Left Main with Chronic Total
Occlusion of Left Anterior Descen
ding Artery in Cardiogenic Shock:
Do or Die
Kunal Bikram Shaha, MBBS, FCPS, Jung Rae Cho, MD, PhD,
Namho Lee, MD, PhD
Kangnam Sacred Heart Hospital, Hallym University College
of Medicine, Seoul, Korea.
Case Detail
Patient Demographics: Male,67 years old
Medical History:
Found unconcious in a Spa ,Defibrilliated By EMT for VT/VF and CPR of 4min fetched ROSC….
Presented In ER in state of Cardiogenic shock
H/o coronary stenting in LCx and RCA in other hospital
Risk Factors: Hypertension, Smoking, Dyslipidemia
EKG: ST elevation in aVR and diffuse significant ST depression in precordial(antero-lat)and limb leads, Poor R wave progression
Cardiac Biomarker reports awaited.
cc COURSE…….taken to cath lab on Inotropes & amiodarone
• Considering the hemodynamic instability, 7.5 Fr 34 cc IABP was placed and oper
ated at 2:1 ratio via left femoral approach
PTCA: LEFT MAIN with LAD Total Occlusion ATTEMPTED
Right Femoral: 6F sheath
Guide catheter :A 6F EBU 3.5
Guidewires: 0.014” Fielder FC, Fielder XT,Runthrough were tried but failed to cross the lesion
THE BATTLE CONTINUES…….
STUMPLESS
OSTIAL LAD
CTO
IVUS
GUIDED
DUAL
LUMEN
MC
INTRA
-PROC
CTA
PREPROC
CTA
BLOCK BALLOON
THE ARMOURY:STUMPLESS CTO AT BIFURCATION
THE PROXIMAL CAP GIVES AWAY WITH SHAPE & STRENGTH GAIA IST
THE TRICKLE STARTED FINALLY……NOW THE STENT SIZING……..
SERIAL PREDILATAION SAPPHIRE 2.0*20 & SAPPHIRE 2.5*20 THE FAINT FLOW VISUALIZED
MEN STILL AT WORK……..
LT MAIN TO LAD: 2.75*38 DISTAL FLOW NOT SATISFACTORY
THE CHALLENGE ACCEPTED …….& WELL DELIVERED
2ND ONYX 2.5*38 (M-D)LAD GOOD END RESULT AFTER PD WITH QUANTUM 3.0*15
POINTS TO PONDER: DO OR DIE SITUATION WELL EXECUTED
• IMPORTANT OR NOT: TO REVASCULARIZE : WHEN ISCHEMIC VT & CARDIOGENIC SHOCK PREVAILS…. INDEED A GOOD DECISION AS HE SURVIVED THE ACS INSULT & HIS EF IMPROVED FROM 25 to 40% at F/U..
• OPTIONS THOUGH AVAILAVLE FOR STUMPLESS OSTIAL LAD CTO, TIME FACTOR & STRESS WAS IMPORTANT FACTOR NOT TO ALLOW US TO USE THEM…
• GOOD AND HANDY HARDWARE SOMETIMES CAN FETCH BETTER RESULTS EVEN……
• IN “DO OR DIE” SITUATION WE THINK “WHO DARES ,WINS” WITH A PROPER LOGIC AND APPROPRIATE HARDWARE
THANK YOU: From “NEPAL THE LAND OF EVEREST” & To KANGNAM SACRED HEART HOSP,HUMC & COMPLEX PCI FORUM,AMC.