed. On the fourth day, we used soft wire as a guide for angioplasty to prevent recurrent vessel perforation. We did balloon predilatation, a local intracoronary eptifibatide 3.75 mg and alteplase 5 mg were given, followed by stent deployment, and angiogram showed TIMI grade2 and after following a local single-bolus intracoronary nitroglycerine 300 μg, angiography demonstrated TIMI grade 3. We then saw another stenosis at mid vessel, and decided to put a second stent. Finally, angiogram showed TIMI grade 3.
A simple lesion in acute myocardial infarction patients as described by a diagnostic angiogram does not guarantee that angioplasty procedure will also be simple. In this case, discretion to postponed or deferred stent for 3 days was considered as an ideal short time for perforation vessel closed. The decision used soft wire is to avoid the complication of vessel perforation. Combination of local intracoronary eptifibatide and alteplase successfully dissolve fresh thrombus, and the addition of nitroglycerine after stent implantation obtained maximal TIMI flow as TIMI grade 3.