Mr M is a 58 years old gentleman who has underlying diabetes mellitus and chronic smoker. He presented with stable angina for 1 month. Coronary angiogram showed triple vessel disease and he was referred to surgeon for early coronary artery bypass grafting. Unfortunately, he presented with acute coronary syndrome complicated with acute pulmonary oedema before surgery date. Blood pressure was 90/60 mmHg, pulse rate 101 bpm, oxygen saturation 92% on air. He was intubated and started on inotrope.

ECG showed sinus rhythm with Q wave at V2 to V4 and ST depression at II, III, aVF and V5 to V6. Echocardiogram showed a left ventricular ejection fraction of 20% and global hypokinesia. His Troponin T was raised at 1054 ng/L.

Coronary angiography showed minor disease at distal left main (LM), diffuse disease from ostial left anterior descending (LAD) artery and a critical 99% stenosis at mid-LAD, 90% stenosis at mid segment of left circumflex (LCX) artery and 70% stenosis at mid-right coronary artery (RCA). 

Heart team discussion was done and he was planned for high risk percutaneous coronary intervention (PCI) under intra-aortic balloon pump (IABP) support. IABP was inserted via left femoral artery upfront and started at full augmentation. Right radial puncture was done with 6Fr radial sheath. The mid-LAD subtotal occlusion was crossed with Fielder FC wire and predilated with SC 2.0 mm balloon and SC 2.5 mm balloon. LCX was wired with Runthrough Floppy wire and mid-LCX was predilated with SC 2.5 mm balloon and was stented with Resolute Onyx 3.0 x 18 mm stent. We opted for provisional stenting at the distal LM bifurcation lesion. Mid-LAD was stented with Resolute Onyx 3.0 x 26 mm stent and another Resolute Onyx 3.5 x 26 mm was stented from body of LM till proximal LAD, overlapped with the mid-LAD stent.  The mid till proximal LAD stent was postdilated with NC 3.0 mm and NC 3.5 mm balloon respectively. Proximal optimisation technique (POT) was done to LM with NC 4.0 mm balloon. The LCX was then re-wired at distal stent strut and ostial LCX was dilated with NC 3.0 mm balloon. Final kissing balloon inflation was done to both ostial LAD and ostial LCX with NC 3.5 mm and NC 3.0 mm balloon at 10 atm with simultaneous balloon deflation. Final POT was done to LM with NC 4.0 mm balloon. TIMI 3 flow was achieved at both LAD and LCX. IABP was weaned off on day 2 and he was extubated after 1 week. PCI to RCA was done successfully after 2 weeks from the index procedure.

This case demonstrated the use of IABP as the mechanical circulatory support system during emergency PCI for a patient with cardiogenic shock. Even though IABP-SHOCK II trial concluded that IABP did not significantly reduce the mortality rate for patient with cardiogenic shock, it is still beneficial in certain cases especially when percutaneous left ventricular assist devices are not available. Early revascularization to culprit vessel is crucial and certainly improved the prognosis of this patient. Provisional stenting of the distal left main lesion also simplify the procedure and shortened the procedure time during this emergency setting.