Sundaravelan

A 43 old male patient who is a diabetic for 7 years and hypertensive for 10 years came with complaints of Chest pain for 1 day duration. Chest pain is retrosternal , burning type with no radiation . It is associated with sweating . No other relevant cardiac complaints On examination, he is conscious, oriented , well built and nourished. Pulse - 64bpm , BP - 130/70 mmhg . CVS :- S1S2 heard with no murmurs. RS : Normal vesicular breath sounds heard with no added sounds.

ECG: Normal sinus rythm with T wave inversions in I,AVL,V2-V6. ECHO: Normalchamber dimensions.Valvesare normal.Midanteroseptum,apical septum,lv apex,apical inferior and apical anterior wallhypokineticMildlv systolic dysfunction ( EF 45%)Hemoglobin – 14.3, TC – 10400,Platelet – 3.56 LakhsCreatinine – 0.9Cholesterol –238HDL           – 38LDL           – 164Triglycerides - 250Troponin I - Elevated  

Mid LAD has thrombus-laden 90% lesion with TIMI II flow. Diagonal 1 is a medium-sized vessel with ostioproximal 90%lesion.(Medina 1,0,1). LCX - OM1 has proximal 50% lesion and it divides into superiorbranch and inferior branch.Superior branch has 50% lesion and inferior branch has 30%lesion. OM2 has proximal 30% lesion. Distal LCX has 99% subtotal occlusion.RCA-Mid RCA has long segment 50% lesion. RV branch has proximal 50-60% lesion.IMPression - CAD -Triple Vessel Disease
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Right radial artery wascannulated and access was secured with 7 French slender sheath.  Using 7 French EBU 3.5, left coronary systemwas selectively engaged. Initially, BMW wire was used to cross the lesion and it was parked indiagonal and Runthrough wire was parked distally in LAD.  Predilatation was done in LAD using 2 x 12 mmSprinter balloon at high pressure. Later, serial predilatation was done in diagonal using 1.5 x 10 mmRyurei balloon and 2 x 20 mm Sprinter balloon at nominal pressure.  Later, diagonal was stented with 2.5 x 24 mmSynergy DES and LAD was stented with 2.75 x 38 mm Synergy DES successfully.  Post dilatation was done in LAD with 3 x 8 mm Accuforce balloon at nominal pressure.  Later, BMW wire was used to re-cross into the diagonal and due to lack of support, BMW wire was exchanged to Whisper wire for extra support.  Using 1 x 10 mm Sapphire balloon was re-crossed into the diagonal and ostial flaring was done.  Patient during the procedure suddenly developed transient bradycardia due to slow flow. Hence temporary pacemaker was placedin IVC as a backup .  In view of thrombus in LAD, 10 ml of intracoronary Tirofiban was given. Later using 2.5 x 10 mm Sapphire NC balloon, post dilationwas done in diagonal at nominal pressure. Final kissing balloon dilatation was done using 2.5 x 10  balloon in diagonal and 2.5 x 12 mm Sapphire NC balloon in LAD simultaneously at 12 atm pressure. Check angio confirmed distal TIMI III.
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