A59-year-old woman is referred for pre-operative coronary evaluation prior toplanned mitral valve replacement for symptomatic severe mitral regurgitation. Pastmedical history includes she denies coronary artery disease risk. On examination Cardiac exam reveals alaterally displaced, dynamic PMI and a grade 3/6 high-pitched holosystolicmurmur best heard at the apex with radiation to the left axilla.

ECG: AF without acute ischemic change.CXR:CardiomegalyEchocardiogram: Severe primary (degenerative) mitral regurgitation due to mitral valve prolapses with flail P2 segment (Carpentier Type II), by integrative criteria (EROA ≥0.4 cm²,regurgitant volume ≥60 mL, vena contracta ≥0.7 cm, systolic PV flow reversal,dense triangular CW jet). Baseline ECG: sinus rhythm without acuteischemic change. 

Right Coronary Artery (RCA): Dominance right. Large caliber, no significant stenosis. Angiographically normal with TIMI 3 flow.Left Main (LM): On first contrast injection afterJL engagement, mild ostial contrast staining was observed. On the second injection, there was more pronounced staining with dye hang-up, consistentwith catheter-induced LM dissection with suspectedpropagation toward the LAD/LCX. 

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• Actions: Stopped contrast injections; converted to RFA for stronger guide backup. Wired LAD and LCX in true lumen (confirmed by IVUS).
• Stenting: LM → LAD drug-eluting stent (DES) to seal LM entry; mini-TAP to LCX for ostial coverage.
• Imaging: IVUS pre-PCI confirmed dissection/intimal flap with intramural hematoma extending into proximal LAD/LCX; post-PCI showed good expansion/apposition, no residual entry.
• Final result: TIMI 3 flow in LAD and LCX; LM sealed; no residual flow-limiting dissection.

 



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Iatrogenic LM dissection is rare but rapidly life‑threatening—wire first, inject later.

Access change (RRA → RFA) can be decisive to gain support for equipment delivery in an unstable LM scenario.

IVUS changes management—confirms true lumen and guides stent sizing, expansion, and identification of residual hematoma.

Mini‑TAP provides efficient LCX ostial coverage after LM→LAD stent with minimal metal overlap.

Early Heart Team discussion is essential to balance DAPT and timing of planned MVR.