SHERIF WAGDY AYAD SRG Ass. Lecturer of cardiology Alexandria ...

• The patient was admitted to CCU & receivedAspirin 150mgclopidogrel loading 600mg followed by 75 mg.LMWHglycoprotein IIB/IIIA inhibitors• After 24 hours no resolution of chest pain or ECGchanges.• The patient was referred to cath. lab.Coronary angiography• LMCA: Normal bifurcating into LAD, LCX.• LAD: Proximal tight lesion with 95% stenosis followedby another mid to distal lesion with 90% stenosis &TIMI II distal flow.• LCX: Proximal atherosclerotic plaque with nosignificant lesion.• RCA: Mid RCA lesion with 50% stenosis & good distalRCA: Mid RCA lesion with 50% stenosis & good distalflow

• After discussion with the patient & the family decisionwas PCI to LAD with 2 BMS .• 6 FR XB 3.5 guiding catheter for engagement ofLMCA was chosen.Before eoeengagement, e t,during test dye‐injection,the manifold fractured due to badmanufacture allowing AIR into the system !!!!!

• Few seconds later, the patient c/o ofsevere chest pain associated with hypotension, hisBP fell to 60/40, bradycardia with HR 35/min.• ECG at this moment showed ST elevation 2mm in theinferior leads.• Immediate control angio for the RCA which revealed

• Patient HR dropped to 20 & he was not responding toatropine & lastly…….. l ARRESTED.• Immediate insertion of temporary pace maker.What to do next ?????

• The decision of auto transfusion of blood from theaorta and manual reinjection under high pressurerepeated several times aiming to disrupt these airbubbles or push them distally was successful & weregained TIMI III flow into RCA.

• Even though TIMI III flow was regained into RCApatient still had severe chest pain & severehypotension• Decision to control angio of the left system wastaken & revealed a bad surprise !!!!

• We tried to do for the LAD the same as we did for theRCA with auotransfusion of blood from aortareinjected manually under high pressure into LAD.• This was repeated several times but still noimprovement of flow into LAD !

• At this point patient BP 80/50.• Chest pain decreased a little.

So now…What do YOU think ??• To stop procedure & give full medical therapy thencontinue procedure 24 HR later?OR• To do PCI of LAD as was planned before Airembolism?• While deciding patient BP dropped again & chestpain increasedPCI LAD.

• Patient BP returned to normal, with normal sinusrhythm, pace maker was shut down but kept in placefor 24 hrs.• Patient had smooth course in CCU & was dischargedhome after 3 days free of symptoms .Take Home Message :• Coronary air embolism is an uncommon complicationduring coronary angiography & PCI.• Mild forms of air embolism may pass uneventful ormay cause transient bradycardia & hypotension.• Severe air embolism is a serious condition that mayend by serious ventricular arrhythmias h (VT/VF),cardiac arrest & death.

• Review of literature for management of coronary airembolism:‐Catheter aspiration.‐ high pressure injection of saline or blood from aortainto culprit artery manually may resolve the condition.• Sometimes with underlying significant coronarystenosis , air bubbles are trapped behind occlusion, soPCI must be done.• ALWAYS double check the system before starting &ensure absence of air by yourself, as at the end thepatient’s life is your responsibility….. ALONE.