EG

Patient is a known hypertensive and diabetic with prior  history of stroke. A day prior to admission, the  patient presented with  sudden onset of chest pain , non radiating, graded 9/10 in severity accompanied with dyspnea and shortness of breathing hence rushed  to the emergency room. Upon arrival he was recieved unstable and drowsy. Work ups done confirmed ST elevation myocardial infarction with posterior involvement  and RT PCR for SARS CoV-2 revealed positive.

 On arrival, diagnostics were  done  which include electrocardiogram  showing  inferior wall infarction with posterior wall involvement .Chest radiograph was also requested which revealed congested lungs and pneumonia. High sensitive troponin I showed elevated value. Complete blood count also showed leukocytosis with neutrophilic predominance. A SARS-CoV 19 swab was done which revealed positive for Covid-19 infection.

Left heart catheterization and coronary angiogram were done which showed  calcifications .The left main coronary artery  showed a fair sized vessel with 70-80% aortoostial stenosis. The left anterior descending artery showed a  95-99% ostioproximal  stenosis. The left circumflex artery is totally occluded at the proximal segment and the right coronary artery showed 95% proximal segment stenosis becoming totally occluded at the mid segment .Left ventricular end diastolic pressure is elevated at 40mmHg.

Video A right coronary artery (2).mp4

Video B Left main ,Left anterior descending and left circumflex artery.mp4

Video C Left anterior descending artery (2) (2).mp4

Initially, balloon angioplasty of the right coronary artery was done over the culprit lesion. Intraprocedural event noted, he had hypotension and bradycardia hence an intra aortic balloon pump and temporary pacemaker were inserted. Patient was referred to surgery for urgent coronary artery bypass however since patient was positive for COVID -19 infection a 21-day recovery  period was recommended prior to operation thus Percutaneous Coronary Intervention was decided by the Heart Team . Percutaneous transluminal coronary angioplasty of the right coronary artery  was done and  stents were placed at the proximal , proximal to mid and distal right coronary artery. Intravascular ultrasound post stent  showed well opposed and expanded right coronary artery. An  intravascular ultrasound guided percutaneous intervention of left main and left anterior descending artery  was also done. A  percutaneous transluminal coronary angioplasty guidewire was  advance across the left main  coronary artery to proximal left anterior descending artery and noted heavy calcification at proximal left anterior descending artery hence rotational atherectomy  was carried out. A guidewire  was  then advance to the proximal to distal left anterior descending artery and a stents were placed  at the left main to proximal left anterior descending artery  and proximal to mid left anterior descending artery. Intravascular ultrasound post stent  showed well opposed and expanded proximal to mid left anterior descending artery.

Video A right coronary artery (1).mp4

Video B rotational atherotomy (3) (1).mp4

Video C Left anterior descending artery .mp4

Covid-19 pandemic has affected the standard of care on managing acute coronary syndrome . Patients with COVID -19 infection have an overwhelming inflammatory and catabolic state therefore the recommendation for urgent coronary artery bypass cannot be done hence exploring complex procedure applying rotational atherectomy plus intravascular ultrasound technique  is a favorable option for this complex case with multiple comorbidities and multivessel coronary artery disease involvement . Given the urgency in this case the team has successfully revascularized the patient and weaned off from mechanical ventilatory and medical support.