CORONARY - Complex and Higher Risk Procedures for Indicated Patients (CHIP)
The Death Combo of Triple CTO and EF 15%
Ka Hei Ho1, Ho Lam1
Tuen Mun Hospital, Hong Kong, China1,
A 72-year-old gentleman with good past health was admitted to us for acute coronary syndrome with acute pulmonary edema. He complained of chest pain with sweating 2 days ago, associated with shortness of breath. Upon admission, he was dyspneic requiring oxygen supplement and was also tachycardic. Blood pressure was normal.
ECG showed sinus tachycardia, subtle ST elevation over anterior leads. CXR showed a congested lung field. Troponin I was raised to 5700.
Echocardiogram showed severely impaired left ventricular systolic function with EF 15%, akinetic anterior wall and severely hypokinetic inferior wall.
MRI heart showed evidence of old myocardial infarction along with three coronary artery territories with total of 9 segments demonstrating > 50% degree of transmural LGE.
Coronary angiogram showed triple total occlusion.
Left main: Normal
LAD: mid LAD aneurysm then total occlusion.No collateral supply.
LCx: proximal LCx 80% stenosis, mid LCx total occlusion with retrograde from left system
RCA: proximal RCA 99% stenosis, followed by a short normal segment, then total occlusion, collateral supply from both left and right system Coro- leftside.wmv coro- right side.wmv
In view of triple CTO with poor LVEF, we consulted cardiothoracic surgeon for CABG, however he was considered not benefit from CABG and therefore we proceeded to Impella supported PCI.
PCI- LCx fina.wmv PCI- LAD final.wmv PCI-RCA final.wmv
Impella was implanted over left femoral artery and PCI was performed via right femoral artery.
PCI to LAD
EBU 3.5 7F engaged left main artery. Runthrough NS was able to wire through the total occlusion under Caravel support. Predilatation with 1.5mm balloon and 2.0mm NC balloon, IVUS showed distal severe disease with no good landing zone, therefore we decided to land at mid-LAD normal segment. Stenting with a 2.2/530 (Orsiro) stent. Post-dilatation with 3.0mm NC balloon at p-mLAD then 3.5mm NC balloon at proximal stent edge.
PCI to LCx
Sion was unable to wire through lesion. Finally successful wiring with XT-A. Predilatation with 1.5mm balloon. Stenting with 2.25/40 and 3.0/35 (Orsiro) stent. PSHP with 3.0mm and 3.5mm NC balloon.
PCI to RCA
Initially planned for contralateral injection, however, Terumo sheath was unstable to negotiate through the bend in left iliac artery through Impella sheath. JR 3.5 engaged RCA. Unable to wire through with XT-R and Gaia Second. Gaia Third went into subintimal space. Failed parallel wire technique. Finally able to wire through with XT-A. Difficult passage of eve 0.85mm balloon at mRCA, finally able to negotiate through after multiple balloon dilatations. Stenting with 3.0/40, 3.0/40 and 3.5/18 (Orsiro) from distal RCA up to ostial RCA. PSHP with 3.0mm and 3.5mm NC.
We described a case of Impella supported PCI case with triple CTO (actually four CTO, if PDA CTO was included) and severely impaired LVEF. Haemodynamic support is of paramount importance in high-risk PCI case. We achieved full revascularization and patient successfully weaned off Impella support at the end of procedure. With advances in PCI technique and haemodynamic support tools, we are able to offer high risk surgical candidate a chance to revascularise, recover and survive.