Simultaneous Left Anterior Descending Artery and Right Coronary Artery Total Thrombotic Occlusion in the Context of STEMI: a case report
Presenter
Ingrid Valdez, M.D., FSCAI, Hospital General de la Plaza de la Salud, Santo Domingo, Dominican Republic
Brian J Crespo, MD, Hospital General "Plaza de la Salud", Santo Domingo, Dom. Rep., Santo Domingo, Dominican Republic and Ingrid Valdez, M.D., FSCAI, Hospital General de la Plaza de la Salud, Santo Domingo, Dominican Republic
Title:
Simultaneous Left Anterior Descending Artery and Right Coronary Artery Total Thrombotic Occlusion in the Context of STEMI: a case report
Introduction:
Acute Myocardial Infarction involving multiple major coronary arteries is very rare, and usually fatal. This is a case report of a 58-year-old Dominican male with COVID-19 and simultaneous Left Anterior Descending and Right Coronary Arteries (LAD and RCA), with a clinical presentation of chest pain and diaphoresis. Percutaneous coronary intervention (PCI) with deployment of 4 Drug Eluting Stents (DES) was performed. The patient survived.
Clinical Case:
A 58-year-old Dominican man was admitted to the Emergency Department with chest pain and diaphoresis, Real-Time Polymerase Chain Reaction for SARS-CoV2 was positive. A 12-lead surface electrocardiogram (EKG) revealed anteroseptal ST-segment elevation and inferior ST-segment depression. Patient was taken to the cath-lab to perform Cardiac Catheterization, which found total occlusion of the LAD at the ostium, total occlusion of the middle RCA and significant stenosis of the circumflex artery (Cx) ostium. PCI of the LAD was performed using a JL 3.5 6F guide catheter and a workhorse 0.014” guidewire; after balloon angioplasty with a semi-complacent (SC) 2.5x12mm balloon, Thrombolysis In Myocardial Infarction (TIMI) II flow was obtained and diffuse atherosclerotic disease was observed with significant stenosis at the middle portion. Then, after stenting with a 4.0x22mm and 3.5x15mm DES, TIMI III flow was regained. PCI of the RCA was performed with XB RCA 6F guide catheter and a floppy 0.014” guidewire; balloon angioplasty with a SC 2.0x12mm balloon was performed and a dominant RCA with middle significant stenosis and diffuse distal disease was observed. After stenting with a 3.5x18mm and a 3.5x15mm DES and post-dilation with a non-complacent (NC) 4.0x12mm TIMI III flow was obtained. During the procedure he was hypotensive (80/50 mmHg), so aminergic support with phenylephrine was started and O2 support with a reservoir oxygen mask was used for respiratory support. Follow-up echocardiogram reported global hypokinesia with a 32% ejection fraction.
Discussion:
Acute myocardial infarction (AMI) with compromise of multiple main arteries is rare and usually fatal. Multiple conditions can cause AMI, but the most common one is atherosclerotic plaque rupture. It has been stablished that SARS-CoV2 can have thrombotic complications, including coronary artery occlusion, which could be another cause of a presentation such as this one. This patient was able to leave the hospital after two weeks in the COVID-19 care unit and was appointed to the cardiac failure and rehabilitation program.