From Syncope to Shock: Emergency PCI Case Report in Multivessel Acute Coronary Occlusion

Multivessel acute total occlusion (ATO) represents an exceedingly rare and catastrophic form of acute myocardial infarction (MI), characterized by complete cessation of coronary flow in multiple epicardial vessels and profound ischemic burden. Such extensive coronary involvement often precipitates cardiogenic shock and carries exceptionally high mortality. This case report describes a 51-year-old male who presented with syncope and persistent chest pain following vigorous exertion. On admission, electrocardiography indicated acute anteroseptal and high lateral wall MI, and echocardiography revealed left ventricular dysfunction (LVEF 36%) with regional wall motion abnormalities. Coronary angiography demonstrated multivessel ATO involving proximal-mid left anterior descending (LAD) subtotal occlusion (TIMI 0-1), proximal left circumflex (LCx) total occlusion (TIMI 0), and mid right coronary artery (RCA) occlusion (TIMI 0). The patient developed cardiogenic shock requiring norepinephrine support. Guided by contemporary recommendations, culprit-only percutaneous coronary intervention (PCI) of the LCx was performed via right radial access, with intracoronary administration of a glycoprotein IIb/IIIa inhibitor (Prolifiban). A 2.75 × 23 mm drug-eluting stent was successfully implanted, achieving full reperfusion (TIMI 3) and rapid hemodynamic recovery. Subsequent staged LAD intervention was also successful. Post-procedural outcomes were favorable, with no recurrent syncope or chest pain and improved left ventricular ejection fraction to 46% at 30 days. This case highlights the clinical complexity and therapeutic dilemma of multivessel ATO presenting with syncope and cardiogenic shock. It underscores the importance of selective culprit-lesion revascularization, radial access, and adjunctive pharmacotherapy in achieving stabilization and favorable outcomes in this high-risk setting.