Case Report: A case of successful treatment of STEMI following intra-coronary thrombolysis and re-transplantation in a heart transplant recipient.

BACKGROUND

The role of the Intracoronary fibrinolysis with distal occlusion (the Marinade technique) in managing refractory no-reflow during ST-segment elevation myocardial infarction in heart transplant recipients remains unknown.

CASE PRESENTATION: We report a case of a 38-year-old heart transplant recipient who presented with anterior ST-segment elevation myocardial infarction caused by total occlusion of the proximal left anterior descending artery. Despite repeated balloon dilations and thrombus aspiration, severe refractory no-reflow persisted and was complicated by ventricular fibrillation cardiac arrest requiring venoarterial-extracorporeal membrane oxygenation (VA-ECMO) support. Rescue intracoronary fibrinolysis using the Marinade technique-consisting of distal balloon occlusion and localized alteplase delivery with a prolonged dwell time-was repeatedly performed, resulting in partial restoration of coronary flow. Additional selective distal intracoronary alteplase administration via aspiration catheter successfully re-established distal coronary perfusion and thereby allowed completion of percutaneous coronary intervention (PCI). A total intracoronary alteplase dose of 25 mg was administered without major bleeding complications, despite concurrent VA-ECMO support. Although ST-segment resolution was limited, chest pain improved and hemodynamic stabilization was achieved, enabling successful redo heart transplantation.

CONCLUSION

This case highlights the potential utility of intracoronary fibrinolysis using the Marinade technique as a bailout strategy for refractory no-reflow during PCI, even in high-risk settings such as heart transplant recipients with advanced microvascular dysfunction.