12 Jan 2019
So many culprits, so little time
Consult this Twitter Case concerning a 43-year-old male with severe multi-vessel coronary artery disease
Severe multi-vessel coronary artery disease in a survivor of in-hospital VF cardiac arrest – what is the best revascularisation strategy?
This case was originally published on Twitter by @IamSpurs via #CardioTwitterCase
Clinical presentation
- 43-year-old male
- No previous medical history
- Chest pain at home – drives own car to hospital and walks into the emergency department
Admission ECG confirming sinus rhythm and inferior ST-segment elevation with reciprocal ischaemia in the high lateral leads.
- Witnessed VF cardiac arrest in the emergency department. Immediate CPR including 2 DC shocks for VF. ED team achieve ROSC. Patient intubated and sedated and taken to catheterisation laboratory.Targeted echocardiogram in ED showed no VSD, myocardial rupture or pericardial effusion; left ventricle was moving
Case management
- 6F right femoral artery access
- Coronary angiography demonstrates:
- unobstructed left main stem
- proximally occluded left anterior descending artery
- subtotally occluded circumflex vessel in the mid segment
- proximally occluded right coronary artery
- Patient requiring metaraminol infusion during procedure to maintain systolic BP >100 mmHg. Predominant issue was deciding which was the culprit lesion. Decision made to attempt PCI of the RCA. AL1 guide catheter + heparin anticoagulation. Coronary guidewire escalation from Sion Blue to Whisper MS then Fielder XTA. Unable to cross proximal RCA lesion. At this point, dye hold up was noted at the RCA ostium - ? coronary dissection.
- Given severe multivessel CAD in a young male with no previous cardiac history and haemodynamic instability – we discussed potential emergency CABG with our surgical colleagues. Cardiothoracic surgeons accepted the patient. IABP inserted via the same RFA access site prior to bailout CABG. Patient received 3 grafts to RCA, OM and LAD. Patient extubated the next day and made an excellent recovery
- Post CABG echocardiogram revealed moderate LV dysfunction but reasonable function in spite of the acute cardiac event.
Discussion points
- What was the true culprit lesion?
- In these types of cases, should we “always” attempt revascularisation of the LAD first?
- What to do next if the surgeons had declined taking the patient to theatre?
- Should we have used upfront mechanical circulatory support?
- If so, then what MCS to use – IABP or Impella?
Original tweet and Twitter discussion
43Y Chest pain @ home. WALKS into ED. VF arrest x 2 in ED. Pre arrest ECG below. Amazing ED team get ROSC. Stabilised intubated & taken to cath Lab. Diagnostic images follow below. #CardioTwitter#CardioEdpic.twitter.com/1Qvl5MNQ2J
— Aung Myat MD (@IamSpurs) 23 novembre 2018
Authors
4 comments
The RCA and LAD has chronic total occlusion ,the distal LCX subtotal lesion was the culprit lesion and it's give the collateral to the RCA so when the acute event occur LCX lesion the ST elevated in inferior leads because of diminished collateral supply of RCA, first we do PCI LCX which was the culprit lesion. If surgeon declines to do CABG so we can do PCI LCX Impella is better than IABP in this case if patient need mechanical circulatory supports.
LAD &RCA is chronic . CX is culprit. I agree .
LAD &RCA is chronic . CX is culprit. I agree .
LAD &RCA is chronic . CX is culprit. I agree .