Cathalogue

Spontaneous Coronary Artery Dissection: A Challenge for an Interventional Cardiologist

2025-01-31T12:22:14+00:00

Background: Spontaneous Coronary Artery Dissection (SCAD) is a rare cause of acute coronary syndrome primarily affecting younger women, distinct from traditional coronary artery disease as it is not associated with atherosclerosis or conventional risk factors. Its etiology is multifactorial, encompassing hormonal, genetic, and mechanical factors. Timely diagnosis and intervention are critical due to the risk of severe complications, including cardiac arrest.

Case Presentation: A 32-year-old female with an unremarkable medical history, who had given birth 24 months prior, presented with a sudden choking sensation in the neck, chest heaviness, and diaphoresis while at work, followed by sudden cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated promptly, achieving return of spontaneous circulation within two minutes. Post-resuscitation electrocardiogram (ECG) revealed extensive anterior wall myocardial infarction (MI). Coronary angiography confirmed a type 2 SCAD in the mid-left anterior descending artery (LAD).

Results: Due to hemodynamic instability, the patient underwent percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement, successfully restoring TIMI III flow in the affected artery. The patient’s recovery was smooth, and follow-up echocardiogram at three months demonstrated normalization of left ventricular function, indicating a positive response to the intervention.

Conclusion: This case highlights the critical importance of early recognition and intervention in SCAD, especially in hemodynamically unstable patients, to facilitate favorable outcomes.

Effective Interventional Strategies for Bifurcating Lesions in Acute coronary syndrome (ACS): Insights into the Jailed ballon stent kissing technique (J-BSKT) Approach

2025-01-31T12:24:42+00:00

Background: Percutaneous coronary intervention (PCI) for bifurcation lesions is a challenging aspect of coronary intervention. The Jailed Balloon Stent Kissing Technique (J-BSKT) is one approach for managing bifurcation lesions, though it remains a controversial technique with limited data, particularly in the context of Acute Coronary Syndrome (ACS). This case discusses the use of J-BSKT in a Non-ST Elevation Myocardial Infarction (NSTEMI) and highlights its complications.

Case Presentation: A patient with Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS) presented with echocardiographic findings of an ejection fraction of 50%, along with hypokinesia of the apex and anterior wall. Coronary angiography revealed triple-vessel coronary artery disease, including a bifurcation lesion in the left anterior descending artery (LAD) involving the diagonal branch.

Results: Following a successful PCI to the LAD, the patient developed chest pain. An immediate relook angiogram demonstrated occlusion of the side branch at the ostium. Subsequent intervention to the side branch was performed, but it resulted in thrombus propagation within the main vessel. The main vessel was then reintervened, while the branch vessel was managed medically. On a follow-up angiogram, both the main vessel and side branch showed patent flow, with TIMI III flow in both.

Conclusion: Bifurcation lesions in coronary arteries pose a significant challenge for interventional cardiologists. The Jailed Balloon Stent Kissing Technique (J-BSKT) can be an effective strategy for managing such lesions, though complications such as side branch thrombosis may occur, necessitating careful patient monitoring and management.

The Critical Role of Imaging in Managing Complex PCI: A Case Report

2025-01-31T12:27:41+00:00

Background: Left Main Stem (LMS) disease presents significant challenges in interventional cardiology, particularly when the severity of lesions is ambiguous. Accurate assessment is crucial for determining appropriate treatment strategies.

Case Presentation: A 45-year-old male presented to a tertiary care hospital with post-myocardial infarction (MI) angina, five days after being thrombolyzed at a secondary care facility. At presentation, he was clinically stable, with normal baseline investigations. An echocardiogram revealed an ejection fraction (EF) of 35% and anterior wall hypokinesia. Coronary angiography demonstrated severe ostial stenosis of the left main stem (LMS) and subtotal occlusion of the left anterior descending (LAD) artery, persisting even after intracoronary nitrate administration.

Results: Initially planned for PCI of the LMS to the LAD or potential LMS bifurcation stenting, the patient underwent an intravascular ultrasound (IVUS) study three weeks later, which clarified the situation. Contrary to earlier expectations, the IVUS revealed no significant LMS disease. This unexpected finding suggested that the initial pressure damping during angiography was likely due to a thrombotic plaque and superimposed spasm at the LMS ostium. The procedure was performed using a 7F guiding catheter with planned intra-aortic balloon pump (IABP) support, but it ultimately resulted in a simpler PCI of the LAD with ostial coverage.

