Simple and acceptable solution for catastrophic situation PPCI in left main STEMI and cardiogenic shock in a single remaining vessel in an octogenarian patient: a case report

Simple and acceptable solution for catastrophic situation PPCI in left main STEMI and cardiogenic shock in a single remaining vessel in an octogenarian patient: a case report

Mochammad Yusuf Alsagaff, Kandita Arjani, Yudi H. Oktaviono, and Reddy Ramundito

Department of Cardiovascular Medicine, Dr Soetomo General Hospital, Surabaya, East Java, Indonesia

Background   Primary percutaneous coronary intervention in left main STEMI can be a catastrophic condition due to hemodynamic instability and cardiogenic shock. Primary percutaneous coronary intervention in an octogenarian and single remaining vessel can be undertaken although perceived to be a very high-risk procedure.

Case summary A 84 years old Asian male with a history of smoking, presented with typical chest pain and diagnosed with aVR STEMI and hypotension, on support by inotropic. Patient already hospitalized for eight days in the local hospital , was referred to Dr Sutomo general hospital Surabaya. Emergent coronary angiography revealed total occlusion on ostial left main coronary artery (LMCA) and critical stenosis 90% on distal Right Conorary Artery (RCA). From 1^st attempt PPCI, there was failed to obtain cannulation on LMCA. Intra aortic balloon pump (IABP)  was implanted due to hypotension condition. 2^nd  attempt PCI was performed in single remaining vessel. The target was critical stenosis 90% on distal RCA that giving collateral to left coronary artery (LCA). The  Stent has been implanted on distal RCA, patient was transferred to ICCU for observation. Patient’s symptoms and hemodynamics were gradually recover.

Discussion PPCI in left main STEMI can be catastrophic condition due to hemodynamic instability and cardiogenic shock. PPCI in octogenarian and single remaining vessel can be undertaken although perceived to be very high risk.

Keywords STEMI left main   PPCI single remaining vessel  PPCI in octogenarian  Case report

Learning points

• Degree of collaterals can be helpful for deciding intervention or conservative strategy in single remaining vessel
• Intra Aortic Ballon Pump (IABP) as circulatory support device can be used while performing PPCI in left main STEMI with hemodynamic instability and cardiogenic shock
• PPCI can be perform in Octogenarian with single remaining vessel although pecieved to be very high risk

Introduction

STEMI AVR describes the presence of coronary disorders in the left main coronary artery (LMCA), left anterior descending (LAD), or 3 vessel disease. LMCA provides most of the blood flow to the left ventricular myocardium.¹ Acute obstruction in LMCA can cause sudden cardiac death and cardiogenic shock (CS) due to malgina arrhythmias and heart pump failure.² Primary percutaneous coronary intervention (PPCI) in a single remaining vessel is very high risk procedure, but can be an option by considering the presence of collateral and outcome of the patient³

We report case reports with a diagnosis of STEMI left main in octogenarian individual with total LMCA obstruction, and RCA is a single remaining vessel that provides a collateral to the left coronary artery (LCA). In this case PPCI was done with IABP due to cardiogenic shock conditions, PPCI was performed by direct stenting implantation on single remaining vessel (RCA) .

