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Types of the Wellen’s Syndrome

Illinois Medical District Cath Conference

Anish Shah, MD/MS
Marianna Sargsyan, MD
Adhir Shroff, MD/MPH

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History

  • Ms. LB is a 59 year old woman
  • She presents with chest pain overnight - worsening, exertional, and typical
  • Past medical history of hypertension, hyperlipidemia, diabetes
  • Former drug use, and active smoker
  • Additional history of untreated HCV, bipolar disorder
  • In the emergency room, initial ECG shows concerning TWI in anterior leads
  • Cardiology consulted for potential cath lab activation

Physical

  • HR 95 bpm, BP 144/90, 95% on room air
  • Thin woman in acute distress, alert and oriented
  • +2 radial and +2 femoral pulse bilaterally
  • Normal rate, regular rhythm
  • S1/S2 with soft systolic murmur
  • Initial ECG with Wellen's syndrome type 2, and subsequent ECG with Wellen's type 1
  • Bedside echocardiography with anterolateral wall hypokinesis, LVEF of 25%
2 / 12
knitr::include_graphics("lb-ecg-first.png")

knitr::include_graphics("lb-ecg-second.png")

Initial ECG and subsequent ECG approximately 30 minutes apart in setting of persistent chest pain.

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  • Right radial artery with vasospasm
  • Left radial artery used for 6F introducer sheath with US
  • 5F JR-4 used for RCA selective angiography
knitr::include_graphics("lb-01-rca.gif")

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  • Exchanged for 5F JL-3.5 over wire
  • LCA selective angiography performed in multiple views
knitr::include_graphics("lb-02-spider.gif")

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  • Ostial LAD deemed culprit lesion
  • Started on IV cangrelor and heparin boluses
  • Exchanged to 6F XB-3.5 guide catheter
  • BMW wire positioned in distal D1 artery
  • Pilot 50 advanced to distal LAD
knitr::include_graphics("lb-03-wire-lad-d1.gif")

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  • Initial angioplasty with 2.5 x 12 mm SC balloon
  • IVUS performed showing 360 degree of calcium in ostial LAD
knitr::include_graphics("lb-ivus.gif")

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  • Proceeded with IVL
  • 6F guideliner advanced for support
  • 4.0 x 12 mm Shockwave balloon positioned
  • 1 cycle at 4 atm and 4 cycles at 6 atm performed 
knitr::include_graphics("lb-04-first-balloon.gif")

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  • Predilated lesion to 12 atm with NC balloon
knitr::include_graphics("lb-05-stent-position.gif")

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  • 4.0 x 18 mm DES deployed at 14 atm
  • Post dilated with 4.5 mm NC balloon 
knitr::include_graphics("lb-06-stent-deployed.gif")

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  • Diagonal branch mildly pinched but with TIMI-3 flow
  • Confirmed TIMI-3 flow in LAD
  • No evidence of dissection, perforation, or distal embolization
knitr::include_graphics("lb-08-final.gif")

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Conclusion

The highly calcific nature of the ostial LAD benefited from IVL in the setting of a STEMI. The patient did well afterwards, with no further chest pain. Formal echocardiography with anterolateral hypokinesis and LVEF of 25%. Discharged with cardiac rehab, beta blockade, RAAS inhibition.

12 / 12

History

  • Ms. LB is a 59 year old woman
  • She presents with chest pain overnight - worsening, exertional, and typical
  • Past medical history of hypertension, hyperlipidemia, diabetes
  • Former drug use, and active smoker
  • Additional history of untreated HCV, bipolar disorder
  • In the emergency room, initial ECG shows concerning TWI in anterior leads
  • Cardiology consulted for potential cath lab activation

Physical

  • HR 95 bpm, BP 144/90, 95% on room air
  • Thin woman in acute distress, alert and oriented
  • +2 radial and +2 femoral pulse bilaterally
  • Normal rate, regular rhythm
  • S1/S2 with soft systolic murmur
  • Initial ECG with Wellen's syndrome type 2, and subsequent ECG with Wellen's type 1
  • Bedside echocardiography with anterolateral wall hypokinesis, LVEF of 25%
2 / 12
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