CASE20210804_001
"In Pursuit of Perfection" Triple CHIP Procedure with Calcified Chronic Total Occlusion , Bifurcation Lesion Involving the Left Main Artery in Patient with Depressed Ejection Fraction and High Bleeding Risk
By , ,
2
Presenter
Tjen Jhung Lee
Authors
1, 1, 1
Affiliation
, Malaysia1
High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk Intervention
"In Pursuit of Perfection" Triple CHIP Procedure with Calcified Chronic Total Occlusion , Bifurcation Lesion Involving the Left Main Artery in Patient with Depressed Ejection Fraction and High Bleeding Risk
1, 1, 1
, Malaysia1
Clinical Information
Patient initials or Identifier Number
ZBS
Relevant Clinical History and Physical Exam
A 69 year old gentleman presented to his district hospital with chest pain and breathlessness, with several episodes of pre-syncope. On examination blood pressure is 88/40 mmHg, pulse rate 141 bpm, lungs had crepitation to upper zones, and peripheries cold and clammy. Our working diagnosis was cardiogenic shock with NSTEMI. He was transferred to our cardiac center for further treatment.
Relevant Test Results Prior to Catheterization
Electrocardiogram shows atrial fibrillation with dynamic ST-segment changes. Chest X-ray showed cardiomegaly with pulmonary edema. As patient required high flow oxygen, he was stabilized with Non-Invasive Ventilation and intensive care, and we successfully offloaded him with intravenous infusion of Frusemide. 2D Echocardiogram shows global hypokinesia with ejection fraction 25%.
echo.avi
echo.aviRelevant Catheterization Findings
Coronary angiogram done on day 2 of admission once patient was able to lie flat. Right radial approach, with the findingsLMS: Severe distal Left Main diseaseLAD: Severe ostial disease with chronic total occlusion of the proximal segmentLCX: Severe proximal segment disease, severe mid segment diseaseRCA: Subtotal disease at the mid segment, TIMI 2 flow distallyProcedure was stopped, with heart team discussion.Viability scan done showing all cardiac territories are viable.Patient opted for PCI.
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1.avi 4.avi 5.aviInterventional Management
Procedural Step
We decided to perform revascularization in stages. The RCA was opened first with IABP support, engaged with JR 3.5 6Fr guide, wired with Runthrough Floppy which successfully crossed the lesion. Ballooned with 2.5 mm cutting balloon, followed by 3.0 mm cutting balloon. Drug Coated Balloon 2.75x40 mm applied for distal RCA, and a 3.0x48 mm Drug Eluting Stent applied from the mid to ostial RCA. Post dilated with 3.5x20 mm NC balloon with good results.
1 week later, we performed intervention to the LMS, CTO LAD and LCX, again with IABP support. Engaged with a 7Fr EBU guide for good support. Wired with Runthrough Floppy to the LCX-OM branch, and with a FIELDER XT with FINECROSS support we successfully crossed the LAD CTO into the distal true lumen. Further prepared LAD lesion with scoring balloons 2.5 to 3.0 mm size, with significant waisting in the mid LAD due to heavily calcified plaque. This plaque was successfully modified by OPN 3.0x15 mm balloon at 32 atm. LCX was prepared with 3.0 and 3.5 mm scoring balloons. We then decided to perform bifurcation stenting with the DK-Crush technique. LCX was treated with 3.0x38 mm and 3.5x30 mm DES, which was crushed at the ostium with a 4.0x15 mm NC balloon in the LM-LAD. Proximal side optimization was done, then rewired LCX and performed kissing balloon inflation (KBI) at 12 atm. LAD was stented with 2.75x48 mm and 3.5x48 mm DES up till ostial LM. 2nd KBI then POT with 4.0x8 mm NC balloon at 22 atm. We had good final results on angiogram and IVUS.
final RCA.avi
final left.avi
final left RAO CRA.avi
1 week later, we performed intervention to the LMS, CTO LAD and LCX, again with IABP support. Engaged with a 7Fr EBU guide for good support. Wired with Runthrough Floppy to the LCX-OM branch, and with a FIELDER XT with FINECROSS support we successfully crossed the LAD CTO into the distal true lumen. Further prepared LAD lesion with scoring balloons 2.5 to 3.0 mm size, with significant waisting in the mid LAD due to heavily calcified plaque. This plaque was successfully modified by OPN 3.0x15 mm balloon at 32 atm. LCX was prepared with 3.0 and 3.5 mm scoring balloons. We then decided to perform bifurcation stenting with the DK-Crush technique. LCX was treated with 3.0x38 mm and 3.5x30 mm DES, which was crushed at the ostium with a 4.0x15 mm NC balloon in the LM-LAD. Proximal side optimization was done, then rewired LCX and performed kissing balloon inflation (KBI) at 12 atm. LAD was stented with 2.75x48 mm and 3.5x48 mm DES up till ostial LM. 2nd KBI then POT with 4.0x8 mm NC balloon at 22 atm. We had good final results on angiogram and IVUS.
final RCA.avi final left.avi final left RAO CRA.aviCase Summary
As patient has Atrial Fibrillation and Chronic Kidney Disease, he is considered a High Bleeding Risk (HBR) patient. He was prescribed triple therapy for 1 month, then NOAC and Clopidogrel planned for 1 year. Repeat ECHO at 3 months shows EF of 38% and NYHA class 2 functional status, with no chest pain. He is on optimal heart failure medications.
In conclusion, Complex High-risk Interventional Procedures (CHIP) can be safely performed even in HBR patients with proper planning and adequate hemodynamic support. In severely diseased triple vessel disease, identifying and protecting the primary supporting vessel is also important, in this case it was the LCX.
In conclusion, Complex High-risk Interventional Procedures (CHIP) can be safely performed even in HBR patients with proper planning and adequate hemodynamic support. In severely diseased triple vessel disease, identifying and protecting the primary supporting vessel is also important, in this case it was the LCX.