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High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk 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:
-Relevant clinical history and physical exam:
This45 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 wasin Killip Class IV with cardiogenic shockand recurrent VT. 
vECG:  LBBB, Diffuse ST depressionin all leads except aVR & V1 & ST elevationin I,aVL & aVR 
v2 DEcho suggestive of severe LV Systolic Dysfunction( LVEF-20%),SevereMR, Moderate TR ,Moderate PAH
-Relevant test results prior to catheterization:
The patient was taken for Urgent CAG withintent to primary angioplasty.

 Coronary angiography suggested critical LM stenosis with significant ISR of LADstent in proximal part.
- Relevant catheterization findings:
Patient was put on Intra-aortic balloonpump.
JL 3.5- 7F guiding catheter was engaged inleft cusp near LM ostium

After crossing the lesion & serial predilatation with semicompliant balloons,  4.0x 23 Xience Prime DES was implanted from LM to LAD covering the ISRsegment.
Post dilatation with proximal optimization was done using4.5x 8 mm NC sprinter balloon
[Interventional Management]
- Procedural step:
After explaining the high risk & takingconsent of death on table IABP support (34cc linear balloon) was put through leftfemoral artery. Left CoronaryArtery:- JL 3.5,7F guide catheterwas engaged in left cusp near Left main ostium A 0.014” RUNTHROUGH WIRE was parkedin distal LAD &  another 0.014 BMWwire was parked in LCX. Pre dilatation done with SC sprinter balloon 2.5 x 12mm @ 10-12 atm & another balloon NC sprinter balloon 3.0 x 9 mm @12-14 atm.Drug eluting Stent Xience Prime  4.0 x 23mm was deployed from Left Main to LAD @ 12 atmosphere. Post dilatation donewith NC sprinter balloon 4.5 x 8 mm @ 14 atm. GP IIb IIIa inhibitor andtemporally pacemaker were used during the procedure. Excellent result with TIMIIII flow. Successful PTCA with stenting to Left Main. 
- Case Summary:
  Significant (defined as a greater than 50 percentangiographic narrowing) left main coronaryartery disease (LMCAD) is found in 4 to 6 percent ofall patients who undergo coronary arteriography. It is associated with multivessel coronary artery disease about 70 percent of the time
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