The Fellow’s Corner | 1st Clinical Case: All That Glitters Is Not Gold

We present the first clinical case in the section “The Fellow’s Corner”, aimed at fellows in Latin America who wish to learn and always be up to date in interventional cardiology.

Leave your thoughts in the comment section of this article and join the conversation!


Case Authors: Jair Suriano Martins (ARG), Leonardo Ripa (ARG).

Moderator: Dr. Nicolas Zaderenko (ARG).

Site: Sanatorio Allende Cerro, Córdoba, Argentina.

Guest Specialist: Dr. José Mangione (BRA). Sao Paulo Beneficencia Portuguesa Hospital.


Case Introduction

DEMOGRAPHICS

  • Female
  • 55 years old
  • Housewife

CURRENT BACKGROUND

  • Sedentary lifestyle
  • Current tobacco use
  • Early menopause (LMP at 38 years old)

REASON FOR CONSULTATION

Chest pain.

CURRENT DISEASE

Consultation in peripheral center due to 30-minute long angina at rest, with peak intensity, which irradiates to an upper limb, is accompanied by neurovegetative symptoms, and changes with respiratory movements.

Emergency ECG shows a right branch conduction disorder. Anti-ischemic treatment is conducted and a cardiac enzymes test is requested, which comes back positive (1.3 mcg/mL, NV: < 0.01).

Patient experiences a new angina episode (without electrocardiographic changes) that subsides with nitroglycerin.

Symptomatology is interpreted as high-risk non-ST-segment elevation acute myocardial infarction and the cath lab is activated. An emergency coronary catheterization is performed.

ADDITIONAL STUDIES

ECG

Coronary Angiography

An anterior descending artery lesion is considered as the origin of the event and specialists decide to perform an angioplasty with a 3.0 × 30 mm stent (DES).

DOPPLER ECHOCARDIOGRAPHY

LVEF 58%, LV apical hypokinesis, other parietal motility preserved. Mild LA dilatation. Normal function and contractility RV. Normal Doppler evaluation.

PROGRESS

Patient shows good progression. For administrative reasons, she is referred to our institution to continue her recovery after the infarction and decide whether a complete revascularization should be performed before discharge.


Moderator Comments

Congratulation to Dr Suriano and Dr Ripa of Mendoza Central Hospital for presenting this case.

I believe this is an excellent case to kick-start this discussion forum thought and created for all Latin American fellows.

This is one of the most frequent situations in the cath lab, a patient with a moderate to high-risk non-ST-elevation ACS assessed as an emergency, who has two severe lesions and we need to decide which one to treat. Afterwards, the patient is referred to another site to continue her progress and decide the therapeutic course of action.

Therefore, to start this debate, here are my questions:

  1. In this case, would you all have treated the LAD?
  2. What would you take into account to decide the therapeutic course of action?
  3. Does this case warrant using an invasive or a non-invasive diagnostic method?
  4. Which would be the therapeutic course of action to follow?

Regards to all!

Dr. Nicolas Zaderenko.


During hospitalization, the case is reassessed with intracoronary imaging following stent implantation in distal left main towards anterior descending, in addition to testing the right coronary.

OCT reveals fibrolipidic plaque in right coronary artery, with erosion and dissection flap, and significant stenosis with thrombus inside.

CD

And stent malapposition in descending artery and left main

DA

INTERVENTION

Based on the new imaging, the culprit artery is reinterpreted, the right coronary being the new suspect, which leads to right coronary stenting (video 3 image 3).

CCG

Post OCT

A new strategy is decided, to optimize instent with 3.5x20mm balloon proximal to anterior descending and 4.5mm balloon in middle and distal segment of left main.

Post OCT

EVOLUTION

Asymptomatic at discharge and one-year followup, assessed with non-invasive studies.


Comments by Dr. Mangione

This is a very interesting case of a patient with non-ST-segment elevation myocardial infarction and bilateral lesions, elevated serological markers of myocardial necrosis, and recurrent chest pain. According to these data, this patient is considered high risk; therefore, early invasive therapy should be recommended within 24 hours of the event.

According to the new guidelines for non-ST-segment elevation myocardial infarction presented at the European Society of Cardiology 2020 Congress (ESC 2020) and published in the European Heart Journal based on the ISAR REACT V study, if we decide on an early invasive strategy ≤2 h, a routine pre-treatment with P2Y12 inhibitors is not recommended. These should be prescribed after defining coronary anatomy (in the aforementioned study, prasugrel was used). It is important to remember that clopidogrel should only be prescribed in case of contraindication for these new antiplatelet agents.

The initial impression was that the most severe angiographic injury was located in the anterior descending artery; given the apical hypokinesia shown on the echocardiogram, that seemed to be the culprit lesion.

I believe another important aspect is that the stent could only be implanted on the anterior descending artery, as the left main coronary artery was not significantly obstructed.

Nonetheless, in this situation, where we face two major lesions without ischemic changes in the echocardiogram, imaging methods—particularly, optical coherence tomography (OCT)—are paramount to define the artery to treat.

OCT was decisive in this case because the right coronary artery was the culprit lesion and would necessarily have to be treated before discharge from the hospital. It was also key for correcting the bad positioning of the stent in the left main coronary artery.


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