Mr Tang

Mr Tang, a 61 year old man, was admitted to our hospital on 12/6 for chest pain since 1am, associated with sweating, dizziness and vomiting.He is a construction site worker with a good past health. He does not smoke, and only drinks socially.On arrival at AED at 9am, BP 144/97, Pulse 39, SpO2 97% RA. CXR was clear.ECG showed complete heart block with ST elevation at inferolateral leads. 

Bedside vscansevere hypokinesia over inferoposterior wall of left ventricle and right ventriclepoor LV systolic function EF 30%mild MR, no ARno VSD/pericardial effusionBlood tests were unremarkable. 

Coro results:LM minor diseaseLAD mLAD totally occludedLCX minor diseaseRCA pRCA totally occluded
Conclusion double culprit STEMI, planning for primary PCI to LAD and RCA.
RCA was engaged with JR 3.5 6F.Lesion was wired with NS runthrough, predilated with 2.0 balloon, then stented with Osiro 2.5 x 4.0 at 16 atm.
LM  was engaged with JL3.5 6Fr.Lesion wired with NS runthrough, predilated with 2.0 Ryurei, then stented with Osiro 2.5 x 4.0 and 2.5 x 3.5 at 18 atm.
Successful PCI to LAD and RCA done. 
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But patient remained in severe shock, SBP ~ 40despite succssful PCI.He was decided for ECMO and impella insertion (Ecpella).BP was stabilized before leaving catherization lab.
Staged PCI done on 16/6/2021. 
IVUS showed RCA distal stent landed on plaque.Osiro 3.0/14 was deployed at mRCA at 14 atm, overlapping with old stentStents were post dilated with NC sapphire 2.5/12 and Raiden 3.0/13 at 20 atm. 
IVUS showed LAD stent mild malapposition and underexpansion.LAD stent was post dilated with NC trek 2.5/14 and Raiden 3.5/15 at up to 20atmFinally VUS showed satisfactory results and TIMI 3 flow.Good angiographic result was achieved. 
ECMO was removed before the patient left the catherization lab.Impella was removed on day 8. 
Serial Echo showed improving LV and RV function.LVEF 15 -> 30%; TAPSE 0.6cm -> 1.3cm.
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This case illustrated with a difficult scenario where a patient had both cardiogenic shock and STEMI at the same time. It is difficult to decide to deal with which problem first in order to stabilize the patient. It depends on a number of factors, including vitals, difficulty in stenting, availability or time to set up mechanical circulatory support. Each case is different and difficult. It requires experience, careful consideration and perhaps some luck to save patients successfully.