Multiple and anecdotic complications during angioplasty in a severe patient with acute coronary syndrome

Introduction: The risks and complications associated with PCI are related not only with the clinical evolution of the patient but also with the technical difficulties that can occur during procedure. We present a complex case of acute coronary syndrome with multiple complications (clinical and also technical non-procedural) during PCI. Methods: A 82 year old male, with VVI pacemaker, hypertensive, dyslipidemic, presented with rest unstable angina pectoris. ECG: ventricular paced rhythm, 70/min., atrial fibrillation, normal cardiac enzymes. Echocardiography: EF 40%, severe anterior wall hipokinesis. Coronarography revealed complex lesions: 50% ostial LM stenosis, 95% ostial LAD stenosis, occlusion LAD II, 50% stenosis LCX I, 90% proximal stenosis RCA II, 80-85% stenosis distal RCA II, 85% long stenosis RCAIII. SYNTAX score > 22, with the indication for CABG, refused due to low LVEF. During hospitalization patient developed MI with high cardiac enzymes. Echocardiography revealed: extended LV akinesis, EF 15%, hipokinesia RV. Results: We performed PCI with BMS on RCA III-II-I. During stent implantation on RCA I patient goes into cardiac arrest concomitant with an electricity blackout in the cathlab. After CPR, oral intubation, patient status is recovered. Echocardiography: EF = 20-25%, RV wall normokinesia. Double innotropic support and IABP are initiated. Subsequently patient’s status improved. IABP stopped, extubation performed. Patient developed infection with multidrug resistant Klebsiella pneumoniae. Despite antibiotherapy and triple innotropic support, patient goes into septic shock, cardiopulmonary arrest nonresponsive to CPR. Conclusions: This is a complex case of ACS with CABG indication and an off -label approach followed by multiple difficulties in its management: anecdotic complications during PCI followed by improvement of general status and subsequently cardiac decompensation secondary to infection.

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