PMC5433551_01
(a) Diffuse ST-segment elevations in both anterior and inferior leads, suggestive of global ischemia. (b) A chronic total occlusion of the mid left anterior descending artery with right to left collaterals. (c) The culprit lesion in the mid right coronary artery with high thrombus burden at site of plaque rupture. (d) Successful implantation of the drug-eluting stent with a good angiographic result.
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Asian male with no prior medical history presented with an anterior ST-segment elevation-ACS and new-onset diabetic ketoacidosis in cardiogenic shock. A 12-lead electrocardiogram revealed ST elevation in anterior and inferior leads with reciprocal ST depression in the lateral and septal leads (see Figure 1a). TIMI grade 5 thrombus in the mid right coronary artery (RCA), the suspected culprit lesion (ACC/AHA Type C; see Figure 1b and c, respectively). The patient's SYNTAX score II was 39. Percutaneous coronary intervention (PCI) was performed via manual aspiration thrombectomy, and subsequently, a 2.5 x 28 mm Boston Scientific Promus Premier (Marlborough, MA) DES was successfully implanted into the culprit vessel (RCA) with a good angiographic result and no complications (see Figure 1d).
(a) The apical 25 mm x 15 mm left ventricular thrombus. (b) Complete dissolution of the preexisting apical left ventricular thrombus after adopting the antithrombotic strategy.
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PCI, the patient was treated with an insulin infusion and an antithrombotic strategy that consisted of aspirin 81 mg daily, ticagrelor 180 mg load, followed by maintenance dose of 90 mg twice daily and a therapeutic dose of subcutaneous enoxaparin (80 mg). Post-PCI 2D-transthoracic echocardiography (2D-TTE) revealed a large apical thrombus with an LV ejection fraction of approximately 25% (see Figure 2a). At 3 months, a 2D-TTE revealed complete interval dissolution of the apical thrombus; however, apical dyskinesia persisted with aneurysmal changes and a substantial improvement in ejection fraction to 37% (see Figure 2b).