CASE PRESENTATION
A 59-year-old male presented to the emergency department of a local general hospital with inferior ST-elevated myocardial infarction (STEMI). The patient had no previous medical history. His vital parameters were stable. After the administration of 300 mg of aspirin and 180 mg of ticagrelor loading dose, eptifibatide infusion was commenced in combination with unfractionated heparin. Emergency angiography revealed severe coronary artery disease (CAD) including long segment disease in mid and distal right coronary artery (RCA), as well as long segment stenosis in the proximal left anterior descending (LAD) artery including ostium of the first diagonal artery. Consecutively, the patient underwent an attempt of PCI to mid and distal RCA, but with suboptimal result due to extensive calcification. Transthoracic echocardiography (TTE) demonstrated a normal-sized left ventricle with a mild systolic impairment. After a 60-mg loading dose of prasugrel, DAPT with aspirin and a 10-mg daily maintenance dose of prasugrel was commenced. The patient was transferred to our tertiary cardiothoracic surgical center for urgent CABG due to the unsuccessful PCI.
At the admission, he remained stable. Troponin I was 625 ng/L and other blood tests were unremarkable, including platelet count (367 10^9/L). Four days after discontinuation of prasugrel, a preoperative TEG PlateletMapping (Haemonetics, Braintree, MA) was performed and ADP-induced platelet aggregation test detected a complete platelet function recovery with maximal platelet aggregation and normal maximum amplitude on TEG (Fig. 1). Therefore, decision was made to proceed with an urgent off-pump CABG which included LIMA-LAD, long saphenous vein to the first diagonal artery and to the posterior descending artery anastomoses. Perioperative blood loss was minimal and no cell salvage or blood product transfusion was required. A loading dose of aspirin (300 mg) was administered within the first 6–24 hours after the surgery and DAPT including 75 mg of both aspirin and clopidogrel was started on the first postoperative day. Postoperative recovery was uneventful and the patient was discharged on the 5th postoperative day and remained well during a 6-month follow-up. Informed consent and patient’s permission were obtained to report this case.