Cardiogenic shock in ACS - Image 3

Image in Interventional Cardiovascular Medicine: what do you see? How would you treat?

Read this clinical case and  indicate ithe most appropriate answer for the findings revealed by the angiography image below and the treatment that followed:

A 62 year-old woman affected by systemic arterial hypertension and with previous pulmonary neoplasm in good clinical status was admitted in the Emergency Department with acute marked asthenia rapidly deteriorating with diffuse ST segment and T wave changes and complete atrioventricular block complicated by cardiogenic shock and metabolic acidosis.

Left ventricle was not dilated and systolic function was normal with an ejection fraction of 60%. Right chambers and aorta were normal. There was no pericardial effusion. Fluid therapy, Oxygen, Bicarbonates and Noradrenalin were promptly administered.

During an emergency angiography we noticed evidence of subsequent findings and we consequently treated the patient in one of the following ways -  (please read this multiple-choice question and then indicate the most appropriate answer):

1. Normal dominant Right Coronary Artery, thus excluding ischaemic etiology of atrioventricular block: temporary transvenous pacing by femoral vein was inserted
2. Congenital single coronary artery, with Left Coronary Artery arising from continuation of the Right Coronary Artery: temporary transvenous pacing by femoral vein was inserted
3. Ostial Left Main occlusion, thus explaining very low cardiac output at the basis of shock and complete atrioventricular block:left angioplasty with mechanical support was performed (i.e.IABP)
4. Congenital single coronary artery, with the Left Coronary Artery arising from continuation of the Right Coronary Artery with acute occlusion of Posterolateral Artery(PLA): temporary transvenous pacing by femoral vein was inserted and PLA primary angioplasty was performed

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