CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 160 AFRICA (AF).7,8 A transoesophageal echocardiogram, which we did not perform in our patient, can identify the probable source in 76.2% of patients, and it is 92% sensitive and 98% accurate for detecting thrombi in the left atrial appendage,9 which is the most common area for thrombus formation, particularly in the setting of AF. However, in our patient, premature atherosclerosis, initiated and promoted by conventional cardiovascular risk factors such as smoking and hypertension, is the most plausible underlying mechanism explaining the coronary artery disease. He denied other drug use, including marijuana, cocaine or methamphetamines, which are classical in this group of the population, as shown in the Partners Young-MI registry.10 When it comes to practical considerations, we learned in the CULPRIT-SHOCK one-year follow-up study11 that culpritlesion-only PCI rather than immediate multivessel PCI leads to fewer drawbacks, especially in terms of renal replacement therapy. However, the mortality rate did not differ significantly between the two groups. In our patient, identification of the culprit vessel was quite challenging. Neither ECG nor echocardiography was very helpful. For this reason, PCI of both vessels in the same procedure was decided on in order to improve the haemodynamics and prognosis. Fig. 6. Successful PCI of the bifurcation of the mid-LAD/ diagonal lesion with a drug-eluting stent implantation. Fig. 5. LAD recanalisation. Occlusion crossing by a PROVIA guidewire through a microcatheter (A). Guidewire in the true lumen, confirmed by injecting gently into the distal tip of the microcatheter (B). Mid-LAD bifurcation lesion (Medina 0-1-0) revealed after small balloon inflation (C). Drug-eluting stent implantation in the mid-LAD with pinching of the diagonal branch ostium (D), motivating a proximal optimising technique (E), side branch re-crossed and balloon angioplasty of the latter (F). A D B E C F
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