Thai female 77 years, risk HT, DLP presented with chest pain 8 hours prior to admission. BP 104/62 mmHg, HR 76 bpm, heart normal s1, s2, no murmur, Lungs clear. EKG showed Normal sinus rhythm, diffused depression c ST elevation at aVR. Echocardiogram showed LVEF 42%, Hypokinesia at anterior, anteroseptal, anterolateral wall, no significant valvular heart disease. Troponin T 30,000 pg/ml.

EKG showed Normal sinus rhythm, diffused depression c ST elevation at aVR.Echocardiogram showed LVEF 42%, Hypokinesia at anterior, anteroseptal, anterolateral wall, no significant valvular heart disease. Troponin T 30,000 pg/ml.CXR showed cardiomegaly c pulmonary congestion

CAG via right femoral approach with JL 3.5/6 Fr, JR 3.5/6 Fr diagnostic catheterRt dominantLM: 95%  stenosis ostial LMLAD: 70% stenosis proximal LADLCx: non significant stenosisRCA: 70% stenosis proximal RCA, give collateral to LCCA

What is the best strategy revascularization for critical ostial LM-LAD? (1. CABG 2. Inserted IABP c PCI LM-LAD, Which technique? 3. PCI LM-LAD, Which technique? 4. Other options? ). PCI LM-LAD via Right femoral approach 7 Fr sheath with Short tip JL 3.5/7 Fr guiding catheter to LCA. Rinato for floating wire technique, Fielder XT try to pass through LM. Fielder XT pass through LM subintima. The patient developed chest discomfort and blood pressure drop 84/47 mmhg. The patient was given inotrope and IABP support. What will you do next? (1. Consult CVT for emergency CABG 2. Reattempt PCI LM-LAD 3. Medication treatment 4.Other options?).  Try reattempt PCILM-LAD. Fielder XT can cross LM through LCx, SC balloon 2.0 x 20 mm inflated LM-LCx upto12 atm, Rinato pass to LM-LCx, move Fielder XT to LAD, Predilate LM-LAD c 2.0 x 20 mm SC balloon upto 12 atm, 3.5 x 20 mm NC balloon upto 24 atm, Everolimus eluting stent 3.5 x 23 mm deployed LM-LAD upto 12 atm, Balloon stent POT LM 18 atm, Rinato rewire to LCx c Crusade, open strut c2.0 x 20 mm SC balloon 12 atm, KBI c 3.5 x 20 mm NC balloon LM-LAD vs 2.0 x20 mm sc balloon LM-LCx upto 14 atm, Final POT c NC 3.5 x 20 mm NC balloon upto18 atm. The final angiogram was acceptable result.

1.Clinical, anatomic, and procedural factors should be taken into account when selecting the mode of revascularization for LM disease2.IABP implantation can provide additional hemodynamic support in high risk PCI, particularly Low SBP, RCA stenosis, severely reduced LVEF3.Floating wire technique can prevent guiding catheter deeply intubating the vessel      4.Severe ostial disease, preload the wire in the guiding catheter will facilitate rapid wiring and catheter disengagement after wiring5.Balloon predication in bifurcation lesion during hemodynamic compromised without protecting the side branch for rapid recoverblood flow, should weight risk of jailed side branch and BP compromise