E-Science Station

BAM

81 year old lady presented with typical chest pain and breathlessness. ECG showed dynamic anterolateral and inferior T wave inversion. Troponin elevated and treated as NSTEMI. She has a background history of hypertension, and strong paternal family history of coronary artery disease. She is a non smoker and non alcohol drinker. She is physically active and independent of her daily activities. Clinical examination of  the cardiovascular and respiratory system is unremarkable, no signs of failure

Blood investigations: Haemoglobin 10.3 g/dlPlatelet 231 x 10⁹/lCreatinine 89 umol/leGFR 53 ml/min/1.73m²Total cholesterol 4.5 mmol/lHDL 1.9 mmol/lLDL 2.0 mmol/lTriglycerides 1.3 mmol/lFasting glucose 5.0 mg/dl Chest X-Ray: normal, no pulmonary congestion or effusion. Transthoracic echocardiogram: Left ventricular ejection fraction 55%, Hypokinetic basal and mid inferior wall, and basal inferoseptal wall (RCA territory). Normal right ventricular function. No significant valvular abnormalities.

Left main stem: Normal. Large, short vessel. Almost separate ostium of LAD and LCXLAD: Moderate ostial lesion, with further moderate to severe disease proximal to mid segment (heavily calcified)LCX: Mild disease proximal segmentRCA: Severe disease ostial to mid segment (pressure drop on engaging RCA) 
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Angioplasty to RCA
JR 3.5/6Fr (with sideholes), Heparin 5000 IURunthrough floppy wired into RCA/PL branchPredilated - WILMA 2.0/13mm at 14 atmPredilated - SAPPHIRE II PRO 2.5/20mm at 16 atmStented (proximal to mid RCA) - SYNERGY MONORAIL 2.5/28mm at 11 atmStented (ostial to proximal RCA) - SYNERGY MONORAIL 2.75/28mm at 11 atm, and flaring done at 18 atmPost dilated overlap area - 2.75 stent balloon at 18 atmPost dilated mid to ostial RCA - SAPPHIRE II NC 2.75/12mm at 18 to 20 atm  High risk Angioplasty to LAD with FFR, OCT and orbital atherectomy  (staged 1 month after angioplasty to RCA) Right femoral approach, Arrow sheath 6 French, 45cm (tortuous iliacs and abdominal aorta)EBU 3.0 6 French, Heparin 6000 IUFFR wire wired down past mid LAD. Baseline FFR reading 0.79 without IV adenosine, demonstrated functionally significant lesionProceed with OCT - severe stenosis proximal LAD, with concentric calcification and MLA 2mm². Vessel size approximately 3.25mmFINECROSS microcatheter used for FFR wire exchange to orbital atherectomy guidewireOrbital atherectomy done at 80000rpm, total 6 runsOCT done - demonstrated lesion modification, with multiple cracks in the calcified LAD lesionPredilation done from ostial to mid LAD - SAPPHIRE II 3.0/15mm at 10 atm Stented - XIENCE ALPINE 3.0/33mm at 14 atmPost dilated proximal to ostial LAD - SAPPHIRE II NC 3.25/12mm at 12-20 atm

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Importance of identifying calcified lesions and staging high risk procedures. In this case angioplasty done to RCA vessel first. After successful angioplasty of RCA, counseled patient and family for high risk orbital atherectomy angioplasty to LAD
Utility of intra-coronary functional assessment to confirm significant lesion. In this case FFR assessment confirmed significant lesion (FFR value 0.79 before adenosine). OCT pre-orbital atherectomy also showed significant stenosis with minimum luminal area of 2mm²
OCT is also useful to demonstrate adequate debulking of calcified lesion for better lesion preparation, and to optimize stent deployment (assess stent sizing, apposition, and expansion)