Coronary cannulation challenge in a patient with tetralogy o
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A 33-year-old heavy smoker male was admitted for inferior ST-elevation myocardial infarction, cardiogenic shock, and complete atrioventricular block. The patient had a history of tetralogy of Fallot (TOF) surgery, but surgical data were not available. We conducted an emergent primary percutaneous coronary intervention (PCI).

They succeeded to cannulate the left main using an Amplatz Left 1.0 guiding catheter, after the failure of many attempts using JL 3.5 and EBU catheters. The right coronary artery (RCA) was also cannulated using the same guiding catheter; the JR 3.5 catheter was not useful. The RCA had an anterior position, close to the midline. We also diagnosed an accessory left anterior descending artery (LAD) originating from the RCA.

The PCI was successfully performed using a drug eluting stent (DES), with a thrombolysis in myocardial infarction III final flow. The computed tomography scan performed 2 days later, showed an anterior position of the RCA and a posterior position of the left main stem (LM) as well as an accessory LAD arising from the RCA with an intra-myocardial course.

Coronary artery anomalies are not exceptional in patients with TOF. The common coronary abnormalities include origin of a canal branch or LAD from the RCA or right sinus and single coronary from the right sinus. In fact, in patients with TOF, there is a counter-clockwise rotation of the aorta (when viewed from above), therefore RCA will be found in an anterior position and LM in a posterior position.

The interventionalist should think about this issue when performing coronary angiography in patients with TOF. Appropriate guiding catheter selection is of an important concern. Sakar et al. reported in a series of anomalous RCA originating from the left Valsalva sinus, that ‘the Left Amplatz is the most appropriate guiding catheter for coronaries taking off along the midline’. The management of this patient was not easy given the cardiogenic shock and electric disorder.