Conclusion: This case illustrates the critical role of IVUS in managing LMS disease and highlights how advanced imaging can alter treatment strategies. The ability to differentiate between significant and non-significant LMS lesions led to a less complex intervention than initially anticipated, contributing to an excellent post-procedural outcome for the patient.

Catheter Catastrophe: Facing Left Main Dissection in the Cath Lab

2025-01-31T12:31:37+00:00

Background: Iatrogenic left main dissection is a serious complication that can arise during coronary interventions, significantly increasing the risk of myocardial infarction and mortality. Understanding the clinical presentation and management strategies for such complications is critical for improving patient outcomes. This case discusses an acute coronary syndrome patient diagnosed with Wellen’s syndrome, emphasizing the importance of early recognition and effective intervention.

Case Presentation: A 62-year-old hypertensive female presented with a 3-day history of chest pain. The ECG demonstrated Wellen’s pattern characterized by deep, symmetrical T wave inversions in the precordial leads. Baseline investigations indicated elevated troponin levels and echocardiographic findings of anterior wall hypokinesia with an ejection fraction (EF) of 48%. The patient was subsequently admitted to the cardiology ward for coronary angiography.

Results: Angiography revealed significant disease in the left anterior descending artery (LAD). During the angioplasty procedure, a simultaneous catheter-induced left main stem (LMS) dissection occurred, along with wire-induced distal stent edge dissection. Both complications were managed successfully.

Conclusion: Iatrogenic left main dissection is a catastrophic complication that, while preventable, cannot be entirely avoided. It requires urgent recognition and prompt management to minimize adverse outcomes.

Successful Mechanical Thrombectomy in Acute Ischemic Stroke Due to Right MCA Occlusion: A Case Study

2025-01-31T12:33:27+00:00

Background: Acute ischemic stroke is a significant cause of morbidity and mortality, with rapid intervention being crucial to improving outcomes. This case report describes a successful mechanical thrombectomy using the ADAPT technique in a patient with complete occlusion of the right middle cerebral artery (MCA).

Case Presentation: A 70-year-old male with a history of left bundle branch block (LBBB) and reduced ejection fraction (EF) presented with acute left-sided weakness and expressive aphasia. Neurological assessment revealed complete motor loss in the left limbs, with a National Institutes of Health Stroke Scale (NIHSS) score of 16 and an Alberta Stroke Program Early CT Score (ASPECT) of 8/10.

Results: Urgent imaging ruled out hemorrhage and confirmed a 100% occlusion of the right MCA. Mechanical thrombectomy was performed using the ADAPT technique, successfully restoring cerebral blood flow. Post-procedure, the patient exhibited marked improvement in neurological function.

Conclusion: This case underscores the importance of rapid diagnosis and timely intervention in acute ischemic stroke. The use of mechanical thrombectomy with the ADAPT technique proves effective in revascularization and significantly enhances patient outcomes.

Mysteriously Mysterious MI: Recurrent ACS Secondary to Spontaneous Coronary Artery Dissection Associated with Rheumatoid Arthritis.

2025-01-31T12:37:21+00:00

Background: Spontaneous coronary artery dissection (SCAD) is a rare but significant cause of myocardial infarction (MI), particularly in young females who often lack traditional cardiovascular risk factors. This condition is characterized by a tear in the coronary artery wall, which can lead to serious cardiac events.

Case Presentation: We present the case of a 36-year-old female who experienced recurrent episodes of myocardial infarction. Her clinical presentation included severe chest pain, ECG abnormalities, and angiographic findings consistent with coronary dissection. During her evaluation, she was also diagnosed with rheumatoid arthritis (RA), which was found to be an incidental but relevant finding in her medical history.

Results: Despite appropriate treatment, the patient continued to experience recurrent cardiac events, underscoring the chronic nature of her condition. The repeated episodes of MI were ultimately attributed to SCAD. The interplay of her chronic inflammatory state, autoimmune vasculitis, connective tissue abnormalities, and potential medication effects from RA were considered contributing factors to the development of SCAD.

Conclusion: This case underscores the challenges of managing spontaneous coronary artery dissection (SCAD) in a young woman with rheumatoid arthritis. It highlights the importance of thorough diagnostic evaluation and ongoing monitoring due to recurrent acute coronary syndrome episodes. Early identification and effective medical management, including dual antiplatelet therapy and anticoagulation, were crucial for favorable outcomes.