CASE20230823_009
LM Trifurcation –Nemo Resideo
By Himanshu Gupta
Presenter
Himanshu Gupta
Authors
Himanshu Gupta1
Affiliation
PGIMER, Chandigarh, India1,
View Study Report
CASE20230823_009
Complex PCI - Left Main
LM Trifurcation –Nemo Resideo
Himanshu Gupta1
PGIMER, Chandigarh, India1,
Clinical Information
Relevant Clinical History and Physical Exam
•92 years old man
•Physically active
•Presenting with Class 3 AOE x 3 months
• UA with recurrent rest angina for 6 weeks
•Old IWMI 20 yrs backmanaged medically
•LVEF- 40%, Mild MR , Normal valves
•Normal Renal function ( GFR 40ml/min)
•BMI 27, Good Cognition
Media1.mp4 Media2.mp4 Media3.mp4Relevant Test Results Prior to Catheterization
•90 years old
•Heavily calcified LM trifurcation
•Need to save all branches
•Will need plaque modification
•Will be a long procedure
•LV support – Get the best possible
•Significant worsening in clinicalcondition
•Recurrent rest angina and class 3 DOE
•LVEF dropped to 30-35%, Mild MR
•LVEDP at baseline – 28 mm HG
Media4.mp4 Media5.mp4 Media6.mp4Relevant Catheterization Findings
•Sub total distal LM, Very tortuous,angulated proximal LAD – Very calcified
•Upfront imaging – Not possible
•Needs Rotablation
•Start with with 1.25 burr
•Use 5th Generation stents
•HopeImpella takes care of the rest !!
•
Media7.mp4 Media8.mp4 Media9.mp4Interventional Management
Procedural Step
Impella was inserted, XB 3, 7F guide was cannulated and wiring was done in LAD, LAD lesion was subtotal lesion, the moment wire crossed, flow in LAD was stopped, Wire exchanged with Rotawire floppy and Rotablation was done with 1.25mm bur, after 4 mins of burring bur did not crossed, Wire was exchanged and Rotawire ES was taken and new 1.25mm bur was taken and burring was done, afte 7 nmins of burring, bur crossed and bur was upgraded with 1.5mm and rotablation was done. Post Rota DEB was done in Ramus and IVL, Cutting balloon was done in LAD and CX. Ivus was done to document cracks and MINI CRUSH LM bifurcation was done and IVUS was done to check the final result
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Media10.mp4 Media12.mp4 Media14.mp4Case Summary
•Post Rota DEB was done in Ramus andIVL, Cutting balloon was done in LAD and CX. Ivus was done to document cracks and MINICRUSH LM bifurcation was done and IVUS was done to check the final result
•Advancedhemodynamic support gives us the courage and safety to attempt these lifesaving procedures
•Advancedhemodynamic support gives us the courage and safety to attempt these lifesaving procedures
••Imagingat each step is back bone of every complex PCI
••Rotablation an-d IVLare complimentary and not competitive Devices
••Patientsafety should be the most important factor in device choice
••Avoidcomplex stenting in Trifurcation disease ( Hybrid DEB/DES an option)
••Use 5th generationstents when possible