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CASE20200925_098
| High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk Intervention | |
| Complex High-risk PCI: The Heart Team Approach | |
| Michael N. Gergis1 | |
| Aswan Heart Center (Magdi Yacoub Foundation), Egypt1, | |
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[Clinical Information]
- Patient initials or identifier number:
A. M
-Relevant clinical history and physical exam:
History: Male patient, 83 years, X-smoker, not diabetic,not hypertensiveComplained of severe burning chest painClinical examination: Cardiogenic shock (Bl.P : 80/50 - HR: 120 beat/min), Congested with bilateral fine crepitation -Relevant test results prior to catheterization:
qECG: Diffuse ST depression in inferior and anterior leadsqEcho: Normal LV dimensions,EF = 30 %Global hypokinesia- Relevant catheterization findings:
Proximal RCA total occlusion with faintTIMI I and retrograde filling from left system.Distal left main severe stenosis, (Medina1-1-0)Ostial LAD and proximal to mid segmentsevere stenosis
SYNTAX score calculated : 23 ¨ª Heart team discussion: - Frailty due to advanced age, patient is Nubian (a minority tribe in upper Egypt) with language barrier affecting rehabilitation- Heart team decision ¡¦. PCI was planned Media1.wmv Media2.wmv Media3.wmv |
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[Interventional Management]
- Procedural step:
- The whole 4 IABPs in our centre are already busy on other patients. ¨ªPlan: ü Tackle RCA first .. If failed .. Postpone PCI till secure an IABP / CABG ü Provisional stenting strategy ü PCI to LCX using TAP technique as a bailout Procedural steps: - Bifemoral access - PCI to RCA - Lesion passed with a regular workhorse wire. Predilatation, followed by two DESs (2.5 x23mm) overlapped with (2.75x38mm) Post dilatation using NC balloon(2.75x15mm) - Predilatation to the LM with compliant balloon (2.5x15 & 2.75x15) both ruptured. - Another predilatation with NC balloon(3x12mm) at 14 atm.- PCI to mid LAD, DES(2.75x30) and Post dilatation with NC balloon ( 3x15mm)- PCI to LM-LAD cross over the LCX with DES (3.5 x 38mm), flaring at the ostium.- POT with NC balloon (4.5 x 12 mm)- PCI to LCX- Wires were recrossed, the side strut was opened using balloon (2 x 20mm) followed by kissing balloon inflation >>haziness at LCX ostium.- PCI to LCX with DES (2.75 x 23 mm) TAP technique- Kissing balloon inflation followed by final POT. > IVUS- Well opposed stent, MLA = 7.5 mm2 at the LAD and 10 mm2 at the distal LMT Media5.wmv Media6.wmv Media7.wmv- Case Summary:
- Complex high risk patients are not uncommon during the daily practice - Heart team discussion is considered a cornerstone in the management plan - Anatomical complexity (Syntax score) is not the only parameter judging revascularization strategy- Some clinical and non clinical factors (not adequately reflected by scores) may favor PCI - Ability to achieve complete revascularization is a key issue when choosing revascularization strategy |
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