Journal of Invasive Cardiology

After an uneventful initial follow-up period, we performed coronary angiography on the fourth day of admission, as the patient was complaining of exertional angina. His left coronary system was normal, his right coronary artery (RCA) was dominant and distally totally occluded, with thrombolysis in myocardial infarction (TIMI) 0 flow (Figure 1A), with retrograde filling of the posterior descending artery (PDA) and the posterolateral branch (PL) from the left system. He underwent balloon angioplasty to the distal RCA and was noted to have a thrombotic lesion. A bare-metal stent (BMS) 2.5 x 20 mm was implanted (Figure 1B) with restoration of TIMI 3 flow, but a few small clots were seen in the distal circulation. The patient was started on tirofiban (glycoprotein IIb/IIIa antagonist) and a UFH infusion for 24 hours followed by enoxaparin until discharge. The rest of his stay was uneventful, and he was discharged home after 5 days on dual-antiplatelet therapy.

After 1 week of hospital discharge, he was readmitted with chest pain with no significant new ischemic changes, but a rising troponin T level. His echocardiogram was the same as before. Coronary angiography showed a totally occluded distal RCA with in-stent thrombosis and TIMI 0 flow (Figure 2A). He was started on tirofiban and UFH infusion and the next day underwent balloon angioplasty to in-stent thrombosis and deployment of a stent in PL origin (BMS 2.25 x 12 mm), as there was a tight thrombotic lesion noted, followed by TIMI 3 flow (Figure 2B). He was administered tirofiban for another 24 hours and UFH was continued.

After 48 hours of his intervention while transferring out of CCU, he suddenly collapsed with a loss of consciousness, an absent pulse and heart sounds. The paddle rhythm showed ventricular fibrillation and was successfully defibrillated. Electrocardiography (ECG) done post resuscitation showed new right bundle branch block (RBBB) with no ST elevation or depression. He was suspected to have in-stent thrombosis, and an emergency coronary angiogram was performed, which showed patent stents with TIMI 3 flow and no significant clots. His blood pressure was 90/60 mmHg on inotropes, his heart rate was 110 beats/minute and room air saturation was 92%. His UFH was continued.