Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 34 years old gentleman, driver by occupation unknown case of diabetes mellitus or hypertension nonsmoker but occasional alcoholic, presented to the emergency (ER)of our hospital with severe ongoing chest pain from 4 hours. Prior to this, he went to another hospital where he was diagnosed with an acute myocardial infarction and was referred to the higher center. He was very agitated literally tossing in the bed when presented.
P- 84 /min. Bp- 130/80 mm of Hg
RR- 16 per minute
Systemic examination was normal.
Relevant test results prior to catheterization
ECG was done immediately which was suggestive of acute anterior wall myocardial infarction. An echocardiogram was s/o LAD territory akinesia with moderate LV systolic dysfunction and LVEF of 40%
Blood urea 17 mg/dl
Serum creatinine 0.89 mg/dl
Hemoglobin 17.8 gm/dl
HIV, HBsAg, HCV were negative
Relevant catheterization findings
As a protocol of our hospital primary PCI team was activated. Loading doses of antiplatelets atorvastatin and heparin were given and in next 15 minutes, the patient was shifted to Cath lab. The door to balloon time was 20 minutes. Left main coronary artery was directly engaged with XB3 6F guiding Catheter and first cine run was taken in AP caudal view. It was showing distal left main artery large thrombus with total occlusion of LAD. Thrombus was extending into an ostium of LCX with TIMI 2 flow.
Immediately intra-aortic balloon (IABP) was inserted. Two wires were passed in LCX and large RAMUS. After a quick discussion amongst the primary PCI, team decision was taken to give intracoronary inj. Tenecteplase as the patient being a young person and predominantly a thrombus containing lesion. Inj. Tenecteplase 30 mg bolus was given intracoronary, after this, we waited for around 10 minutes closely monitoring the hemodynamics. Then further cine images were taken which were showing TIMI 2 flow in LAD and Ramus. After this we gave intracoronary abciximab and waited for 5 more minutes, the third wire was passed in LAD. There was still a large thrombus burden. So multiple runs of thrombus aspiration were done. After this there was TIMI 3 flow in all the arteries and still residual lesion with thrombus in ostioproximal LAD. At this point, the decision was taken not to stent the artery as a predominantly thrombus containing lesion. The patient was shifted to ICCU given unfractionated heparin infusion for 48 hours followed by fondaparinux for 4 more days. IABP was removed 48 hours after the index procedure. Patient was symptomatically better hemodynamically stable. After 5 days check, an angiogram was done which showed no residual lesion in LAD with small thrombus in distal most (apical) LAD. So the patient was discharged with optimal medical management.
On follow-up, the echo was so only apical LV akinetic with fair LV systolic function with LVEF of around 50%.
In complex scenarios like this where a left main coronary artery is involved management of thrombus burden is crucial. TIMI 3 flow in Infarct related artery should be the goal for a successful outcome. Mechanical interventions with thrombus aspiration device along with Intra-Coronary thrombolysis with bolus thrombolytic agents like INJ. TNK is a promising approach in young patients with persistent large thrombus burden. And last but the most important in young patients with acute myocardial infarction where thrombus burden is high and only minimal underlying plaque is present, judicious use of above-mentioned strategies can help us to avoid unnecessary stenting of the culprit artery.