Lots of interesting abstracts and cases were submitted for TCTAP 2022. Below are the accepted ones after a thorough review by our official reviewers. Don’t miss the opportunity to expand your knowledge and interact with authors as well as virtual participants by sharing your opinion in the comment section!

TCTAP C-006

Emergency Complex Left Main Bifurcation PCI in a Case of NSTEMI With Pulmonary Edema and Cardiogenic Shock: Should We Strive for Angiographic Perfection in Unfavorable Anatomy?

By Vipin Thomachan, Ali Shamsi, Ahmed Siddiqui, Gohar Jamil

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Presenter

Vipin Thomachan

Authors

Vipin Thomachan¹, Ali Shamsi¹, Ahmed Siddiqui¹, Gohar Jamil¹

Affiliation

Tawam Hospital, United Arab Emirates¹,

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TCTAP C-006

CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS)

Emergency Complex Left Main Bifurcation PCI in a Case of NSTEMI With Pulmonary Edema and Cardiogenic Shock: Should We Strive for Angiographic Perfection in Unfavorable Anatomy?

Vipin Thomachan¹, Ali Shamsi¹, Ahmed Siddiqui¹, Gohar Jamil¹

Tawam Hospital, United Arab Emirates¹,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

This 77-year-old male patient presented to ED with complaints of dyspnea,cough and chest discomfort of 3 days duration which worsened on the day ofadmission. He has a known case of hypertension, diabetes, dyslipidemia,bronchial asthma and CAD with history of coronary intervention in the remotepast, the details of which were not available.
He was tachypneic with respiratory rate 38/min, SpO2 86%, HR 111 bpm, BP91/61 mm Hg.
He had bilateral rhonchi with crepitation and muffled heart sounds.

Relevant Test Results Prior to Catheterization

ECG showed sinus tachycardia with diffuse ST-Tchanges in inferolateral leads and poor R progression in anterior leads.
Blood investigations revealed acute kidney injury on CKD, elevated cardiactroponin and NT-proBNP.
Sodium 136mmol/L
Potassium 3.7mmol/L
Creatinine 187micromol /L
Urea 12.8mmol/L
eGFR 33mL/min/1.73m2
Hb 12.2gm/dL
Troponin 9.43micrg/L
NT-pro BNP 10388 ng/L
Echo: mid to distal septum, anterior wall and apex akinetic. Apical inferiorand posterolateral wall hypokinetic.

Relevant Catheterization Findings

LMCA: Tapering of distal left main with 60% stenosis.
LAD:
Severe (99%) stenosis of ostioproximal LAD.
Severely calcified vessel throughout.
Severe diffuse tubular stenosis throughout with total occlusion distally.
Diagonals-severe diffuse disease.
LCX:
Severe (95%)ostial stenosis
Moderate to severe stenosis of proximal segment at a sharp bend.
Moderate to severe diffuse tubular stenosis of distal LCX, OM1 and OM2.
RCA: Patent stent in proximal RCA.
Moderate diffuse disease throughout; calcified vessel.

Interventional Management

Procedural Step

PCI - Left main to LAD(POBA&DEB) and left main to LCX with DES:During catheterization, patient developed VT and cardiogenic shock. Afterimmediate cardioversion, an IABP was inserted from right femoral side as leftfemoral arterial puncture failed. After IABP insertion, we succeeded in left femoral access forintervention. Patient was intubated. LCA cannulated with 6F XB3.0 guiding catheter, LAD wired with BMW0.014"; Sion blue ES into LCX; difficult wiring due to heavy calcificationand previous stents.Left main-LAD serially dilated with 2.0x12 mm, 2.5x12 mm and 2.75x12 mm SCballoons at 14-16 atm.Mid-distal LAD serially dilated with 2.0x12, 2.5x12 mm SC balloons.Ostioproximal LAD further dilated with a DEB 2.75x25 mm Dior at 12 atm for60 sec.Flow established in LAD& diagonals up to apical total occlusion. Proximal LCX serially dilated with 2.0x12, 2.5x12 SC balloons.Left main- ostial LCX serially dilated with 2.0x12,2.5x12, 2.75x12 mm SCballoons and 3.0x15 NC balloon. Various stents 3.5x15 mm Xience, 3.5x18 mm, 3.5x20 mm Synergy failed to trackthrough ostial LCX due to tortuosity and calcium; further dilated with NCballoon.Then with Guidezilla support stenting of distal left main to proximal LCXwas done with a DES, 3.0x18 mm Synergy. Postdilated with 3.5x15 mm NCballoon. Good result in LCX with TIMI 3 flow. Patient's hemodynamicsgradually improved, and we could stop dopamine infusion.Norepinephrine on flow at reduced dose. IABP setting 1:1 with augmented BP120 mmHg. Patient was shifted to ICU.

Case Summary

This 76-year-old gentleman who presented with ACS-NSTEMI and pulmonaryedema and impending shock developed VT and cardiogenic shock during CAG. He hadvery unfavorable coronary anatomy with left main bifurcationstenosis, severe diffuse disease with calcification and multiple stentsdeployed in the remote past. We did not strive for angiographic perfection as the main aim was tosave the patient with whatever revascularization possible. Ultimately, hewas revived and resuscitated with cardioversion, IABP,vasopressors and crucial revascularization.Patienthad a protracted course in the hospital with multiorgan failure but gotdischarged after 2 weeks of hospital stay and is on regular follow upnow.

Case

TCTAP C-006