Miss Chow

Miss Chow is a 63 year old woman with unremarkable past health.She was admitted this time for STEMI with cardiogenic shock.She presented with chest discomfort, SOB and orthopnea.ECG showed STE aVR and V1, ST depression V5-6, TwI V4-6. She was taken over to CCU for STEMI with APO.She was intubated and sent to cath lab directly for primary PCI.

CXR showed congested lung fields.Bedside V scan showed impaired LV systolic function, EF ~ 20%, global hypokinesia, mild MR/TR, no pericardial effusion. 

LMS: dLMS 50% (MLA 5-6mm2)LAD: oLAD >5mm2, pLAD 90%, mLAD 30-40%, dLAD 30%, Big D1 90%LCx: oLCx >5mm2, pLCx 99% subtotal, dLCx 80%RCA: mRCA CTOconclusion: severe LMS + TVDp-dLCX stented with 2.25x23 & 3.0x23Kissing inflation done to LCX/OM1 bifurcation with 3.25 & 2.0 balloon  pLAD stented with 2.75/38. But noted slow flow and BP drop, then cardiac arrest 13 + 8 +8 min, likely due to D1 closure. IABP implanted.Kissing inflation to pLAD/D1 done with 2.5&1.5 balloon. 2.0 POBA to D1.

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Proceeded to stage PCI the next day as the patient was still in cardiogenic shock not responding to double inotropes and IABPECMO was inserted before procedure. 
Coro showed distal LM 80% lesion with hazziness, ostial LCx and ostial LAD 90% lesion, calcifiedBoth LAD and LCX were wired first. IVUS showed under expansion of stent and severe stenosis over distal LM, ostial LCx and LAD.LAD was predilated with accuforce 3.0 x 12.LCx was predilated with Raiden 3.0 x 10.LAD balloon was kept. LCx was stented with Xience 3.5 x 12.Crushed with NC 3.0 x 12 AccuforceLM to LAD stented with Xience 3.5 x 18PSHP to LM to LAD stent done with 3.5 x 15 NC trek
Noted closure of diagonalDiagonal was re wired with Fielder FCpredilated with 1.0 and 1.5 balloon But flow was still not restored. Xience 2.0 x 18 could be delivered.Coreflex 2.0 x 16 was successfully delivered.TAP was doneLCx was rewired and predilated with 1.5 RyureiKissing done by 3.5 x 10 Sapphire 3 and NC Trek 3.5 x 8POT by accuforce 4.0 x 6 at 18 ATMGood angiographic and IVUS result was achieved. 
Conclusions: Successful PCI to LM, LAD, D1 and LCx with DES x 2. 
Echo showed improving EF to 30% 4 days later.ECMO and IABP were improved.The patient was extubated and transferred to general ward.She was fit for discharge after a month of cardiac rehabilitation. 
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In this case, we saw a difficult scenario of TVD and LM disease, together with unstable hemodynamics. After primary PCI, the patient was still in cardiogenic shock despite inotropes and IABP.Therefore, we proceeded to stage PCI with ECMO support to help restore the heart function. There were 2 bifurcation lesions to treat in this case: the LM/LAD/LCX & the LAD/D1 lesions.We used 2 different strategies to deal them respectively: Mini Crush for the LM & TAP for the LAD/D1 lesions respectively. The choice of strategy depends on the anatomy of lesions in order to achieve good angiographic result.