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(Circulation. 2000;101:214.)
© 2000 American Heart Association, Inc.

Images in Cardiovascular Medicine

IIb/IIIa Receptor Antagonists for Failed Rescue Angioplasty

Eelko Ronner, MD; L. Ron van der Wieken, MD; Ton S. Slagboom, MD; Gert-Jan Laarman, MD, PhD; Ferdinand Kiemeneij, MD, PhD

From Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands.

Correspondence to Eelko Ronner, Onze Lieve Vrouwe Gasthuis, Eerste Oosterparkstraat 279, PO Box 95500, 1090 HM Amsterdam, Netherlands.

A46-year-old woman presented with 3 hours of severe chest pain, sweating, and nausea. The cardiac history included a small anterior wall infarction 8 years earlier, a slightly impaired left ventricle, and a successful balloon angioplasty of the left anterior descending and right coronary artery 11 months before presentation. Systolic blood pressure was 85 mm Hg, but further physical examination was normal. The ECG demonstrated an acute inferior wall infarction with extension to the right precordial leads without rhythm or conduction abnormalities.

The patient was included in the HIT-4 trial, in which heparin was compared with hirudin in combination with streptokinase for acute myocardial infarction.

Treatment per protocol was started with streptokinase 1.5 million IU in 60 minutes, aspirin 300 mg, and heparin 12 500 IU SC. No signs of reperfusion were seen; sinus bradycardia developed, blood pressure was unchanged, and diaphoresis was noted. Diuresis was absent.

Thirty minutes after streptokinase infusion, protocol angiography revealed a dominant right coronary artery with TIMI 2 flow (Thrombolysis in Myocardial Infarction flow grade 2 denotes partial perfusion) and a thrombus measuring 10 mm in length (Figure 1). Because of persisting pain, hypotension, and bradycardia with hampered coronary flow, it was decided to perform balloon angioplasty.

View larger version (158K): [in this window] [in a new window]   Figure 1. Before balloon angioplasty. Acute inferior myocardial infarction with hampered flow and cardiogenic shock. A thrombus is seen in middle of right coronary artery (arrow).

After balloon inflation, cardiogenic shock worsened, despite intra-aortic balloon pumping and inotropics. Total AV block developed, and shortly thereafter, ventricular fibrillation. Angiography showed that . . . [Full Text of this Article]

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