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Anterior Extensive ST-Elevation Myocard Infarction With High Thrombus Burden Given Intra-Coronary, Intra-Venous Eptifibatide and Plain Old Balloon Angioplasty : A Case With Satisfying Result

Author : I.N.G.Sudiarta, I.W. Wita
Upload Date : 19-04-2018

Introduction: Although primary PCI has been the primary choice in the treatment of STEMI, one of the technical problems that arises in primary PCI is the presence of intracoronary thrombus. It has been well known that thrombus is an independent risk factor for angioplasty failure associated with restenosis, occlusion after PCI, increased incidence of myocardial infarction and death. An evidence-based comprehensive approach is needed to deal with STEMI with high thrombus burden cases in order to obtain better outcomes.

Case Illustration: A 41 years old man presented with 14 hours onset of infarction typical chest pain and ongoing despite standard protocols treatment has been given. He was an active smoker with 2 packs of cigarette per day since 20 years. On admission, he had BP 120/80 mmHg, HR 70 beats/min, RR 20 times/min, and SaO2 99% on room air. Physical examination within normal limit. ECG showed sinus rythm, ST segmen elevation on V1-V6, I and AVL along with pathological Q wave and mirror image ST depression on inferior leads. Laboratory findings showed marked cardiac markers elevation. Diagnose of late onset anterior extensive STEMI was established and patient rushed into cath lab for primary PCI strategy. The coronary angiogram showed total occlusion on proximal LAD and slow flow on the RCA. Balloon inflation was performed on proximal LAD and revealed thrombus formation along the LAD. The procedure was terminated and administration   180 mcg/kgbw of eptifibatide intra coronary continued with continuous intra venous administration 2 mcg/ kgbw/minute of eptifibatide for 12 hour was given along with previous standard treatment of aspirin, ticagrelor, enoxaparin, atorvastatine, bisoprolol and captopril. He was discharged without any residual symptom and planned for elective PCI. The next coronary angiogram showed 90 % stenosis at mid LAD without any thrombus formation and normal flow and non stenotic RCA. Balloon predilatation was performed and followed with DES deployement at mid-distal LAD. Final angiogram showed no complication and TIMI 3 flow in LAD. Patient was stable on discharge and planned for dual anti platelet for 12 months.

Discussion: High thrombus burden is one of the challenging problem in the era of interventional treatment for STEMI. Latest guideline have showed us some new evidence based recommendation in order to achieved better outcome. In this case we have chosen to administered eptifibatide intra coronary and intra venously along with standard anticoagulant, anti platelets and other treatment before we did further angiographic reevaluation and intervention and the result was quite satisfactory.

KEYWORDS : STEMI, High Thrombus Burden, Primary PCI, Eptifibatide


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