Case presentation

An active 94-year-old retired psychiatrist with prior acute myocardial infarction 3 years earlier presented to the emergency department after awakening from sleep with severe chest pain. He was transported by ambulance where an electrocardiogram confirmed an acute anterior ST-segment elevation myocardial infarction. History obtained from his wife along with a quick review of the records revealed that, 3 years earlier, he presented with an acute anterior infarction complicated by cardiogenic shock and underwent emergent catheterization. That examination uncovered moderate disease in the right coronary artery, chronic occlusion of the proximal circumflex artery, and an acutely occluded, proximal left anterior descending artery. Reperfusion of the left anterior descending artery was successfully established by balloon angioplasty followed by placement of a 2.5 mm diameter by 16 mm long paclitaxel-eluting stent and he remained symptom-free until presentation.

Soon after arrival, his rhythm deteriorated to polymorphic ventricular tachycardia and he was successfully cardioverted to normal sinus rhythm. Two additional episodes of sustained ventricular tachycardia requiring cardioversion followed by progressive hypotension and diminished mental status led to endotracheal intubation and mechanical ventilation. He was administered intravenous infusions of amiodarone and dopamine and transported emergently to the cardiac catheterization laboratory.

Cardiac catheterization

Coronary angiography confirmed complete occlusion of the previously placed stent in the proximal left anterior descending artery and total occlusion of the left circumflex, as previously noted (Figure 26-1 and Video 26-1). There was moderate disease in the right coronary artery (Figure 26-2). After administration of a heparin bolus of 50 units/kg and an eptifibatide bolus (12.6 mg) followed by an infusion (2 mcg/kg/min), balloon angioplasty using a 2.5 mm diameter by 20 mm long balloon inflated to high pressures was performed. This restored TIMI-3 flow (Figure 26-3 and Video 26-2).

FIGURE 26-1 This angiogram of the left coronary artery shows the acute occlusion of the proximal left anterior descending artery stent and chronic occlusion of the left circumflex artery.

FIGURE 26-2 This is an angiogram of the right coronary artery. There is moderate nonobstructive disease noted in the proximal segment of the artery.

FIGURE 26-3 Angiogram obtained following balloon angioplasty of the occluded stent showing restoration of flow.