• PRIMARY PCI FOR ACUTE ANTERIOR MYOCARDIAL INFARCTION WITH PULMONARY EDEMA AND LAD OSTIAL STENOSIS

    November 16th 2009 www.tctmd.com

    By Deepak Natarajan

    Monday, November 16, 2009

    Operator(s):

    Deepak Natarajan

    Affiliation:

    Max Heart and Vascular Institute
    New Delhi, India.

    Facility:

    Max Heart and Vascular Institute
    New Delhi, India

    History:

    A 73 year old long standing diabetic and hypertensive man with an old CVA was admitted for severe central chest pain and breathlessness accompanied by ST segment elevation in precordial leads suggestive of acute anterior myocardial infarction. The 2D echocardiogram demonstrated akinesia of the entire septum from base to apex as also the apex with a global LV ejection fraction of 30%.

    Angiography:

    • Tight 90% ostial and 95% proximal LAD stenoses (Figure 1Figure 2Figure 3).
    • The LCX (dominant) and RCA (non dominant) were normal. The patient had to be intubated and put on mechanical ventilation prior to the angiogram because of the extensive pulmonary edema.

    Procedure:

    The patient had to be intubated and put on mechanical ventilation prior to the angiogram because of the extensive pulmonary edema. The coronary angiogram was done with the patient on dopamine infusion approximately 6 hours from pain onset. The left coronary artery was engaged with a 7Fr JL guiding catheter, and 2 BMW guidewires were positioned in the LAD and LCX arteries. After predilation with a 2x15mm balloon, a 3x28mm everolimus-eluting stent was deployed at 18atm covering both the ostial and proximal LAD lesions with extremely careful positioning of the proximal segment of the stent (Figure 4Figure 5Figure 6). Brisk antegrade flow was achieved, and there was no residual stenosis (Figure 7Figure 8). There was no compromise of either the left main or LCX arteries. The patient received 2 boluses of injection eptifibatide followed by an 8 hour infusion.

    Conclusion:

    The patient was gradually weaned off inotrope support over 24 hours and also extubated. There was complete resolution of the ST segments accompanied by marked clinical improvement. Subsequent 2 D echocardiogram done showed marked improvement in septal/apical wall motion with the LV ejection fraction at 45%.

    Comments:

    This case demonstrates that in emergency situations such as an acute anterior myocardial infarction with pulmonary edema presenting almost 6 hours from pain onset primary PCI of ostial and very proximal stenoses of the LAD artery is effective and feasible.

    Conflict of Interest:

    None