Not all STEMI cases are straightforward and interventional complexities are common, require experienced operators, and interventions are often nuanced and challenging.

In this case, the ECG suggested the coronary anatomy accurately predicted the infarct artery and myocardial zone supplied. However, the complexity of the coronary atherosclerosis and the challenge of using direct PCI to manage this case was not expected. In this patient, complex coronary aneurysms led to significant intraluminal thrombosis and distal embolization. An experienced operator made difficult technical and pharmacologic decisions to achieve an optimal outcome without complications.

The management of the persistent complete heart block complicated the treatment of the acute infero-posterior ST-elevation MI and generated significant discussion with respect timing and the best use of a semi-permanent pacing system.

Note: This course is eligible for ACPE credit.

• To describe the angiographic features of coronary aneurysms.
• To apply the STEMI clinical guidelines to angiograms that are not typical of STEMI.
• To describe the therapeutic options for patients with persistent heart block in the days following acute inferior STEMI.