Left main coronary artery occlusion, Cardiogenic shock, ST elevation acute myocardial infarction, primary (direct) angioplasty
Coronary angiogram showed intra-luminal thrombus in the body of the left main coronary artery (arrow) causing a subtotal luminal stenosis (A). An unobstructed right coronary is shown in B.
Balloon dilatation (2.0/20) was performed during cardiopulmonary resuscitation (A) an resulted in re-established coronary flow with residual stenosis of less than 20% (open arrow in B).
Coronary angiogram performed 2.5 years later in 1998 and showed a smooth lumen of the left main trunk with no re-stenosis.
The 1st ECG of case report 2 showed diffuse ST segment depression in leads I, aVL, II, V2-V6 (black arrow) and > 1mm ST elevation in leads aVR and V1 (white arrow). Early transition (tall R in V2) suggested posterior wall extension.
Showed a totally occluded distal LM artery (black arrow, left) and unobstructed right coronary artery (middle) that provided a major collateral supply to distal part of the left coronary artery (white arrows). After balloon dilatation, the flow improved to Cx and proximal LAD/diagonal arteries (black arrow, right) but we could not pass the wire across an obstructed LAD artery.
Upper tracing showed frequent short coupling premapure vemtricular complexes (PVCs) (black arrow) induced non-sustained VT (in bracket) during and after balloon dilatations resulted in transient hypotension (arterial pressure 50-60 mmHg in lower tracing)
ECG after PTCA showed improvement of ST depression in all leads and lesser degree of ST elevation in lead aVR. Tall R in V1, Q in V2 and tall T in V1-3 were also noted.
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