A 83-year-old woman was admitted ourhospital due to acute decompensated heart failure.She did not have obvious dementia, but herADL (Activities of Daily Living) was decreased, and her clinical frailty scalewas 6 that means moderate frailty.After admission, we treated her withoptimal medical therapy but her clinical course had not been improved.Her electrocardiogram(ECG) and echocardiography had suggested severe ischemia of myocardium.

Chest X-ray showed bilateral lung congestion and pleural effusion.Electrocardiography showed poor progressionR in V1 to V4 inductions and ST depression in V5-6 induction.Echocardiography revealed ejection fractionof left ventricle (LV) was 25% with thinning of anterior wall of LV.Carotid artery ultrasound examination foundbilateral carotid artery severe stenosis.Laboratory data demonstrated elevation of serumBNP (677.9 pg/mL) and high sensitive Troponin T (0.059 ng/mL).

Coronary angiography (CAG) showed triplevessel disease with 2 vessel CTO. There was 99% stenosis with severecalcification in LMT, 99% stenosis in LAD seg7, and CTO in LCx seg11 and RCAseg2.After angiography, we considered how torevascularization for this patient in our heart team including cardiac surgeon.However, surgeon hesitated to CABG because of her severe comorbidities.The day after CAG, she fell into cardiogenic shock, so we had no choice but to performed emergent revascularization.

At first, we inserted the Impella CP, and triedto revascularization for LMT and LAD lesion.IVUS findings revealed concentric severecalcification in LMT lesion, because we performed rotational atherectomy byusing 1.75mm and 2.0mm burr.After that, we implanted the DES from LMTto LAD seg7, and gained enough expand the lumen.Furthermore, we negotiated RCACTO lesion and selected the strategy of retrograde approach first.Because RCA CTO was long CTO and unknownvessel route, we considered that it is absolutely necessary to establishbi-directional approach.We could success epicardial channeltracking from diagonal branch, and punctured distal cap of the CTO by Gaianext3(Asahi Intecc, Japan).However, Gaia next3 advanced outside thevessel and other wires also could not puncture distal cap of the CTO correctly becauseof severe calcified plaque in CTO.Then, we tried antegrade approach, butantegrade wiring was also difficult because of severe calcification.Antegradewire finally advanced out of vessel, furthermore, even knuckle wire technique wasnot effective.We finally broke through this nightmaresituation with scratch and go technique by antegrade approach, and make a largeshape of knuckle wire in the subintimal space at the end of CTO lesion.Bydoing that, we could retrograde puncture easily, and retrograde wire was intothe same subintimal space.We finally could establish r-CART, and successfulrevascularization of RCA CTO.

We finally could success the one stagerevascularization both LMT to LAD lesion and RCA CTO supported by Impella CP.This case is CHIP, and CHIP is known to becompose of three factors (patient factors, complicated heart disease, complexPCI).Among CHIP factors, unstable hemodynamics and frailty like this case wereassociated major complications.Impella CP is definitely effective in CHIPPCI but also it is reported VA-ECMO or combination with Impella and VA-ECMO inducehigh mortality and adverse event.In CHIP PCI like this case, strategy ofearly introduction of Impella and avoidance of ECMO might reduce perioperativecomplications and improve patient outcomes.