mrs. O N

82 year old Thai femaleCC:  chest pain for 2 day   underlying disease DM , HT , CKD , old CVA , COPDBP :  80/50 mmHg , RR 20 bpm         Good consciousness         normal heart sound , lung clear , no edema Dx .   NSTEMI  high risk  with  cardiogenic shock   blood test           BUN 60 , Cr = 3.2 , Trop T 556  ECG  :   Q V1-V3 , ST elevation V1 , AVR  and generalized ST depression CXR  : mild  cardiomegaly  Echo :  mild LV dilatation ,  hypokinesia anterior and lateral wall              LVEF = 32 % , mild  MR , no clot

CAG   : LM: 98 % LM stenosis from ostial  to distal bifurcation  ( medina 1,0,1 )LAD  : 50 % mid LAD  stenosis LCX :  60 -70 % ostial LCX stenosis  , 70 % mid  LCX  stenosis 
RCA :  50 -60 % mid RCA  stenosis

at first on IABP for hemodynamic support admit  @ CCU and  patient was advice for CABG , however denied for Sx  later developed VT and sent to PCI to LM bifurcationfemoral approach , 7F guiding JL4/side hole to LCAwhisper wire to LAD --> VT then dilated LM with 2.0 x 20 balloon after that wire to LCX  and dilated with 2.0 x 20 @ 14 atm --> plaque shift to LAD thenfirst kissing balloon with  3.0 x 20 @ LAD and 2.0 x 20 @ LCX  then IVUS was checked show diffused  disease  from ostial LM-proximal LCX  and minimal  disease at ostial LADthen  DK crush was performed  with Xience Prime DES 4.0 x23 @ LAD-LM and  Xience Prime DES  3.5 x 23 @ LCX  then FKB and final POT IVUS was check for  stent  optimization and area , FFR mid LCX = 0.85 patient was sent to CCU with stable , off IABP at day 2 
patient discharge at day 5 Echo follow up at 3 month  LVEF  improve to 52 % , FC  2follow up angiogram at 1 year with  patent  stents  , No ISR 

LM bifurcation  mostly diffused disease  and angiography may be inaccurate for assessing disease of ostial both branch IVUS assessment  is key for  choosing  the appropriate LM bifurcation strategy if 2 stent strategy is needed , DK crush provided a reliable  with data driven option