Methods:
Baseline investigations showed WBC of 14.9 and urinalysis suggestive of
UTI. Her Troponin level and proBNP were reported high (troponin 56 and
proBNP of 16, 484). Electrocardiography (EKG) revealed atrial
fibrillation with rapid ventricular response, low voltage QRS, poor R
wave progression, and non-specific T wave abnormalities. Transthoracic
echocardiography reported a mildly dilated left ventricle and new
severely reduced systolic left ventricular ejection fraction (LVEF 24%)
with moderate diffuse hypokinesia, akinetic left ventricular apex, and
severely hypokinetic inferolateroseptal wall, features suggestive of
Takotsubo cardiomyopathy (Figure 1). There were no LA or LV clots
detected on this echocardiogram, but this study was done without
contrast. CT head reported negative for acute intracranial abnormality
and the patient was started on IV antibiotics for treatment of sepsis in
the setting of a urinary tract infection.
Cardiology was consulted for the newly depressed EF who recommended
starting a statin, beta-blockers, and angiotensin-converting enzyme
inhibitor (ACEI) if tolerable and a pharmacologic nuclear stress test to
evaluate cardiomyopathy further.
The next day, the rapid response team (RRT) was called for hypotension
of 66/38 mmHg and chest pain. EKG revealed atrial fibrillation with
rapid ventricular response, right bundle branch pattern (RBBB), and ST
elevations in the anterolateral leads suggestive of acute ST-elevation
myocardial infarction (Figure no. 2).
The patient was started on inotropic support and was emergently
transferred to the cardiac catheterization laboratory. On coronary
catheterization, after placement of a balloon pump for hemodynamic
support, a proximal LAD lesion with 100% occlusion and heavy thrombus
burden was discovered (Figure 3). Initially, thrombus aspiration using a
Pronto Extraction Catheter was attempted which was unsuccessful, but
after POBA (percutaneous old balloon angioplasty) of the proximal LAD
flow was restored. Post-injection revealed TIMI 3 flow in the LAD with
no further underlying LAD disease, but a new 100% occlusion of the
proximal LCx was now detected which likely occurred due to clot
embolization during PCI to LAD (Figure 4). Again, after a trial of
unsuccessful thrombectomy using the Pronto Extraction Catheter, POBA
followed by deployment of a DES to the pLCX was performed without any
further complications.
.
A repeat transthoracic echocardiogram after PCI revealed an improvement
in LVEF from 24% to 45% EF. The patient was eventually weaned off the
balloon pump and pressor support after 4 days and was started on beta
blockers and angiotensin-converting enzyme inhibitors (ACEI) and
clopidogrel along with rivaroxaban and was discharged home after a week
with outpatient follow-up at the cardiology clinic.