An 82-year-old male with history of PCI in LAD was sent to our hospital for severe chest pain which was experienced 10 days before and subsequent breathing difficulty. His blood pressure was 125/75 mmHg, heart rate was 90 bpm, saturation was 92% on 10 L/min O2 by mask. Wheezes were heard on chest auscultation and the chest X-ray showed bilateral pulmonary edema (Figure 1).

His ECG showed slight ST elevation over aVR lead and diffuse slight depression over precordial leads (Figure 2). Bedside echocardiography revealed globally decreased LV contraction with EF of 25% and moderate MR. . Because the blood test showed elevated troponin I of 6.36 ng/ml and NT-proBNP of 5300 pg/ml, he was transferred to catheterization laboratory suspected with acute hear failure due to recent myocardial infarction.

Coronary angiogram was demonstrated with 4 Fr diagnostic catheter via the right radial artery, which showed 90% stenosis in ostial LAD,99% stenosis in ostial LCX, and significant disease in the mid segment of LAD with hypoplastic RCA (Figure 3,4).

Because his saturation gradually went down under 85% and blood pressure also fell under 80/60 mmHg during coronary angiogram, he was put on Noninvasive Positive Pressure Ventilation (NPPV) and Percutaneous Left Ventricular Assist Device (Impella) was inserted via right femoral artery. After the initiation of mechanical circulatory support, 6Fr BL (backup left) catheter was engaged to LCA, and both LAD and LCX were wired. After both ostial LCX and ostial LAD (- LMT) were pre-dilated with a 3.0 x 15 mm noncompliant balloon, a 3.0 x 8 mm drug eluting stent was deployed in proximal LCX leaving a chance of treating mid-proximal LAD and LMT with stents after the patient’s overall condition was stabilized (Figure 5). After the ICU admission, Impella was removed on the 2^nd post-procedural day, and he did not require NPPV after the next day. The 2^nd stage PCI was performed on the 5^thday.  Because no significant stenosis was found in proximal LAD and LMT on coronary angiogram and IVUS (Figure 6), only the mid-segment of LAD was treated using 3.0 x 15 mm noncompliant balloon for pre-dilation and 3.0 x 15 mm drug eluting stent(Figure 7). The patient was discharged to home on the 15^th day with full social and ambulatory ability.

By the rapid introduction of Impella, unnecessary intubation and aggressive complex procedure for the elderly patient was avoided, even with the challenging clinical situation. This powerful device may leave physicians a good margin to discuss about the better treatment options.