TCTAP & AP VALVES 2020 Virtual

CASE20191115_015

CORONARY - Bifurcation/Left Main Diseases and Intervention
IVUS Guided Left Main Bifurcation PCI
Hameeth Shah Abdul Wahid¹, Asri Ranga², Nor Hanim Mohd Amin¹, Hazleena Mohamed Hasnan¹, Shathiskumar Govindaraju³
Hospital Raja Permaisuri Bainun, Malaysia¹, Sultan Idris Shah Serdang Hospital, Malaysia², Hospital Serdang, Malaysia³,

[Clinical Information] - Patient initials or identifier number: Mrs SAZ -Relevant clinical history and physical exam: This is a 29 years old lady, previously not to have any medical illness, presented with history of typical angina chest pain for 1 week duration. She had a very strong family history of ischemic heart disease. Father died at the age of 57 for Myocardial Infraction. Mother underwent angioplasty in 2004. She is the only child. During this admission she was newly diagnosed with Diabetes Mellitus, Hypertension and Hyperlipidemia. -Relevant test results prior to catheterization: ECG: mild St depression in 1. aVL troponin T: 128 Random Blood Sugar: 18.9 mmol/L Total Cholesterol: 6.3 TG 2.06 LDL 4.4 HDL 0.92 Echocardiography EF57% No regional wall motion abnormality - Relevant catheterization findings: Femoral ApproachRight Femoral Approach 6French Sheath6 French JL 4 and 6 French JR 4 LMS: SmoothLAD: Ostial 80% stenosis. Mid 30-40% stenosisLCx: High OM 1. Ostial OM 1 95% stenosis. TIMI 3 Flow(Medina classification 0/1/1)RCA. Dominant. Smooth diagnostic 1.avi diagnostic 2.avi diagnostic 3.avi
[Interventional Management] - Procedural step: PCI LM-LADRight Femoral Approach 6FrCoronary Guiding Catheter : 6Fr EBU 3.5 Coronary Guiding Wire : Sion Blue / BMWBoston Opticross IVUS Patient was given Brillinta 180mg stat at the beginning of the procedure. BMW wired into LAD and Sion Blue into OM1.Predilated OM1 with Tazuna balloon 2.0 x 15mm @ 10 ATMPredilated OM1 with NC Accuforce balloon 2.75 x 15mm @ 12 ATM Plain Old Balloon Angioplasty (POBA) Ostial-Prox OM1 with INPACT FALCON (DCB) 2.75 x 20mm @ 8 to 10 ATM for 45 seconds. IVUS LM – LAD Before PCILM : LM diameter 5mm vesselsLAD : Prox LAD diameter 4mm vessels Predilated ostial-prox LAD with NC Scoreflex balloon 3.0x15mm @ 4 to 16ATM Predilated ostial-prox LAD with NC Sapphire balloon 4.0x15mm @ 14 to 18ATM Noted Dissection at distal LM. IVUS doneLM : dissection localized at distal LMLAD : no dissection noted. Stented LM-LAD with Xience Sierra (DES) 4.0 x 23mm @ 12 ATMPostdilated with NC Euphora balloon 4.0 x 15mm @ 8 to 24 ATM Post Stenting ( LM- LAD) IVUS doneLM: Stent well opposed. LM MSA 15.3mm²LAD: Stent well opposed. Ostial LAD MSA 10.0 mm² Kissing Balloon Technique ( KBT) done LAD : NC Accuforce balloon 4.0x12mm @ 10ATMOM1 : NC Accuforce balloon 2.75 x 15 @ 10 ATM Proximal optimization technique (POT) done to LM with NC Trek Balloon 5.0 x 8mm @ 14 ATM. disection at dLM1.avi KBT1.avi FINAL SHOT 1.avi - Case Summary: Conclusion 2 Vessel Disease successful PCI to LM-LAD-OM1 ( Drug Eluting Stent and Drug Coated Balloon ). When we are dealing with possible LM stenting, the use of IVUS is particularly helpful in the determination of the plaque and characteristics within the LM as well as in determining the ostial involvement of the daughter vessel. The other value of IVUS is to ensure stent optimization of LM PCI. IVUS can ensure adequate expansion and apposition of the stents after LM PCI. In this case we manage to act promptly after we noted the dissection at the distal LM which would potentially be fetal. Overall the use of IVUS in LM PCI improves clinical outcomes.

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