Intracoronary fibrinolysis as a bailout strategy for massive thrombotic catastrophe. Case resolution

CASE RESOLUTION Intensive intracoronary vasodilators, including intracoronary nitrates and adenosine also proved ineffective. A total of 0.3 mg/Kg of enoxaparin were given during the procedure. Finally, intracoronary fibrinolysis was attempted with the administration of tenecteplase (8000 IU). About 10 minutes after instillation, recanalization was not possible, and the procedure was terminated. A type 4a myocardial infarction was diagnosed and an additional 48-hour course of eptifibatide was administered (bolus of 180 µg/Kg followed by the perfusion of 2 µg/Kg/min) (figure 1). Figure 1. Angiography after instilling 8000 IU of tenecteplase with no repermeabilization; then, the procedure was terminated. After the procedure, the patient complained of chest pain and an ST-segment elevation was seen. Pain was successfully controlled within the first 12 hours. The troponin peak levels were 113 ng/mL. A triple antithrombotic strategy with aspirin, ticagrelor, and full-dose enoxaparin was maintained during hospitalization (1 week). Serial echocardiographic evaluation revealed the presence of mild left ventricular dysfunction with severe inferior wall hypokinesis. Right ventricular systolic function was depressed (a 12 mm tricuspid annular plane systolic excursion [TAPSE]). The patient was discharged on dual antiplatelet therapy. The patient remained asymptomatic at 5-month follow-up. Cardiac magnetic resonance imaging (figure 2) showed a normal-sized right ventricle with preserved...