Pharmacology > Cases

Sudden Cardiac Death After Drug-Eluting Stent Implantation and Interruption of Antiplatelet Therapy

- Operator: Sang-Sig Cheong, MD

Past History

A fifty-nine year old man was referred to Asan Medical Center for elective lung cancer operation. He had previous history of myocardial infarction (MI) in inferior wall 13 years ago and received conservative medical management without thrombolysis or percutaneous coronary intervention. His coronary risk factor was smoking. Two-month ago, he was admitted to other hospital with unstable angina. Baseline ECG showed pathologic Q wave in inferior leads and left ventricular hypertrophy (Figure 1). Echocardiography revealed a regional wall motion abnormality in right coronary artery (RCA) territory with preserved left ventricular (LV) systolic function (EF = 60%).

Stenting procedure and clinical course

Baseline coronary angiogram showed total occlusion at proximal RCA with bridging collaterals and significant diffuse narrowing at proximal left anterior descending artery (LAD) (Figure 2, Figure 3, Figure 4). After engaging of a 6F Judkin 3.5 guiding catheter via trans-radial approach, a 0.014 inch Ninato wire was introduced into the LAD. After pre-dilatation with a Maverick 3.0 mm x 10 mm up to 3.09 (12 atm), proximal LAD was stented with a 3.0 mm x 33 mm Cypher stent at 13 atm (Figure 5). Post-stenting balloon dilatation was performed with a Maverick 3.0 mm x 10 mm up to 3.23. Final angiogram showed a good result (Figure 6, Figure 7). Concomitant work-up for lung mass in left upper lobe (Figure 8) showed a squamous cell carcinoma in pathologic examination and T2/3N2M0 in staging.

After stenting, he was referred to Asan Medical Center for the treatment of lung cancer. He underwent a 3 week course of pre-operative neo-adjuvant chemotherapy and then was scheduled for curative operation. For elective operation, aspirin and clopidogrel were discontinued 1 week before surgery of lung cancer (57 days after stenting). On the morning of surgery (64 days after stenting), the patient suddenly present with severe chest pain. In an instant, bradycardia and hypotensive shock developed. Twelve-lead ECG revealed an undetermined idio-ventricular rhythm (Figure 9). Despite a prompt cardiac resuscitation, he finally expired.
The cause of sudden cardiac death in this patient was assumed as clinical late stent thrombosis.

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