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TCTAP C-088

High Risk left Main Intervention in an Octogenarian

By Punish Sadana

Presenter

Punish Sadana

Authors

Punish Sadana1

Affiliation

Max Super Specialty Hospital, India1,
View Study Report
TCTAP C-088
Coronary - Complex PCI - Left main

High Risk left Main Intervention in an Octogenarian

Punish Sadana1

Max Super Specialty Hospital, India1,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

A 86 year old male a known case of hypertension,Diabetes Mellitus presented in other hospital with  complaints of chest pain on exertion  for 3-4 monts ,increased for 10-15 days.Came to our hospital for further management.Physical examinationPulse rate 88/min,BP 116/64mmhgChest-B/l ClearCVS S1S2 normal,no murmurP/A -soft,normal bowel sounds

Relevant Test Results Prior to Catheterization

ECG-t inversion anterior and inferior  leads Echo: Global hypokinesis,LVEF 45%HB 9.8Creatinine 1.5

Relevant Catheterization Findings

CAG REVEALED Left Main 50% with Calcified triple vessel disease

Interventional Management

Procedural Step

Heart team meeting was done,High risk for CABGso planned for PTCA/Stent to Left Main bifurcation stenting with Rotablation under IVUS guidanceRotablation to LAD/LCX done using 1.5mm Burr followed by NC  balloonMini crush technique for bifurcation stenting used -2.75x24mm DES from Lt main to LCX and 3.5x24mm DES  from Left main to LAD deplyoed followed by kissing balloon and POT by using 4,5mm balloon in Left Main.Final IVUS run taken with MSA of 6.1mm2 ,7.2 and 9.4mm2 in LCX/LAD and Left Main respectively


Case Summary

In hospital course
•2hrs later , patient had sudden hypotension, nausea,, vomiting, hematemesis
•Urgentendoscopy – large Mallory Weiss tear , hemoclipping done
•Antiplateletwithheld ,Hb dropped to 5 gm/dl, 3 PRBC Transfusion done
•SAPTstarted after 48hrs
•4th day -AF With FVR , medical cardioversiondone
•AcuteRT Lower limb DVT , Anticoagulation started
•Patientdischarged on day 7 on SAPT WITH NOAC 
Conclusion:
•Bleedingand bleeding-related hospitalization are common in patients receiving DAPTafter PCI. In studies evaluating bleeding and thrombotic risk in patientstreated with DAPT after coronary stenting, clinically relevant bleedingoccurred in up to 6.2% of patients and up to 4.8% patients had bleeding-relatedhospitalization.The mostcommon site is Gastrointestinal bleeding.
•PatientsundergoingLM PCI , those with HBR are at increased risk of all cause death,MI  MI and bleeding(4 fold)
•Frailtyand comorbidities are primary cause of worse outcomes in patient at HBR.
•Useof intracoronary imaging, trans-radial route, optimal selection of antiplateletstrategy has been shown to improve outcomes in these patients
•Multidisciplinaryapproach and team work helps in saving lives in these high risk  patients