Acute STEMI With Multiple Culprit Vessels in Young Male

ACUTE STEMI WITH
MULTIPLE CULPRIT VESSELS

IN YOUNG MALE
Submitted By:
Vickry H.Wahidji MD
Interventional Cardiology Fellow
Wahidin Sudirohusodo General Hospital/
Awal Bros Hospital
Makassar
INDONESIAN SOCIETY OF INTERVENTIONAL CARDIOLOGY ANNUAL MEETING
19th & 20th November 2016
Fairmont Hotel, Jakarta
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Speaker name: Vickry H. Wahidji MD
 I have the following potential conflicts of interest to report:

 Research contracts
 Consulting
 Employment in industry
 Stockholder of a healthcare company
 Owner of a healthcare company
 Others
 I do not have any potential conflict of interest

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Introduction
• Coronary artery disease is the leading cause of
mortality and morbidity and one of the acute
presentation occurs in the form of ST-elevation
myocardial infarction (STEMI) 1
• Acute myocardial infarction (AMI) involving two or

more culprit lesions at the same time, known as
double or combined infarction, is an extremely rare
event with a grave prognosis 2
1
O’Gara PT, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. JACC 2013
2
Ribeiro H, et al. Sequential double vessel myocardial infarction. Rev Port Cardiol 2011
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Case
• Male, 26 years old
• Typical angina 3 hours before admitted to ER while he
played soccer
• Risk factor: Smoker
• Physical Examination: Within normal limit
• ECG: Inferior + Anterior wall MCI, 1st Degree AV Block,
VES
• Chest X Ray: Cor and Lung within normal limit
• Laboratory result:
WBC 17,400; Cr 1,55 mg/dl; GOT 65 U/L; GPT 128U/L
CK 582 U/L; CKMB 44,2 U/L
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Electrocardiogram
Right and Posterior leads
Sinus rhytm, HR 100 bpm, normoaxis, PR interval 0.22 s, QRS complex 0.12 s, ST elevation lead II,III,AVF,V2R-V4R, ST depression at lead V
Sinus rhytm, HR 100 bpm, normoaxis, PR interval 0.22 s, QRS complex 0.14 s, RBBB, ST elevation lead I, II,III, aVF,V1-V4, VES;
7-V9;
Conclusion: Sinus rhytm, normoaxis, 1st Degree AV Block , Inferior + Anterior wall MCI, VES
Conclusion: Sinus rhytm, normoaxis, 1st Degree AV Block , Inferior + RV wall MCI
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Working Diagnosis:
• STEMI Anterior, inferior et RV onset 3 Hours Killip I
(TIMI Score 4/14, Estimated 30 day Mortality was 7.3%)
• Acute Kidney Injury
Management:
• Oxygen 3 L/minute/nasal canule
• IVFD Nacl 0.9% 500cc/loading
• Aspilet 160mg/loading
• Clopidogrel 600mg/loading
• Primary PCI
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Coronary Angiography
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PCI LAD
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PCI RCA
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2nd Coronary Angiography

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Discussion
• AMI involving two or more culprit lesions at the same
time, is a rare event with a poor prognosis. Pollak et al.
found 18 cases (2.5%) of multiple culprit arteries in a
series of 711 patients undergoing primary PCI 3
• It is relatively common to encounter two occluded

arteries when performing primary angioplasty for acute
myocardial infarction. This is due to the presence of a
chronically occluded artery that received collaterals
from the acutely occluded artery. However, this case
demonstrates that acute simultaneous occlusion of
more than one major coronary artery is possible 4.
3
Pollak PM, et al. Multiple Culprit Arteries in Patients With ST Segment Elevation Myocardial Infarction Referred for Primary
Percutaneous Coronary Intervention. Am J Cardiol. 2009
4
Yuh A et al. Primary Angioplasty for Acute Myocardial Infarction Resulting From the Simultaneous Occlusion of Two Major
Coronary Arteries. Catheterization and Cardiovascular Interventions 47:1999
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Discussion
• This is the third case report of AMI with multiple culprit in
patients aged < 355 . Smoking is a major risk factor for
acute MI among young men6
• Several factors, such as multi vessel spasm7, state of

hypercoagulability8 at the onset of myocardial
infarction, and decreased coronary pressure are
thought to be involved in the mechanism of
simultaneous occlusion. In this case, It is assumed that
double infarction results from the overall pro thrombotic
and inflammatory conditions associated with AMI
5
Yoshitomi et al. Acute Myocardial Infarction with Simultaneous Occlusions of Two Major Coronary Arteries in a Young Man. Clin. Cardiol 1998
6
Kool MJF et al. Short- and long-term effects of smoking on arterial wall properties in habitual smokers. J Am Coll Cardiol 1993
7Vincent GM, Anderson JL, Marshall HW. Coronary spasm producing coronary thrombosis and myocardial infarction. N Engl J Med 1983;309
5Yoshitomi et al. Acute Myocardial Infarction with Simultaneous Occlusions of Two Major Coronary Arteries in a Young Man. Clin. Cardiol 1998
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Conclusion
• We report a case showing a unique condition
suggesting simultaneous double coronary artery
occlusion. These acute condition probably due to a
heightened thrombotic state
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Thank You
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The 3 PCI strategies for STEMI patients with MVD:

• The culprit vessel only PCI (culprit PCI) strategy was
defined as PCI confined to culprit vessel lesions only.
• The multivessel PCI (MV-PCI) strategy was defined as
PCI in which lesions in the culprit vessel as well as 1
nonculprit vessel lesion were treated. All interventions
should have had taken place within the same
procedure.
• The staged PCI strategy was defined as PCI confined
to culprit vessel lesions only, after which 1 lesions in
nonculprit vessel were treated during planned
secondary procedures.
1
Flaar P.J et al, et al. Culprit Vessel Only Versus Multivessel and Staged Percutaneous Coronary Intervention for
Multivessel Disease in Patients Presenting With ST-Segment Elevation Myocardial Infarction. JACC 2011
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ACUTE STEMI WITH

MULTIPLE CULPRIT VESSELS

Speaker name: Vickry H. Wahidji MD

 I have the following potential conflicts of interest to report:

 I do not have any potential conflict of interest

• Acute myocardial infarction (AMI) involving two or

2nd Coronary Angiography

• It is relatively common to encounter two occluded

• Several factors, such as multi vessel spasm7, state of

The 3 PCI strategies for STEMI patients with MVD:

The Patophysiology of cigarette smoking and Cardiovascular diseases

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