CASE PRESENTATION
A 59-year-old male presented to the emergency department of a local
general hospital with inferior ST-elevated myocardial infarction
(STEMI). The patient had no previous medical history. His vital
parameters were stable. After the administration of 300 mg of aspirin
and 180 mg of ticagrelor loading dose, eptifibatide infusion was
commenced in combination with unfractionated heparin. Emergency
angiography revealed severe coronary artery disease (CAD) including long
segment disease in mid and distal right coronary artery (RCA), as well
as long segment stenosis in the proximal left anterior descending (LAD)
artery including ostium of the first diagonal artery. Consecutively, the
patient underwent an attempt of PCI to mid and distal RCA, but with
suboptimal result due to extensive calcification. Transthoracic
echocardiography (TTE) demonstrated a normal-sized left ventricle with a
mild systolic impairment. After a 60-mg loading dose of prasugrel, DAPT
with aspirin and a 10-mg daily maintenance dose of prasugrel was
commenced. The patient was transferred to our tertiary cardiothoracic
surgical center for urgent CABG due to the unsuccessful PCI.
At the admission, he remained stable. Troponin I was 625 ng/L and other
blood tests were unremarkable, including platelet count (367 10^9/L).
Four days after discontinuation of prasugrel, a preoperative TEG
PlateletMapping (Haemonetics, Braintree, MA) was performed and
ADP-induced platelet aggregation test detected a complete platelet
function recovery with maximal platelet aggregation and normal maximum
amplitude on TEG (Fig. 1). Therefore, decision was made to proceed with
an urgent off-pump CABG which included LIMA-LAD, long saphenous vein to
the first diagonal artery and to the posterior descending artery
anastomoses. Perioperative blood loss was minimal and no cell salvage or
blood product transfusion was required. A loading dose of aspirin (300
mg) was administered within the first 6–24 hours after the surgery and
DAPT including 75 mg of both aspirin and clopidogrel was started on the
first postoperative day. Postoperative recovery was uneventful and the
patient was discharged on the 5th postoperative day
and remained well during a 6-month follow-up. Informed consent and
patient’s permission were obtained to report this case.