PP-425 - Challenging Management of St Segment Elevated Myocardial İnfarction With Head Trauma

Abstract

A 38-year-old male patient was admitted to the emergency department with head trauma due to dizziness and severe chest pain. It was learned from his story that primary percutaneous coronary intervention (PCI) was applied to right coronary artery (RCA) in January 2015 and to diagonal branch of the left anterior descending artery (LAD) in March 2015 due to ST segment elevation acute coronary syndrome. In the physical examination, blood pressure was 82/51 mm Hg and heart rate was 107 beats/min. Deep incisions related to head trauma were observed on the left temporal region and mandible. There were no pathologic findings on cardiovascular system examination except tachycardia, and no lateralization findings were observed neurologically. On electrocardiography, ST segment elevation was seen in inferior and anterior leads (Figure 1A). The patient having ongoing chest pain and no neurological signs was immediately taken to the catheter laboratory. Critical stenosis in LAD diagonal 2 (D2) bifurcation region and instent thrombotic lesion in D2, 100% circumflex (Cx) lesion after obtuse margin 1 (OM1) and 99% lesion in the mid portion of RCA were detected on coronary angiography (Figure 1B, C and D). Since the patient was in the pre-shock table, revascularization decision for LAD and RCA was taken. No additional anticoagulant was given due to the risk of cerebral haemorrhage as acetylsalicylic acid (ASA), clopidogrel loading therapy and intravenous low molecular weight heparin (LMWH) were administered in the emergency department within the last hour. First, RCA lesion was predilatated with a 2.0 × 12 mm balloon and then revascularized with a 2.5 × 15 mm drug-eluting stent (DES) (Figure 1E). After LAD-D2 bifurcation lesion was dilated with a 1.5 × 15 mm balloon, a 3.0 × 30 mm DES was applied to the LAD lesion followed by postdilatation with a 3.5 × 9 mm non-compliant balloon (Figure 1F). D2 balloon dilatation planned due to hazy appearance in proximal stent of D2. When the guide wire was directed to D2, thrombus formation extending from the left main coronary artery (LMCA) to the LAD was observed (Figure 1G). Despite of intracoronary unfractionated heparin and tirofiban administration, LAD flow was not provided. Repeated dilatations were performed from LAD to the LMCA with a 3.0 × 20 mm balloon (Figure 1H). On the persistence of thrombus in LMCA 4.0 × 20 mm bare metal stent was applied (Figure 1I). Despite these procedures, the left systemic flow was not achieved and cardiac arrest developed. Temporary pacemaker was implanted to the patient with cardiopulmonary resuscitation (CPR). Patient who did not respond to CPR was considered to have died. In this case, it was concluded that anticoagulant and antiagregan therapy management in a patient with ST segment elevation MI accompanied with head trauma was a compelling situation. Despite anticoagulation in accordance with current guidelines, thrombogenic status could be more mortal than the hemorrhage and we should be more courageous about anticoagulation in the absence of neurological findings due to trauma.