Author + information
- Erwin Mulia1
Patient initials or identifier number
Relevant clinical history and physical exam
A 38 year old gentleman with no known medical illness was referred from a distant district hospital for anterior STEMI with failed thrombolysis (streptokinase). Patient was an active smoker (14 pack-year). Upon arrival to our hospital (24 hours from thrombolysis and 48 hours from the onset of chest pain), patient still complained of chest pain and persistent ST-segment elevation was still noted in ECG. Patient was hemodynamically stable without any inotropic support and no sign of heart failure.
Relevant test results prior to catheterization
Cardiac enzymes from previous hospital was increased (3x Upper limit level)
Relevant catheterization findings
LAD- Occluded after first septal branch
LCx- Ectatic but recessive
RCA- Ectatic, 50% stenosis at mid segment, supplies to LAD
During the first PCI (femoral approach), TIMI 1 flow at LAD was achieved after a combination of balloon dilatation, thrombus aspiration using 6Fr aspiration catheter, and intravenous tirofiban (GP IIb/III a inhibitor). We decided to defer stenting strategy. Dual antiplatelet (aspirin+clopidogrel) was continued. We added fondaparinux subcutaneously because of the LV thrombus which was noted from the echocardiogram study. 5 days after PCI, CMRI study showed large area at risk (EGE area-LGE area) with large viable area and signs of microvascular obstruction. This result guided us to repeat coronary angiogram immediately. Repeated coronary angiogram showed TIMI 3 flow at LAD with 90% stenosis at mid segment (Medina 1,1,1) and we did PCI (radial approach) using one DES 4.0 x 12 mm and post dilated using 4.5 x 10 mm NC balloon up to 16 ATM. The pinched ostium of the diagonal branch was dilated using SC balloon 2.5 x 10 mm up to 6 ATM. In short-term follow up, patient had no complaint and now in CCS class I with no cardiovascular event in 9 months time. Echocardiogram showed some improvements.
No reflow phenomenon is common in reperfused acute myocardial infarction patient which is usually related with prolonged period of ischemia (total ischemic time). This case demonstrated the impact of cardiovascular MRI (CMRI) on acute myocardial infarction in current reperfusion era. CMRI helps us to define the benefit of further intervention and which area to be salvaged (area at risk). It is also useful to detect the presence of LV thrombus and other microvascular obstruction features.