A 87-year-old man was admitted for shortness of breath. The patient had productive cough with green sputum and no fever two days before admission. He was diagnosed with moderate pneumonia at the outpatient clinic and given oral antibiotics. Progressive dyspnea without fever led to hospitalization on admission.Physical examination revealed nothing noteworthy. After 5 days, the patient had acute respiratory failure and needed endotracheal intubation and ICU transfer. 

MRI brain imagings were limited by poor cooperation, however DWI revealed a fresh right cerebral hemisphere infarct. Right hemisphere cerebral infarction and pneumonia were listed. hs-TnI was 43.2 -> 1080 -> 2987 pg/mL, NT-proBNP 2540 -> 8299.4. Echocardiogram showed significant left ventricular hypokinesis and posterior wall apical and intermediate hyperkinesis. 18% left ventricular EF. There was no cardiac thrombus or pericardial effusion.

A 6F Radifocus introducer sheath was inserted via the right radial artery. Using an Osprey 5F catheter x02 and Advance system, we found: Right dominant coronary system. LMCA: 40% stenosis. LAD: 90% stenosis in segment I, 90% stenosis in segment II. LCx: 80% stenosis in segment I. RCA: 50% stenosis in segment I,subtotal occlusion in RCA II,  collaterals from Septal and LCX with Rentrop 2; 90% stenosis in segment III, 70% stenosis in PLV, 80% stenosis in PDA.
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RCA II–III via right radial artery with 7F catheter.A 6F ASAHI Hyperion AL0.75 7F guiding catheter was engaged in the RCA.A Cosair Pro XS microcatheter with a Fielder XT-A guidewire was initially advanced but could not cross the RCA I lesion. The guidewire was then exchanged for a Gaia First, which successfully crossed the lesion. The Cosair XS microcatheter was advanced across the lesion, intraluminal positioning was confirmed, and the wire was subsequently exchanged for a Sion Blue. Predilatation was performed with a Sapphire 2.0 × 15 mm balloon at 12 atm. Two stents were deployed: a Boston Scientific SYNERGY 2.75 × 48 mm from RCA II–III and a Supraflex Cruz 3.0 × 48 mm from RCA I–II. Post-dilatation with Sapphire II NC balloon 4.0 × 15 mm within the stent (22 atm). Final angiogram demonstrated TIMI 3 flow. Guidewire and guiding catheter were removed. The procedure was completed.Total contrast volume (Visipaque): 200 mL
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Management of non-culprit lesions in the setting of acute myocardial infarction complicated by cardiogenic shock remains controversial. Current evidence generally supports a culprit-only approach in the acute phase, as multivessel intervention may increase procedural time, contrast load, and hemodynamic instability, particularly in the absence of mechanical circulatory support. However, in selected cases with critical non-culprit stenoses, staged or carefully performed intervention may be necessary to optimize clinical outcomes. Our case highlights the importance of individualized decision-making, balancing immediate hemodynamic risk against long-term myocardial salvage.