CORONARY - Bifurcation/Left Main Diseases and Intervention
The Poseidon Trident
Abdul Ariff1, Shaiful Azmi Yahaya1
National Heart Institute, Malaysia1,
Patient initials or Identifier Number
Relevant Clinical History and Physical Exam
A 73-year-old man, with underlying hypertension, dyslipidemia & chronic kidney disease, admitted to peripheral hospital for NSTEMI with Cardiogenic Shock, was then transferred to us for inpatient coronary angiogram once he was stable & extubated. Angiogram showed tight stenosis distal left main (Medina 1, 1, 1) with high OM1, and normal RCA. IABP was inserted & referred to surgeon for urgent CABG, however, was declined due to poor EF 23%. He was then planned for high risk PCI.
Relevant Test Results Prior to Catheterization
Echocardiogram, 1st October 2020:EF 23%, global severe hypokinesia, dilated LV, TAPSE 2cm, mild MR
Viability Study, 6th October 2020:Large area of transmural infarction at distal LAD.Moderate area of non-transmural infarction at proximal-mid LAD and RCA/LCx territories.
Relevant Catheterization Findings
This is a complex & high risk PCI, hence, IABP support is instrumental. The tight lesion were opened well with NC balloon, thus, eliminating the use of atherectomy. The aim is to keep thing simple & reduce ischemic time, so initially was planned for provisional LM-LAD stenting. However, in view of fear ofLCx occlusion, we decided to stent across LCx via reverse crush technique. Difficulty was encountered in passing down the balloon to LCx. Possibilities include non-coaxial catheter, wire entanglement & suboptimal stent expansion. The problem solved with EBU 3.5, which provided better support & coaxiality. The use of intracoronary imaging will provide us with added value.