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CASE20240805_003

All in One - CHIP Intervention with LMCA Bifurcation in a Case of AWNSTEMI Cardiogenic Shock in a Post CABG Patient with LAD CTO and Diseased Graft

By Kashif Azam Syed

Presenter

Kashif Azam Syed

Authors

Kashif Azam Syed1

Affiliation

Crescent Hospital & Heart Centre, India1,
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CASE20240805_003
High-Risk Intervention - High-Risk Intervention (Diagetes, Heart Failure, Renal Failure, Shock, etc)

All in One - CHIP Intervention with LMCA Bifurcation in a Case of AWNSTEMI Cardiogenic Shock in a Post CABG Patient with LAD CTO and Diseased Graft

Kashif Azam Syed1

Crescent Hospital & Heart Centre, India1,

Clinical Information

Relevant Clinical History and Physical Exam

57 years old HTN & DM Male, history of exertional angina for 5 months back . ECG ST depression in precordial leads, 2D Echo mildly hypokinesia of LAD territory with LVEF of 55%. BP  - 130/80 , PULSE - 86 BPM,CVS - S1 S2 NORMAL , CHEST CLEAR 
CAG revealed DVD Ostial LAD CTO, ostial circumflex 90% lesion & 40% proximalRCA lesion  referred for CABG .CABG done with graft LIMA to LAD & RSVG to PLVB (surgeon discretion) symptomatic again check CAG -- adviced


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Relevant Test Results Prior to Catheterization

2D Echo
(At admission ) Lcx  territory hypokinetic , LAD and RCA territories normal mild lv systolicdysfunction LVEF – 45 %, RVSP- 40 MM OF HG
(After6 hrs) severeLV dysfunction with LVEF 20%, Akinetic LAD and LCX territories with severe PAH(60mm of Hg).

Trop I was elevated > 4 times 

Relevant Catheterization Findings

 CAG: Post CABG LMCA – Distal total occlusion with faintly filling LCx RCA – Proximal 50% lesion LIMA – LAD –anastomotic site 90% lesion . distal to the graft 80% lesion in native LAD 
POST CABG CAG (GRAFT).mp4
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Interventional Management

Procedural Step

IABP inserted - LFA.1.GUIDE -XB 3.5 X 7F 2. Circumflex and OM1arteries wired3. 1.2 X 6 @ 10 atm& 2.75 X 8 NC balloon @ 12 atm dilation of Ostial circumflex4. Flush Ostial CTO of LAD crossed GAIA NEXT 2 wire5. LAD ostial Pre-dilation by 1.2 X6 @ 10 atm & 3.5X 12 NC @ 12 atm Balloon6. Minicrush bifurcation stenting was done in distal LMCA [(3 X 18mm DES, (LCX) & 3.5 X 38 mm DES (LAD)] with final KBI7. POT & Re-POT of LMCA - 4.5 X 8mm balloon@ 18 atm8. Additional stenting of distal LAD (beyond anastomosis of LIMA) done with 3 X 12 mm DES @14 atm9 IVUS- MSA of 17.72 MM 2 LMCA ,11.6 mm2 in LAD
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Case Summary

Discussion -
• A challenging case of ACS with cardiogenic shock involving LMCA, LAD and LCX
• Needed urgent revascularization of LAD and LCX in view of rapidly deteriorating hemodynamics
• Distal LMCA minicrush bifurcation stenting with opening of flush LAD ostial CTO was successfully accomplished with hemodynamic support
• This case stresses the importance of early revascularisation in  cardiogenic shock of ischaemic etiology