CASE20220826_014

Primary Angioplasty of Left Main with Cardiogenic Shock Pulmonary Oedema with IABP Support

By Hariom Tyagi
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Presenter

HARIOM TYAGI

Authors

Hariom Tyagi1

Affiliation

Lokpriya Hospital, India1
Complex PCI - Bifurcation/Left Main Diseases and Intervention

Primary Angioplasty of Left Main with Cardiogenic Shock Pulmonary Oedema with IABP Support

Hariom Tyagi1

Lokpriya Hospital, India1

Clinical Information

Patient initials or Identifier Number

851LK

Relevant Clinical History and Physical Exam

A 45 year old gentleman- a known case of old AWMI (post PTCA to LAD in 2011) presented to us with severe retrosternal chest pain & dyspnoea a/w sweating for last 3 hours. The patient was in Killip Class IV with Cardiogenic shock and recurrent VT.The patient was put on high inotropic & Bipap support.

Relevant Test Results Prior to Catheterization

ECG shows LBBB, Diffuse ST depression in all leads except aVR & V1 & ST elevation in I aVL & AVR. 2D-ECHO suggestive of Severe LV Systolic Dysfunction (LVEF=20%), Severe MR, Moderate TR, Moderate PAH.

Relevant Catheterization Findings

Coronary angiography suggested- Critical LM Stenosis with significant ISR of LAD stent in proximal part. Significant (defined as a greater than 50 percent angiographic narrowing) left main coronary artery disease (LMCAD) is found in 4 to 6 percent of all patients who undergo coronary arteriography. It is associated with multi vessel coronary artery disease about 70 percent of the time.

Interventional Management

Procedural Step

After explaining the high risk & taking consent of death on table IABP support (34cc linear balloon) was put through left femoral artery. Left Coronary Artery:- JL 3.5,7F guide catheter was engaged in left cusp near Left main ostium A 0.014” RUNTHROUGH WIRE was parked in distal LAD &  another 0.014 BMW wire was parked in LCX. Pre dilatation done with SC sprinter balloon 2.5 x 12 mm @ 10-12 atm & another balloon NC sprinter balloon 3.0 x 9 mm @12-14 atm. Drug eluting Stent Xience Prime  4.0 x 23 mm was deployed from Left Main to LAD @ 12 atmosphere. Post dilatation done with NC sprinter balloon 4.5 x 8 mm @ 14 atm. GP IIb IIIa inhibitor and temporally pacemaker were used during the procedure. Excellent result with TIMI III flow. Successful PTCA with stenting to Left Main.

Case Summary

This case shows the importance of primary angioplasty of the Left Main in such critically ill cases where emergency CABG is not practically feasible. Percutaneous intervention with stent implantation for LMCA disease has become a standard procedure in contemporary practice with safety, expedited recovery, and durability. Precise selection of the strategy aided by intracoronary imaging, functional evaluation, and mechanical support when needed have improved the immediate and long-term results in this high risk intervention. It is however important to have a team approach and operator expertise before embarking on LMCA interventions.