Early Rescue PCI in Failed Thrombolysis in STEMI

Madhavan V and Cath team

Cardiac Technician, Department of Cardiology, Kauvery Hospital, Tirunelveli, Tamil Nadu

Abstract

Fibrinolysis is an important reperfusion strategy in the management of ST-elevation myocardial infarction (STEMI) when timely access to primary percutaneous coronary intervention (PPCI) is unavailable. With contemporary interventional techniques and medical therapy, rescue PCI remains a valuable strategy for treating patients with failed fibrinolysis. Where fibrinolysis is successful, a pharmaco-invasive strategy is recommended where coronary angiography and PCI, if indicated, is performed between 2 and 24 hr after fibrinolysis. In contrast, patients with failed fibrinolysis, emergent PCI termed ‘rescue PCI’ is recommended as it is superior to medical therapy for failed fibrinolysis.

Case Presentation

44yrs male patient came to ER with complaints of chest pain, radiating to left arm, associated with sweating and palpitation.

He was a known case of CAD/ S/P PTCA to LCX (24/10/22) and not a known case of DM/HTN. He was a chronic smoker and had a family history of his father dying at the age of 45 from a heart attack.

His follow-up ECHO on (15/11/2023) showed akinetic posterior wall, EF 45-50%, Grade 1 LVDD.

Physical Examination

CVS – S1S2 (+)

RS – NVBS

P/A – Soft

CNS – NFND

Vitals

SpO2 – 98%

BP-130/90

HR – 72/min

RR – 20/min

Pre SK ECG

Impression: ECG showed extensive ST Elevation in the anterior leads- V1 to V6

Pre-procedure ECHO:(14/01/25)

Akinetic LAD & LCX territory; thinned out RCA territory;
Severe LVSD; LVEF – 20-25%; Grade 3 LVDD;
Mild MR; No PE/CLOT.

Initial Management

Patient ECG and ECHO suggested ACS/Acute Extensive AWMI. So, loading dose given and then after consulting with Cardiologist patient thrombolysed with INJ.SK @ 1.5 million units over 1 hr.
Ongoing thrombolysis, patient went to Ventricular Fibrillation, reverted to NSR with 200J DC shock. Then he was intubated with 8 size ET tube on mechanical ventilation.
Again, patient monitor showed recurrent VF, so multiple DC shocks given respectively 200J,200J,300J.
Simultaneously Inj.Amiodarone 150mg Iv stat given according to ACLS protocol. After multiple shocks given patient monitor shows NSR with HR~74/min.
Post SK ECG showed decrease in ST elevation <50% and also patient was hemodynamically unstable, all of indicated failed lysis. So, patient was shifted to cathlab immediately for Rescue PCI.

Post SK ECG

QS inn anteroseptal leads, ST elevated in lateral leads

Coronary angiogram

Route: Right Femoral Artery

G.C: 6F EBU 3.5, 5F JR

Heparin: 2,500 IU + 2,500 IU (During PCI)

Contrast: Iodixanol(100ml)

Procedure

Left sided coronaries engaged using 6F EBU guide catheter and Right sided coronaries engaged using 5F diagnostic catheter and multiple angulated views obtained.
Left sided CAG revealed Ostioproximal LCX to Major OM stent patent and minimal ISR at distal part of stent. Proximal to mid LAD showed Grade 1 thrombus containing 3 tandem lesions with maximum 70-80% lesion& distal LAD had TIMI 1 flow.
Multiple angulated views showed that LAD had significant lesion, so decided to stent the lesions.

Post PCI Angio

Post PCI ECG

Investigations

CBC	RFT
Hb - 13.4 g/dl	Urea-27.5 mg/dl
PCV-44.4 %	Creatinine-1.02mg/dl
RBC-4.85 million/mm3	Na+ - 137.6meq/dl
MCV-92.6 Fl	K+ - 3.78meq/dl
WBC-10570 cells/cumm	RBS-172 mg/dl
Neutrophil-78.1%	ABG
Lymphocytes-17.9%	PH-7.46
Basophils-0.4%	pco2-31mmhg
Monocytes-2.1%	po2-152mmhg
Eosinophils-1.5%	HCO3-22mmol/l
Platelets-210000 cells/cumm

HCV – Non-Reactive

HBSAG – Non-Reactive

HIV – Non-Reactive

Post PCI RFT

Urea – 63.33mg/dl

Creatinine – 1.7mg/dl

Na⁺ – 140.2meq/dl

K⁺ – 3.5meq/dl

Medications

Drug	Dose	Frequency
Inj. Noradrenaline	15ml/hr
Inj. Adrenaline	8ml/hr
Inj. Dobutamine	3.5ml/hr
Inj. Midaz & Fentanyl	5ml/hr
Inj. Ceflon	1.5g IV	BD
Inj. Pantaparazole	40mg IV	BD
Tab. Ticagrelor	90mg	BD
Tab. Aspirin	75mg	OD
Tab. Atorvastatin	40mg	BD
Tab. Bisoprolol	1.25mg	HS
Tab. Ramipril	1.25mg	HS
Inj. Torsemide	10mg IV	OD

Post PCI ECHO

Akinetic LAD & LCX territory; Thinned out RCA territory;
Severe LVSD; LVEF – 25-30%;
Grade 1 LVDD; No PE/Clot;
LV myocardium thickening preserved.

Outcomes

Patient prognosis was good. His BP, SpO2 & HR were stable. Inotropes tapered day by day and he was weaned from mechanical ventilator, then extubated the ET tube after Pulmonologist opinion. He was conscious and obeyed commands well. Patient was discharged after 1 week and advised to follow-up after 15 days.

Early Rescue PCI in Failed Thrombolysis in STEMI

Early Rescue PCI in Failed Thrombolysis in STEMI

Madhavan V and Cath team

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