Timeline

Case presentation

An 84-year-old Asian man with a risk of smoking was referred with diagnosis of STEMI aVR Killip IV and new onset RBBB. Patient complains of typical chest pain and have been treated for 8 days at the local hospital. Patients received arixtra 2.5 mg for 5 days, clopridogel 75 mg, concor 2.5 mg, digoxin 0.25 mg, atorvastatin 20 mg, NE pump 100 nano. On the 9th day of treatment, patients complained of typical chest pain accompanied by shortness of breath and found new onset RBBB. The patient was referred to Dr. Sutomo general hospital Surabaya. He had blood pressure of 97/64 mmHg with NE 100 nano, a heart rate 104 b.p.m., respiratory rate 24 times per minute, oxygen saturation of 96% O2. Electrocardiogram examination showed 104 b.p.m. sinus rhythm, left axis deviation, normal horizontal axis ST elevation aVR and incomplete RBBB (Figure 1). Laboratory tests showed CKMB 23.7 U / L and troponin-I 8.26 ng / ml. TTE data were obtained mild mitral regurgitation, mild aortic regurgitation, and mild tricuspid regurgitation, no thrombus or intracardiac vegetation, decreased systolic LV function (EF Teich 41%), diastolic LV pseudonormal function, normal systolic RV function, hypokinetic in anteroseptal BM, inferoseptal BM, septal A, anterior BMA, other normokinetic, no LVH present. PPCI is late onset due to recurrent chest pain and cardiogenic shock. From diagnostic coronary angiography at RSUD Dr. Soetomo Surabaya, obtained total occlusion in the Left Main Main failed to cannulate (Figure 2) and non-significant stenosis in proximal RCA and 90% significant stenosis in distal RCA (Figure 4). Intra-Aortic Ballon Pump (IABP) was inserted (Figure 3), patient was hospitalized at ICCU to be prepared for the CABG procedure. Patient still suffering with chest pain ( VAS pain scale of 6). After being observed at ICCU the patient still felt pain, so it was decided to do a late onset PCI in the hope of improving the prognosis and reducing symptoms. We found RCA giving collateral grade 2 to LCA (Figure5).Stent is placed on the distal RCA(Figure 6), considering that the RCA is a single remaining vessel that has a stenosis of more than 50%. Post-stenting, patient  was treated at ICCU and on the 6th day post-treatment, complaints of chest pain slowly decreased and hemodynamic improvement occurred, IABP was disconnected. Patient finally discharged successfully at day 13 with aspirin 100mg, Clopridogel 75mg, atorvastatin 40mg, bisoprolol 2.5mg, ramipril 5 mg, ISDN 5 mg if chest pain, 40 mg furosemide, 25 mg spironolactone (optimal medical therapy).

Figure 1 Superficial ECG shows ST elevation in leads aVF and ST depression in all leads.

Figure 2 Total Occlusion in distal LMCA in  Figure 3 IABP insertion in patient with

1^st attempt PCI                                                cardiogenic shock

Figure 4 From diagnostic RCA, there was      Figure 5 There was collateral from mid RCA

Critical stenosis 90% on distal RCA                to distal LAD and

Figure 6 Post implantable stent in distal RCA  Figure 7 ECG when transferred to ward

With TIMI flow grade 3

Discussion

We reported a case of left main STEMI in Octogenarian presented with chest pain and cardiogenic shock with total occlusion in distal LMCA, failed to cannulation in 1^st attempt PPCI, who undergo 2^nd attempt PCI in single remaining vessel (RCA) that give collateral to  LCA.

STEMI in aVR lead to coronary disease from LMCA,  LAD, or 3 vessel disease.¹ In  octogenarian population, the treatment of acute coronary syndromes usually conservative strategy due to presenting comorbidities.⁴ In STEMI with LMCA disease, often comes with poor clinical presentation such as shock cardiogenic, with that condition seems impossible to perform CABG.⁵ In the previous case, reported that PCI has been performed on a single remaining vessel with the consideration that it would be more risky to open the lesion in the LMCA. PCI performed in a single remaining vessel.³

In this case we found total occlusion in distal LMCA, failed to cannulation. Patient with instable hemodynamics, operators decided to use circulatory support device (IABP) to support hemodynamics. CABG was planned, patient transferred to ICCU. Patient suffered with recurrent chest pain with (VAS score 6), 2^nd attempt PCI maybe perform as a escape plan. In 2^nd attempt PCI, from angiography we found critical stenosis 90% in distal RCA, we also found collaterals from mid RCA through distal LAD with partial filling of the main epicardial recipient artery.⁶ Considering risk and benefit, direct stenting was planned in single remaining vessel which is RCA. During stent implantation in RCA, blood pressure was decreased, patient suffered cardiogenic shock. Nor epinephrine was used. Implantation stent using direct stenting method was successful with TIMI flow 3. Day 6 there were significant improvement in symptoms and hemodynamics, IABP was disconnected. Day 8 patient transferred to ward with optimal therapy such as optimal antiplatelet (DAPT), beta blocke, ace inhibitor , venodilator, diuretics, and mra. Day 13 patient was discharged.

Conclusion

This case showed that PCI in single remaining vessel in Octogenarian can be done although very high risk procedure. Using circulatory support device , should be considered due to complication of STEMI left main such as cardiogenic shock.

Lead author biography

Supplementary material

Acknowledgements

The authors are grateful to our collagues, who contributed in this case report

References

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