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CASE20191112_009
| CORONARY - Bifurcation/Left Main Diseases and Intervention | |
| Hybrid DES and Sirolimus-eluting Balloon for the Treatment of an Unprotected Distal Left Main Bifurcation in a Patient with an Evolut R Transcatheter Heart Valve | |
| Alfonso Ielasi1, Maurizio Tespili2 | |
| IRCCS Ospedale Galeazzi Sant'Ambrogio, Italy1, Bolognini Hospital, Italy2, | |
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[Clinical Information]
- Patient initials or identifier number:
MG1933
-Relevant clinical history and physical exam:
An 85-year-old hypertensive and dyslipidemic lady with prior trans-catheter aortic valve replacement (Evolut R 26 mm) and PCI with drug-eluting stent implantation on unprotected left main (ULM) and first obtuse marginal (OM1) was admitted to our Unit because of unstable angina.Physical examination was normal.Cardiac enzymes resulted within the range of normality.
-Relevant test results prior to catheterization:
EKG showed sinus rhythm (72 bpm) without major abnormalities.Trans-thoracic echocardiogram showed a normal function of the THV (peak gradient 20 mmHg, mean gradient 6 mmHg) without paravalvular leak. The left ventricular ejection fraction was normal (LVEF 60%). Coronary angiography was scheduled.
- Relevant catheterization findings:
The right coronary artery engagement was immediately effective using a JR4 catheter. while the left coronary artery cannulation resulted very complex (JR 4 6F, JL 3.5, IM, JR 4, JR 3.5 catheters resulted ineffective to selectively cannulate the left main through the Evolut R THV) and finally a AL1 catheter allowed to obtain a subselective left angiogram showing a severe ostial LCx stenosis (Figure 1).
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[Interventional Management]
- Procedural step:
A XB 3 6F guiding catheter was advanced through the THV frames close to the ULM ostium (not fully selective). A BMW wire was placed in the distal LAD and a Whisper extra-support on the distal LCx. After predilatation on the ostial LCx (2.5 mm NC balloon) a 2.75x15 mm drug-eluting stent was implanted on the ostial LCx (T and small protrusion fashion with the previously implanted DES on the ULM). Then a 4.0x15 mm Magic Touch sirolimus-eluting balloon was gently advanced and inflated on the ULM DES and a final kissing inflation (DEB and NC balloon) was performed at the distal ULM bifurcation. The final angiographic result was satisfactory.
 - Case Summary:
This case demonstrates: 1. An excellent Magic Touch sirolimus-eluting balloon trackability through an Evolut R THV (subselectively engaged)2. The feasibility of the hybrid DEB/DES strategy for the treatment of a Medina 0,0,1 bifurcation.
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