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OBJECTIVECarotid artery stenting for heavily calcified lesions is challenging for interventionists. They had dense calcifications at the lesions, stenosis rates of 95% (near occlusion) and 86% according to the North American Symptomatic Carotid Endarterectomy Trial criteria, and calcification arcs of 270° and 360°, respectively.
Both of these features make inferior + RV MI by far the most likely ( Pseudoanteroseptal MI is another name for this ) There is also sinus bradycardia and t he patient is in shock with hypotension. A narrow complex bradycardia without any P-waves is also likely to respond to atropine, as it may be a junctional rhythm.
The ECG shows sinus bradycardia but is otherwise normal. The LAD has diffuse disease with a few areas of moderate stenosis but no flow-limiting lesions. On the combined basis of angiography and IVUS, this patient received stents to his mid RCA, proximal PDA, and OM. OM before and after, arrow indicating stented region.
A prehospital “STEMI” activation was called on a 75 year old male ( Patient 1 ) with a history of hyperlipidemia and LAD and Cx OMI with stent placement. Angiography revealed a 30% nonobstructive stenosis of the mid LAD. He had multiple episodes of bradycardia and nonsustained ventricular tachycardia. It was stented.
Soon afterward, the patient’s symptoms return along with lightheadedness, bradycardia, and hypotension. The patient has also developed sinus bradycardia, which may result from right coronary artery ischemia to the SA node. Two stents were placed with resultant TIMI 3 flow.
This middle aged male with h/o GERD but also h/o stents presented to the ED with chest pain. The computer called "Sinus Bradycardia" only (implying that everything else is normal. The overreading Cardiologist called it only "Sinus Bradycardia" with no other findings. The rhythm in Figure-1 is sinus bradycardia and arrhythmia.
60-something with h/o MI and stents presented with chest pain radiating to the back and nausea/vomiting. The cath lab was activated: Result: Thrombotic 95% stenosis at the ostium of a small LPL2 with 70% stenosis at the LPL2/LPDA bifurcation in the distal/AV groove Cx Tubular 70% stenosis in the mid-circumflex. (In
Angiogram showed a critical LAD thrombotic stenosis. The patient went to cath and had a distal LAD 99% stenosis with thrombus and TIMI-2 flow. After many hours, the decided that it was appropriate to do an angiogram and they found a distal LAD occlusion which was opened and stented. Why bradycardia? It was stented.
Here is his previous ECG: This was my interpretation of the first ECG: Sinus bradycardia with less than 1mm ST elevation in V4-V6, elevated compared to the previous ECG, suggestive of lateral MI. There is evidence that de Winter's T-waves really represent a tiny trickle of blood through the thrombotic stenosis. Both were stented.
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