A Case of Stemi Complicated by Cardiogenic Shock Treated Using a Minimal Approach

Abstract Introduction An 88–year–old woman was admitted to our hospital for a posterior STEMI. The medical history was significant only for arterial hypertension. The echocardiography showed a mild left ventricular global dysfunction (EF 48%) with hyperkinesia of the posterior wall. After administration of loading doses of acetylsalicylic acid, clopidogrel and heparin, the patient underwent coronary angiography. Investigation The coronary angiography showed an occlusion of a dominant left circumflex (LCx) in the proximal tract and an irregular plaque, determining a critical stenosis of the ostial left anterior descending (LAD) artery. After the diagnostic examination, the patient becomes very hypotensive (65/45 mmHg arterial blood pressure) and sleepy. Management Considering the impossibility of using the impella and the IABP because they were already used for other patients, we decided for a minimal approach guided by intracoronary imaging. We used an XB 3.0 6F guide catheter, crossed the LCx with a BMW wire, and performed an inflation with a Semi–compliant 2.0x20 mm balloon, obtaining TIMI 3 flow. The “culprit lesion” was in the proximal tract of a trifurcation with three vessels of equal size. We decide to implant a 2.75x8 mm stent covering the lesion without protruding inside the left main. Because the patient was still hypotensive and started to have frequent ectopic ventricular beats often organized in run we decided to treat also LAD ostium stenosis avoiding to cover left main in the acute phase. So we implanted a 3.0x15 mm on LAD “nailing” ostium using only angiographic projection. Without the need to administer X, the patient achieved normal blood pressure and became alert. After stabilization of the patient we checked the stent on the LAD and the left main with IVUS. The stent had no significant underexpansion, and the trunk was free of significant plaque or dissection. After primary PTCA in the UTIC, the patient had no complications at 12 months follow up. Conclusions Our clinical case is an example of how in primary angioplasty, often based on the coronary anatomy, a minimal approach with the aim of guaranteeing a stable TIMI 3 coronary flow and avoiding prolonged dilation on the common trunk can guarantee the patient‘s survival. The stenting technique must be personalized based on the patient‘s clinical conditions and the resources available.