Importance of Right Marginal Branch Protection During Primary Angioplasty in Inferior STEMI With Right Ventricular Involvement

J INVASIVE CARDIOL 2019;31(3):E54.

Key words: cardiac imaging, STEMI, mechanical thrombus protection

A 59-year-old male was admitted due to suspicion of myocardial infarction. Left-sided 12-lead electrocardiogram (ECG) revealed ST-elevation in II, III, aVF; inferior ST-segment elevation myocardial infarction with right ventricle (RV) involvement was suspected and right-sided ECG revealed ST elevation in V3R-V6R. Coronary angiography revealed acute occlusion of the proximal right coronary artery (RCA) (Figure 1A). A guidewire was introduced into the distal RCA and manual thrombus aspiration (VMax catheter; Stron Medical) restored normal epicardial blood flow. Significant stenosis of the proximal RCA and a tight ostial stenosis of the right marginal branch (RMB) originating within the prime occlusion site were visualized (Figures 1B and 1C). Another guidewire was introduced into the RMB to mechanically protect its lumen from occlusion with displaced thrombus (Figures 1D and 1E). A 3.5 x 35 mm Xience drug-eluting stent (Abbott) was successfully implanted in the proximal RCA (Figure 1E). Finally, normal blood flow was restored in both the distal RCA and RMB (Figure 1F). Left-sided and right-sided postprocedural ECG revealed complete normalization of ST elevation. Despite persistent proximal RCA occlusion, RV function may recover over time, but the goal is to provide successful and timely restoration of patency in the RMB. This case demonstrates the effectiveness of an extra guidewire in the RMB lumen to provide mechanical protection from displaced thrombus, which frequently occurs during proximal RCA stenting.

From the ¹Medical University of Warsaw, Warsaw, Poland; ²Medical University of Lodz, Lodz, Poland; and 3the Institute of Cardiology, Warsaw, Poland.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 3, 2018.

Address for correspondence: Michał Świerczewski, Institute of Cardiology, Department of Coronary and Structural Heart Diseases, Alpejska 42 Street, 04-628 Warsaw, Poland. Email: swierczewski.michal@yahoo.pl