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CASE20200925_015
High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk Intervention
PCI in Patient with Non-operable Severe CAD Due to Recent Ischemic Stroke Combined with Severe Bicuspid Aortic Stenosis
Wahyu Aditya1, Muhammad Munawar2, Dian Larasati Munawar2, Dian Setiawan3
Bina Waluya Cardiac Center, Indonesia1, Binawaluya Cardiac Center, Indonesia2, Binawaluya, Indonesia3,
[Clinical Information]
- Patient initials or identifier number:
MR. E.S
-Relevant clinical history and physical exam:
Progessive angina every night
Recent SNH (june2020)
Severe AS ec bicuspid valve pro AVR
Patient came to our hospital at 5 august 2020
PE :Ejection systolic murmur (+) 
ECG : SR, inverted T v5-6Echo : EDD 55, ESD 40, EF 53%, TAPSE 1.9 cm LVH eccentric RWMA hypokinetik inferolateral Aorta bicuspid, calcification (+) AVA 0,5cm2, pAVG80mmHg AR  mildMR moderateTR mild TVG 50mmHg, PR mild
-Relevant test results prior to catheterization:
HB 13.7g/dl, 
WBC 8700/uL,

ur 47,
Cr 1.5,  
 eGFR 42, 
NT proBNP 5049
- Relevant catheterization findings:
LM : osteal  60% stenosis, distal  60% stenosis, calcified (+)LAD : calcified at proksimal,  70-80% stenosis at proksimal - mid partLCX : calcified (+) at proksimal, subtotal stenosis at mid partRCA: Dominant, subtotal stenosis at mid partCAD3VD + LM
[Interventional Management]
- Procedural step:
Prepare LCX : Balloon scoreflex 2.5/10IVUS LCX and LADPrepare LAD : Rota bur 1.75 , 5x, 169.000-191. RPM anf Ballon scoreflex 3.5/15DK crushPCI LCX Biofreedom 3.0/36Complete crush LAD B trek 3.5/15recrosingfirst kissing ballon : B trek 3.0/15 (LCX) and B Trek 3.5/15 (LAD)PCI LM-LAD Biofredom 3.5/28 mmPOT LM : B sapphire 5.0/15second recrossingFinal kissing ballon B trek 3.0/15 (LCX) and B Trek 3.5/15 (LAD)
PCI mid LAD resolute integrity 3.0/26 mm
RCA : B scoreflex 3.0/15 and PCI DES Resolute integrity 3.5/22 mm





- Case Summary:
Conclusion, PCI mght be the most appropriate choice for elderly CAD combined severe bicuspid aortic stenosis who got recent   ischemic stroke. Stents which need shorter dual antiplatelet therapy may be needed due to potential of high bleeding risk and  therefore  IVUS guided PCI should be performed. 
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