Acute inferolateral stemi complicated by cardiogenic shock in the setting of first diagnosed multivessel coronary disease in a patient with COVID-19 pneumonia: Management and implications

A 59-year-old man was admitted to our hospital for an acute inferolateral STEMI. His anamnesis was mute. Coronary angiogram showed multivessel disease: critical stenosis of left main at ostium (80%) and in bifurcation with the proximal tract of anterior descending (75%) and circumflex artery (90%). Critical stenosis were also found at first diagonal, intermediate and first obtuse marginal branch (90%). Culprit lesion was the right coronary artery (RCA), stenotic proximally and acutely obstructed at medium tract. Considering the setting of STEMI, the evolution to shock stage C of SCAI classification and that our hospital does not provide cardiac surgery unit onsite we proceeded with percutaneous primary angioplasty of the RCA, preceded by insertion of intra-aortic balloon pump (IABP). An everolimus-eluting stent was implanted. Thus the patient was admitted to CCU. Bedside echo showed a LVEF of 35%. Lung echo showed multiple patchy mid-apical B-lines alternated to spared areas, chest X- ray was normal. Blood tests were not significant. A P2Y12 inhibitor was needed;however due to left multivessel disease involving left main needing urgent intervention with an anatomy not favorable for percutaneous interventions (Syntax 34) a discussion with cardiac surgeons for a prompt procedure of surgical revascularization was planned. Thus P2Y12 inhibitor was omitted and UFH and tirofiban infusion where added to aspirin. Choice of tirofiban was dictated by shortage of cangrelor. Meanwhile the patient had fever (T38 °c) and Covid-19 nasal swab test turned positive. IABP was removed on day 2. This let the patient undergo a CT-scan: despite satisfactory blood gas analyses it showed multiple areas of ground glass at both apices, diffuse septal thickening and a mild consolidative area. Surgery candidacy was therefore put in doubt, deciding to observe the infectious evolution for few days. After two days the case was discussed in an extended Heart Team involving an infectious disease specialist: due to satisfactory respiratory parameters with no need for specific therapy surgery was confirmed. The patient underwent surgical revascularization on day 6 with a LIMA-RIMA y graft bypassing obtuse marginal, intermediate and left anterior descending arteries. He was extubated on day two and on day 3 post surgery he was moved to the ward and the following clinical course was regular. (Table Presented).