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CASE20200925_008
High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk Intervention
Complex High-risk PCI: The Heart Team Approach
Michael Nagy Gergis
,
[Clinical Information]
- Patient initials or identifier number:
A. M
-Relevant clinical history and physical exam:
History:
Male patient, 83 years, X-smoker, not diabetic,not hypertensiveComplained of severe burning chest pain
Clinical examination:
Cardiogenic shock (Bl.P : 80/50 - HR: 120 beat/min), Congested with bilateral fine crepitation

-Relevant test results prior to catheterization:
qECG:
Diffuse ST depression in inferior and anterior leads
qEcho:
Normal LV dimensions,EF = 30 %Global hypokinesia
- Relevant catheterization findings:
Proximal RCA total occlusion with faintTIMI I and retrograde filling from left system.Distal left main severe stenosis, (Medina1-1-0)Ostial LAD and proximal to mid segmentsevere stenosis

SYNTAX score calculated : 23

Ø Heart team discussion:
- Frailty due to advanced age, patient is Nubian (a minority tribe in upper Egypt) with language barrier affecting rehabilitation- Heart team decision …. PCI was planned

[Interventional Management]
- Procedural step:

-This is a complex high risk patient, in Cardiogenic shock Preferably to be done on mechanical circulatory support.- Impella is not available.
- The whole 4 IABPs in our centre are already busy on other patients.
ØPlan: 
ü Tackle RCA first .. If failed .. Postpone PCI till secure an IABP / CABG
ü Provisional stenting strategy
ü PCI to LCX  using TAP technique as a bailout

Procedural steps:
- Bifemoral access
- PCI to RCA 
- Lesion passed with a regular workhorse wire. Predilatation, followed by two DESs (2.5 x23mm) overlapped with (2.75x38mm) Post dilatation using NC balloon(2.75x15mm)
- Predilatation to the LM with compliant balloon (2.5x15 & 2.75x15) both ruptured.
- Another predilatation with NC balloon(3x12mm) at 14 atm.- PCI to mid LAD, DES(2.75x30) and Post dilatation with NC balloon ( 3x15mm)- PCI to LM-LAD cross over the LCX with DES (3.5 x 38mm), flaring at the ostium.- POT with NC balloon (4.5 x 12 mm)
- PCI to LCX- Wires were recrossed, the side strut was opened using balloon (2 x 20mm) followed by kissing balloon inflation >>haziness at LCX ostium.- PCI to LCX with DES (2.75 x 23 mm) TAP technique- Kissing balloon inflation followed by final POT.
> IVUS- Well opposed stent, MLA = 7.5 mm2 at the LAD and 10 mm2 at the distal LMT
- Case Summary:

- Complex high risk patients are not uncommon during the daily practice
- Heart team discussion is considered a cornerstone in the management plan
- Anatomical complexity (Syntax score) is not the only parameter judging revascularization strategy- Some clinical and non clinical factors (not adequately reflected by scores) may favor PCI
- Ability to achieve complete revascularization is a key issue when choosing revascularization strategy
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