A complex case of inferior STEMI, cardiogenic shock and chronic total occlusion

Introduction: Patients presenting with STEMI, cardiogenic shock (CS) and (another) coronary chronic total occlusion (CTO) are a real challenge of management because these cases are associated with a higher rate of early mortality. Our purpose is to present a case of inferior STEMI, cardiogenic shock and CTO. Methods: A 71 year old male, obese, smoker, dyslipidemic, non-DM, presented with CS and inferior and right ventricle STEMI. Sp O2 65% needed oral intubation and mechanical ventilation. I.v. double inotropic support and IABP were initiated. Echocardiography: EF 15%, TAPSE 12 mm, extended LV akinesia. Coronarography revealed: CTO LAD2, CTO LCX-OM1, and acute occlusion of RCA 1. We performed PPCI with BMS on RCA1. Considering CS, we decided to continue with the revascularization of the left coronary system. We solved CTO of LAD2 with a BMS and excellent final result. Results: Subsequently patient status improved: double inotropic support withdrawal, IABP stopped and extubation. Echo: EF 35% and TAPSE 20 mm. After 72 hours the patient developed an ischemic stroke of right posterior cerebral artery with no progression and limited clinical evolution. Also, he developed septic complications: post-intubation bronchopneumonia and urinary infection with Klebsiella, receiving i.v. antibio tics. He was discharged in good condition. After one week he was re-admitted with hemorrhagic transformation of stroke, septic shock and acute abdomen. CT revealed gangrenous non-lithiasic colecystitis. The abdominal surgery noted infected peritonitis. Subsequently, evolution was severe with progressive shock and death. Conclusions: We present a complex case of cardiogenic shock due to STEMI, multiple vessel disease and CTO. Th e interventional approach was a success – PPCI on RCA, IABP and CTO on LAD in the same time, with doubling the EF and no signs of cardiac decompensation at discharge. Nevertheless, septic and neurologic complications have been decisive for the evolution of this case. A multidisciplinary approach of this kind of cases is necessary for a successful management.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)