An 82 years old lady with co-morbids of Type 2 diabetes mellitus, hypertension, chronic kidney disease Stage III B presented with chest pain on exertion and reduced effort tolerance for 2 weeks. Angioplasty (DES) to the mid Right Coronary Artery was done in 2018. She was treated as Non ST elevation Myocardial Infarction. Physical examination revealed bilateral base fine end inspiratory crepitations with minimal pitting pedal oedema. Cardiac auscultation revealed dual rhythm with no murmur.
Chest X-ray revealed pulmonary congestion with minimal left pleural effusion. NT Pro-BNP - 3250, Troponin T - 1245. Echocardiography showed an ejection fraction of 38 % with comparatively normal right ventricular function. There was mild mitral regurgitation. ECG showed T inversions over V2- V6.
Left Main Stem - severe distal Left Main Stem diseaseLeft Anterior Descending - Severe ostial to mid disease calcified lesion with Chronic Total Occlusion of distal LeftAnterior DescendingLeft Circumflex - Severe ostial calcified diseaseRight Coronary Artery - Patent stent with mild stenosis over proximal Right Coronary Artery
CABG was offered in view of high Syntax score (38) and concomitant high bleeding risk but the patient opted for high risk PCI.
Coronary intervention of calcified bifurcation disease involving the left main stem in a high bleeding risk patient is truly a challenge. Rotational atherectomy is an established technique for effective modification of these lesions prior to conventional angioplasty and stent implantation. The combination of Rotablation and DES in calcified coronary artery lesions has a very good angiographic result with satisfactory clinical outcome. DK crush has been proven to be the 'real deal' in bifurcation lesions.