CONGRESS ABSTRACT

A 76 years old men presented to the Emergency Department with typical chest pain. Past medical history included post-ischemic dilatated cardiomyopathy not revascularized in diffuse atherosclerotic aneurysmatic coronary artery disease, CRT-D for secondary prevention, permanent atrial fibrillation. During the stay in ED, the patient experienced a syncopal episode. CRT-D interrogation revealed an episode of ventricular tachycardia terminated by single DC-shock. Subsequent ECG showed paced-rhythm, with negative Sgarbossa-Smith-modified criteria. Blood tests indicated elevation of TnI with a typical rise-and-fall pattern. Echo showed a dilated left ventricle (EF 40%) due to akinesia of the basal inferior wall segments. Coronary angiography identified diffuse aneurysmatic and atherosclerotic coronary artery disease with a critical stenosis in the right coronary artery caused by an intraluminal thrombus not crossable (Fig. 1). The patient was started on medical therapy with ASA and continuous infusion of Tirofiban and unfractionated heparin for 48 hours. A follow-up coronary angiography documented partial recanalization of the thrombotic occlusion in the right coronary artery (Fig. 2A). Thromboaspiration with Indigo System CAT RX (Penumbra Inc.) allowed TIMI flow 3 and subsequent PCI-DES were performed due to an underling ulcerated plaque (Fig. 2B). Triple antithrombotic therapy was initiated with warfarin, aspirin, and clopidogrel for 1 month and then clopidogrel plus VKA. In the context of ACS in aneurysmatic coronary artery disease, the optimal therapy is yet to be established. This percutaneous approach of thromboaspiration represents a promising option with high rate of recanalization and low periprocedural complications. The new device Indigo CAT RX is a mechanical power aspiration with a continuous vacuum source to maintain sustained aspiration. it has a large lumen aspiration catheter (5.3Fr) and neuro-tracking technology permit to remove fresh thrombi. This system has low rates of distal embolization and improved myocardial perfusion respect of manual aspiration (CHEETAH Study). Finally, we believe that an initial triple antithrombotic therapy followed by long-term VKA represents the optimal strategy, as it targets the pathophysiological mechanisms of Virchow's triad during ACS in aneurysmatic coronary disease, effectively reducing long-term recurrence. Further research is needed to refine treatment strategies for patients in this clinical setting.