CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 AFRICA 159 but it did not cross the occlusion. Most of the attempts engaged with the collateral diagonal artery. A CTO-guidewire, PROVIA, finally crossed the occlusion through a microcatheter (Fig. 5A). We took the precaution to ensure that it was the true coronary artery lumen by gently injecting through the microcatheter into the distal LAD (Fig. 5B). After small balloon inflations, the flow towards the LAD was restored with a Medina 0-1-0 bifurcation lesion (Fig. 5C). We then proceeded to a provisional single-stent technique. Unfortunately, it was complicated by flow deterioration towards the diagonal branch (Fig. 5D), causing us to end with the proximal optimising technique with a non-compliant balloon (Fig. 5E) and side branch ostium post-dilatation (Fig. 5F), with a good final result (Fig. 6). The patient’s haemodynamic parameters improved and he was gradually weaned off dobutamine. Follow-up echocardiography 72 hours later showed a better LV function with EF of 35%, but with the persistence of wall motion abnormalities. His medical treatment comprised aspirin, clopidogrel, statin, ACE inhibitor and beta-blocker. The patient was assessed six months after he had completed a cardiac rehabilitation programme. The clinical examination was normal and LV function had improved significantly, with an EF of 45%. Discussion Patients under 40 years of age represent 4% of all patients who present with acute myocardial infarction (AMI).3 Acute coronary syndrome may be very brutal in young patients due to lack of the myocardial pre-conditioning phenomenon. Cardiogenic shock complicates nearly five to 10% of AMI with 30 to 40% of cardiogenic shock following AMI occurring at admission4 and 60 to 70% during the course of hospitalisation. It is the leading cause of death after myocardial infarction,5,6 with an unchanged in-hospital mortality rate of around 40 to 50% during the last decade.6 Our patient presented initially with cardiogenic shock, which was stabilised with dobutamine infusion. Due to his age, a diagnosis of myocarditis was raised but rapidly excluded after coronary angiography. Coronary embolism could be discussed as a potential cause, given the double coronary artery occlusion. Coronary embolism is known to cause AMI in the setting of atrioseptal defect with or without aneurysm or atrial fibrillation Fig. 3. Angiogram showing total occlusion of the mid-left circumflex artery (LCX) (A). Total occlusion of the ostium of the mid-left anterior descending coronary artery (LAD) immediately after the first collateral (first diagonal) (B). A B Fig. 4. Successful PCI of the mid-LCX with a drug-eluting stent implantation.
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