Case Report
An 86-year-old man, known diabetic with chronic renal failure grade III,
established coronary artery disease and history of multi-vessel
percutaneous intervention (PCI) done in the past, presented in accident
and emergency (A&E) with typical chest pain one day back for 1 hour
duration, however he was asymptomatic on presentation. His 12 lead ECG
was performed which showed ST elevations in anterior leads (Fig. 1). His
cardiac enzymes were raised with Trop I of 25000 pg/mL and CKMB 26ng/mL.
His echocardiography was performed which showed reduced ejection
fraction of 35%. Patient was not clinically in congestive heart
failure. Patient was admitted in CCU for further management. Considering
his age and significant comorbids, and as he stayed asymptomatic during
hospital stay, it was decided to manage him with maximum medical
therapy. Patient was discharged on dual antiplatelets, high dose statins
and antianginal medications.
3 days later, he re-presented in A & E with typical chest pain, dyspnea
NYHA class IV and orthopnoea. He had persistent ST elevations in
anterior leads with a CKMB of 31ng/mL and worsening renal functions. So,
patient was admitted again under the working diagnosis of re-infarction
on maximum medical therapy, cardiogenic pulmonary edema and acute on
chronic renal dysfunction (serum creatinine 2.6mg/dL). It was decided
this time to proceed with coronary angiogram. His angiogram revealed
severely calcified triple vessel coronary artery disease with left
anterior descending (LAD) showing subtotal osteoproximal stenosis, left
circumflex (LCX) 95% ostial stenosis with patent stent in proximal to
mid segment along-with mild in-stent restenosis (ISR), right system was
dominant with chronic total occlusion (CTO) after proximal stented
segment with faint retrograde filling from left system (Fig. 2). Based
on these findings, the heart team meeting was called. Patient was given
the option of high risk coronary artery bypass grafting (CABG) versus
high risk Rota-assisted PCI to the culprit lesion in proximal LAD.
Family opted for high risk PCI. Nephrology was taken on board to
optimize his renal function perioperatively.
His percutaneous transluminal coronary
angioplasty (PTCA) to LM and LAD was planned. 6 French femoral venous
access was established. TVP was placed via right femoral vein. LCA was
engaged with 7 French BL 3.0 guide and LAD wired with Runthrough and 1.5
OTW balloon. Wire swapped to rota floppy. LMS to LAD was rotablated with
1.75 burr and PTCA with 3.5 NC at 20 Atm. LCX was wired with whisper and
PTCA performed with 2.5 NC. LMS to LAD was stented with 3.5 x 34mm DES
at 16Atm. Proximal optimization technique (POT) in LM stem performed
with 5.0 NC and distal optimization technique (DOT) with 3.5 NC (Fig.
3). Acceptable final result was achieved (Fig. 4).
During the procedure, patient developed flash cardiogenic pulmonary
edema requiring intravenous diuresis on table and immediately
post-procedure. Patient was shifted back to CCU on low dose inotropic
support and nephrology was called again. Post procedure, patient
required 3 sessions of haemodialysis (HD) and was discharged on
guideline directed medical therapy with continuing twice weekly sessions
of HD. At 4 weeks follow-up in the outpatient clinic, he had significant
normalisation of his functional status and his Echo showed significant
improvement in his LV function. Though having a continuing need for HD.
At 6 month follow-up, he was off-HD, with adequate urine output and
stable cardiovascular status.