Mr B.H

89 year old independent man presented with NSTEMI on the background oflikely ischemic cardiomyopathy EF 30% with moderate mitral regurgitation andadmission with decompensated heart failure in 2020. Other comorbidities includechronic kidney disease stage 5, hypertension, urothelial cancer and rectalcancer. Initially managed medically and not for angiogram due to CKD but the patientpresented again with ongoing chest pain and significantly elevated cardiactroponin. Haemodynamically stable.

cTnI -35906 ng/L Hb - 106 g/LWCC6.5 x 10⁹/L Platelet - 173 x 10⁹/LUrea 26.2mmol/L Creatinine 397umol/LeGFR 10 ml/minUS femoralarteries - right common femoral artery - haemodynamically significantstenosis Renal team agreed to do temporary dialysisif required post angiogram Angiogram performed at another tertiaryhospitalCardiothoracicsurgical team advised not for surgery Transferred to our centre for complex PCI ContrastTTE - EF 27%, Grade 3/4 MR, no LV thrombus 

Pre PCI angio LCA.avi
Pre PCI angio RCA.avi

ImpellaCP assisted left main to mid LAD axis rotablation with 1.25,1.5,1.75 burrs and2.5mm intracoronary shockwave lithotripsy (IVL) was performed.IVUS guidedSynergy 3x 28 and 2.5 x 38 DES were inserted from mid LAD to ostial LM.Diagonal ostium treated with 2.5 IVL.Unable to wire severe calcified ostialleft cicrumflex disease.RCA was treated with Synergy 3.5 x 24 & 3 x48.Impella was weaned off at the end of the case. Patient has been pain free sinceand Creatinine improved to 272umol/l
Rota 1.75.avi
Post stent angio LCA.avi
post stent angio RCA.avi

Impella CP was inserted via left femoral artery.  Right radial artery was accessed with 8 Fr sheath. Using 6 Fr EBU 3.5 guide catheter, LCA was imaged with IVUS. Wired BMW and Corsair Pro was used . Rota 1.25 burr to prox LAD then used 1.75 burr to left main, then 1.5 burr again to proximal and mid LAD. Telescope 6Fr was also used. Predilated with NC 2.5 x12 but there was still a waste remaining. IVL catheter 2.5 x 12 was used and 6 x shockwaves delivered to left main and LAD and 1 shockwave delivered to diagonal. Unable to wire ostial LCx  with Fielder XTR, Sion and Pilot 50 using hairpin technique and Sasuke microcatheter. Deployed DES Synergy 2.5 x 38 to mid LAD and Synergy 3 x 28 to proximal LAD to left main. Post dilated with NC 3 x 20, 3 x 12 and 3.5 x 12. Repeated IVUS after PCI. Using JR4 6Fr guided catheter and with IVUS guidance, RCA was predilated with NC 2x 12, NC 2.5 x 12 , NC 3x 12. Deployed DES Synergy 3 x 48 to mid RCA and 3.5 x 24 to proximal RCA. Post dilated with NC 3.5 x 12. Left cirumfex flow was unchanged in the end of the procedure and it also gets collaterals from RCA. During LM/LAD rota and during RCA PCI , patient was Impella-dependent. Impella was weaned off at the end of the procedure and patient was transferred to coronary care unit. 
Impella insertion .avi
IVL left main.avi
Synergy 3 x 28 to LM to prox LAD.avi

Patient has been chest pain free since procedure. Patient did not require dialysis and renal function was slightly improved. During follow up, complained of lethargy and dyspnoea on exertion but no decompensated heart failure symptoms or chest pain. Repeat TTE showed EF unchanged and grade 2-3/4 MR on transesophageal echocardiogram. CRT-P was implanted 2 weeks ago. Patient was referred to structural heart team and will be monitored  MR for consideration of mitraclip in the future. Patient is still independent with activities of daily living and still drives locally.