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.