PRIMARY PCI LAD Cardiogenic shock Significance of Non-culprit PCI

Dr.S.MANOJ
MD(Gen.Med),DNB(Gen.Med),DM(Cardio),DNB(Cardio),MNAMS

Consultant Cardiologist Specialist in Interventional Cardiology BHARATHI RAJAA SPECIALTY HOSPITAL, CHENNAI, TAMIL NADU, INDIA

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PRIMARY PCI LAD Cardiogenic shock Significance of Non-culprit PCI

61yr male, diabetic, STE-AWMI <40min low volume pulse, BP 95/58mmHg; RWMA+, hypokinesia, LVEF ~50%. No pulm edema First degree A-V block in ECG; HR ~90bpm

Coronary Angiography Large Dominant Cx significant Type A lesion, retrograde collateral from RCA; LAD total occlusion with dense calcification
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PRIMARY PCI LAD Cardiogenic shock Significance of Non-culprit PCI

RCA collateralises dominant Cx

prox LAD CALCIFIC TOTAL Occlusion

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Non-culprit PCI in Pr PCI Direct DES 3.0 x 15mm EXCEL stentto Prox Domn Cx

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Pre-dilatation 2.25mm x 10mm NC balloon deformation

TIMI Grade 2 Flow after wiring Small calibre calified proximal LAD
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Post Pre-dilatation Slow flow

Hypotension; Complete AV block

SBP <30mmHg; ELECTRO-MECHANICAL DISSOCIATION to PACING

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IABP / Ventillator / Pacing Ground glass appearance of Lungs / Cx perfusion maintained / No flow in LAD

External Cardiac Massage required for 40mins

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2.50mm x 36mm BIOMIME DES in LAD

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TIMI grade 3 flow in LAD and Cx / Sinus Rhythm achieved

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RESULT
Survived hospital stay; discharged on 6th day Regained consciousness after 48 hours Was able to resume normal activities after 6 weeks

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LV EF recovered to 55% in 4 weeks

Developed exertional dyspnoea after 14 weeks. No angina able to walk for 2 km An exercise stress test was inconclusive due to limiting breathlessness. Repeat echo showed LV EF ~35% Repeat Coronary angiography: Patent Cx and LAD stent; ostial LAD tight ~90% stenosis.
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Didnt prefer repeat PCI to LAD

Had CABG with LIMA to LAD Leads a normal life; LV EF ~58%

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Non-culprit PCI
Performance of non-culprit PCI may require precedence in select cases as in this. Calcified small LAD with Type A proximal significant large dominant Cx stenosis. PCI with direct Stent to Prox Domn Cx was a savior indeed in this case when no flow in LAD complicated into Cardiogenic shock. Calcified LAD lesions during Pr PCI offers great challenges
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 Slow flow and No flow can be catastrophic and should not give up resuscitation during EMD periods even for an hour or so with all support systems like pacing and IABP in situ. Appropriate measures for slow / no flow should be given without delay.

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 Challenges in Primary PCI are often rewarding. Critical to address PCI to Significant Nonculprit lesion in special clinical circumstances.

It should be operators choice.

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