Conduction disturbances complicating acute myocardial infarction with persistent ST segment elevation are common, especially those of high degree in previous myocardial infarctions. Do these complications occur in the acute phase, before revascularization, with a poor prognosis immediately justifying myocardial reperfusion as well as the placement of an electro systolic training lead. However, their absence before revascularization to occur in post percutaneous reperfusion by angioplasty with placement of an active stent on the culprit artery, with an increase in the ST elevation, is unprecedented and raises as many questions as possible whereas the Stent in place remains permeable. We report the case of a patient presenting, initially, a 3rd degree atrioventricular block after percutaneous revascularization of an ST + extended anteriorly by angioplasty and placement of an active stent on the anterior interventricular coronary artery permeable after a second post-critical coronary angiography.
Keywords: Anterior Myocardial Infarction; 3rd Degree Atrioventricular Block; Cardiac Arrest; Anterior Interventricular Artery; Electro systolic Training Lead; Fibrinolysis; Coronary Vasospasm
Complete or third degree atrioventricular block (cAVB), defined by the complete and permanent interruption of the transmission of atrial impulses to the ventricles [1,2] is one of the early and relatively frequent complications of myocardial necrosis whose pathophysiology and the course differs depending on the seat of the infarction; indeed, AVB always shows anatomically extensive infarcts, the mortality of which from previous infarctions complicated by AVB remains considerable (> 60%) in the absence of early revascularization [3,4]. This complication, very common before the era of revascularization, occurs in the acute phase. Their early installation in post reperfusion of an extensive anterior myocardial infarction is unprecedented and has a particular aspect which justifies our review. We report a case of complete atrioventricular block occurring initially after Percutaneous Revascularization (PR) of extensive anterior ST + (STEMI-EA).
This is a 51-year-old patient, chronic active smoker and diabetic discovered in hospital, with no history; he presented with an inaugural retrosternal infarction stabbing chest pain, radiating to the upper left limbs for which he consulted at H9 in the Emergency Department of the Ibn Sina University Hospital. On clinical examination, the eupneic patient was unwell with a good hemodynamic state, as for his electrocardiogram at H9, we note a super shift of the ST segment in the extended anterior (Figures 1), from which he benefited from thrombolysis with success criteria, and the next day
a) A biological balance made of troponin> 50,000 ng / ml, potassium at 5mmol / l of a DFG at 66 ml / min / 1.73m2.
b) A trans thoracic Doppler echocardiography which shows lesions of disturbed kinetics.
c) A coronary angiogram showing a sub-occluded lesion of the average anterior interventricular artery (AIV) having undergone angioplasty and placement of an active stent.
The immediate evolution, 2 hours later, was marked by the inaugural onset of a complete AVB and a cardiac arrest by asystole, recovered by resuscitation measure, followed by 4 episodes of cardiac pause with an increase in the elevation of the ST segment in the same territory (Figures 2).
d) He underwent a second coronary angiography showing an active stent in place and permeable, without other culpable lesions.
e) Then the setting of a provisional electro systolic training lead.
The medical consequences are marked by a spontaneous recovery after 48 hours of return to sinus rhythm. The patient is declared discharged, the course of which is marked by the sudden onset of cardiac arrest at home after 3 weeks.
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