CASE20230815_001

When Right Not Always Right: Primary PCI in Anomaly Ostium

By Rendra Mahardhika Mahardhika, Taofan Taofan, Doni Firman, Amir Aziz Alkatiri, Arwin Saleh Mangkuanom, Nanda Iryuza

Presenter

Rendra Mahardhika

Authors

Rendra Mahardhika Mahardhika¹, Taofan Taofan², Doni Firman³, Amir Aziz Alkatiri³, Arwin Saleh Mangkuanom³, Nanda Iryuza³

Affiliation

Airlangga University Indonesia, Indonesia¹, National Cardiovascular Harapan Kita Hospital, Indonesia², National Cardiovascular Center Harapan Kita, Indonesia³,

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CASE20230815_001

ACS/AMI - ACS/AMI

When Right Not Always Right: Primary PCI in Anomaly Ostium

Rendra Mahardhika Mahardhika¹, Taofan Taofan², Doni Firman³, Amir Aziz Alkatiri³, Arwin Saleh Mangkuanom³, Nanda Iryuza³

Airlangga University Indonesia, Indonesia¹, National Cardiovascular Harapan Kita Hospital, Indonesia², National Cardiovascular Center Harapan Kita, Indonesia³,

Clinical Information

Relevant Clinical History and Physical Exam

Patient initials: Mr. R

A 55-year-old male, who was obese and a heavysmoker, presented to the Emergency Room (ER) with chest pain that had persistedfor five hours prior to admission. He was diagnosed with Inferior Acute STElevation Myocardial Infarction (ACS-STEMI). His vital signs upon arrival atthe ER were a blood pressure of 140/90 mmHg and a heart rate of 90 bpm. Therewere no rales, and his peripheral perfusions were normal

Relevant Test Results Prior to Catheterization

- ECG: Normal SinusRhythm, with ST Elevation in II-III-AVFEchocardiography: Left Ventricular EjectionFraction (LVEF) measured at 48%, with a regional wall motion abnormality at thebasal mid-inferior region. Right Ventricular (RV) function appeared normal (Tapse2.1 cm).Blood Count: Hemoglobin (Hb) level of 16.1 g/dL,White Blood Cell count (WBc) of 11000 /ÂµL, Platelet count of 191.000 /ÂµL, Urea level of 11.3 mg/dL, and Creatininelevel of 0.71 mg/dL

Relevant Catheterization Findings

Angiography Result LeftMain : Normal, LAD :Tubular stenosis 40% at proximal, LCx :Diffuse stenosis 70-80% at OM, RCA : Anomaly Ostium (Left sided),Tottally oclluded at Distal with Thrombus Grade V and TIMI 0 Flow

LAO RCA.mp4

Caudal.mp4

Cranial.mp4

Interventional Management

Procedural Step

1. Looking For RCA OstiumInitial cannulation attempts of the RCA using a Tiger catheter were unsuccessful, then trying to cannulate Left ostium, The RCA segment was also seen during left injection. Due to right radials spasm, the access moved into right femoral2. Canulation The RCA (3D Perspective)Trying to engage RCA with guiding catheter EBU 3.5/6Fr, but failed. Better engagement was achieved with guiding catheter JL 3.5/6Fr. From the LAO Caudal view, the Ostium RCA not clearly seen, then we make RAO Caudal view, to make better three-dimensional(3D) perspective on ostium RCA. The ostium, clearly seen at RAO Caudal View. 3. WiringWhen do the wiring RCA, we have difficulties, the guiding not fully back up, then we also wiring to distal LAD, to have more back up. Successfully wiring RCA with Runthrough NS Floppy.4. Stent ImplantationWe do pre-dilatation with semi-compliant balloon 2.5 x 15 mm, then continue with DES Implantation 2.75 x 23mm, with good result and TIMI 3 Flow.

RAO Caudal ostium.mp4

DES Implantation.mp4

Final Result.mp4

Case Summary

This case underscores the significance of encountering rare anomalies, such as the Ostium RCA anomaly, in routine daily practice. Thinking quickly about all possibilities, particularly within emergency settings, remains a pivotal skill for every Cardiac Interventionist. The pivotal role of three-dimensional(3D) perspective is highlighted, serving as a crucial guide when confrontinganomalies. It serves as a poignant reminder that the approach to PCI procedures can markedly differ when encountering such anomalies compared to standard PCI practices.

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CASE20230815_001