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.