AA

31 y/o Egyptian male patient with Known h/o heavy cig. Smoker 15 years ago, dyslipidemia. He presented to ER.  troponin mold elevated, ECG showed S-T elevation in antro-lateral leads  with depression in A, aVL

Troponin test: 0.41 on admission. ECG showed anterolateral STEMI.

He was transferred to Cath lab for primary PCI. Coronary angiography showed: no significant disease in RCA while, LAD was total proximal occlusion and LCX was subtotal ostial occlusion with floating thrombus.  Immediately BMW wire passed to LAD then aspiration thrombectomy by export Cath where only TIMI 1 flow resumed but the patient suddenly developed VF where DC shock given once and revived to sinus rhythm, then IC vasodilators was given distal IC improving the flow into TIMI 3 flow. Then DES was deployed precisely into the ostium of LAD. The question was about LCX? is it a second culprit? So we decided to deploy direct stenting to ostial LCX in V stenting like technique with excellent final results.  

 He was transferred to Cath lab for primary PCI. Coronary angiography showed: no significant disease in RCA while, LAD was total proximal occlusion and LCX was subtotal ostial occlusion with floating thrombus.  Immediately BMW wire passed to LAD then aspiration thrombectomy by export Cath where only TIMI 1 flow resumed but the patient suddenly developed VF where DC shock given once and revived to sinus rhythm, then IC vasodilators was given distal IC improving the flow into TIMI 3 flow. Then DES was deployed precisely into the ostium of LAD. The question was about LCX? is it a second culprit? So we decided to deploy direct stenting to ostial LCX in V stenting like technique with excellent final results.  

Conclusion: Pan-Coronary Vulnerability is a rare under-recognized entity only diagnosed during primary PCI as a simultaneous multi-vessel coronary thrombosis. Pan-coronary Vulnerability is a high risk group of patient presented as STEMI with severe clinical instability (Acute heart failure or Pulmonary edema, Cardiogenic shock, even sudden death from life-threatening ventricular arrhythmia (VF)). It has a very poor prognosis and higher mortality risk if not early recognized with timely and efficiently managed. Early prediction of the diagnosis is crucial (high clinical suspension, proper analysis of both ECG (STEMI localization) and echocardiography (SWMA)) to facilitate the early recognition.