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CM

75 year olds lady with a background history of tissue aortic valve replacement and single Saphenous vein grafting to Obtuse Marginal branch in 2018, hypertension, Type 2 Diabetes Mellitus, and Transient ischaemic attack, presented to North Wales Cardiac Centre with non ST elevation myocardial infarction. Prior to her presentation she was complaining of increasing angina pain on exertion. Clinical examination did not show any evidence of heart failure. Coronary angio prior to surgery is below:

An echocardiogram showed well functioning AVR and normal LV systolic function.

RRA 6F, JR 4 5F, EBU 3.5 6F Guide, JL 3.5 6F Guide (via RFA)RCA: Mild diseaseLMS: Severe narrowing at ostium extending to proximal segment. Noted TIMI 2 flow with severe haemodynamic compromise. Patient had PEA arrested on the table. Resuscitation and intubation was performed. LMS wired with SBW. stented with 4.0 x 15 mm Onyx. postdilated with 4.5 mm NCB. Mid LCx stented with 3.0 x 18 mm Onyx DES. Distal OM stented with 2.25 x 18 and 2.25 x 12 mm Onyx DES in overlapping fashion.

RRA 6F JR4 5F, EBU 6F Guide, JL 3.5 6F Guide
RCA: Mild disease as before
LMS: Severe narrowing at ostium extending to proximal segment. Noted TIMI 2 flow with severe haemodynamic compromise. Patient had PEA arrest on table. Resuscitation and intubation was performed.
Access switched to RFA 6F sheath. JL 3.5 6F Guide. LMS wired with SBW. LMS predilated and then stented with 4.0 x 15 mm Onyx DES. Postdilated with 4.5 mm NCB (IVUS guided)
LAD: Mild disease as before
LCx: Severe mid disease. severe distal OM at the anastomosis with occluded SVG
PCI to LCx: Mid LCx stented with 3.0 x 18 mm Onyx DES. Distal OM stented with 2.25 x 18 and 2.25 x 12 mm Onyx DES in overlapping fashion
Good result eventually with TIMI 3 flow
Patient stabilised after LMS stenting and transferred to ICU (Good recovery same night)
Reflection points:
. Access switched from RRA to RFA allowed for better utilisation of equipment in emergency situation. . Switching EBU 3.5 6F to JL 3.5 6F was good decision to perform LMS disease. . I had good support from the cath lab team and anaesthetics. . I was supported by another consultant colleague and therefore I was concentrating on passing the wire through LMS which was the crucial step in the procedure. . Following LMS predilation, the patient stabilised allowing me to use IVUS for optimal PCI result.

The patient's angiographic findings were discussed in our MDT meeting and concluded:1- the LMS lesion is possibly related to AVR operation rather than a complication during PCI procedure. the mechanism of this is not known. No operative notes were available (We are not tertiary centre)2- It is absolutely essential to have a good supporting team that allows you to concentrate on the procedural aspects.3- The patient recovered quickly and discharged after few days and followed up in out patient clinic with no further angina symptoms.