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TCTAP C-016 Left Main Coronary Artery to Left Anterior Descending Artery Percutaneous Coronary Intervention in Acute Anterior Myocardial Infarction Complicated by Ostial Left Circumflex Artery Plaque Shift: Make it Complex or Keep it Simple
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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
TCTAP C-016 Left Main Coronary Artery to Left Anterior Descending Artery Percutaneous Coronary Intervention in Acute Anterior Myocardial Infarction Complicated by Ostial Left Circumflex Artery Plaque Shift: Make it Complex or Keep it Simple Jiyen Kam,1 Benjamin Leo Cheang Leng,1 Hou Tee Lu,1 Chuey Yan Lee1 1 Hospital Sultanah Aminah, Malaysia [CLINICAL INFORMATION] Patient initials or identifier number. HMS Relevant clinical history and physical exam. Mr. HMS was a 65-year-old gentleman who presented with intermittent chest pain for 10 hours. His cardiovascular risk factors were Diabetes Mellitus and 20-pack years of cigarette smoking. BP 152/90 mmHg, pulse rate 72 bpm, SpO2 96% breathing room air and blood glucose 7.4 mmol/l. Cardiovascular examination was unremarkable. Chest auscultation revealed fine basal crackles bilaterally. Relevant test results prior to catheterization. ECG showed ST segment elevation and pathological Q wave in leads V1-V4. Transthoracic echocardiography revealed moderately impaired LV systolic function, LVEF 40-45% with hypokinesia in the anterior, septal and apical walls. Troponin T level was markedly elevated. A diagnosis of acute anterior STEMI Killip class II was made. He received immediate fibrinolysis with IV Tenecteplase, but rescue PCI was performed later for persistent ST elevation and chest pain. Relevant catheterization findings. Coronary angiogram was performed via right transfemoral approach: 1. Mild distal left main coronary artery (LMCA) disease. Tight ostial and proximal left anterior descending (LAD) artery stenosis of 80-90%. Intermediate mid LAD disease. TIMI 2 flow to distal LAD. 2. Dominant left circumflex (LCX) artery with intermediate-mid segment disease and 70-90% stenosis of the obtuse marginal (OM) branch. 3. The right coronary artery was recessive, small and diffusely diseased. [INTERVENTIONAL MANAGEMENT] Procedural step. The LCA was engaged with 6Fr XB 3.5 guiding catheter. Runthrough NS Hypercoat wire (Terumo) was placed in LCX. PT2 moderate support wire (Boston Scientific) was advanced into distal LAD. Ostial and proximal LAD was predilated with GENOSS 2.5 x 10 mm balloon up to 12 atm. IVUS (Boston Scientific) of mid LAD to LMCA showed heavy plaque burden in proximal LAD with MLA of 3.3 mm2. Xience Prime DES (Abbott) 4.0 x 23 mm was deployed at proximal LAD-mid LMCA at 10 atm. Post-dilatation was performed with NC EUPHORA balloon (Medtronic) 4.0 x 8 mm up to 16 atm. Subsequent cine showed severely pinched ostium of LCX but perfusion remained TIMI 3. Run through wire recrossed into LCX. IVUS of LCX showed MLA of ostium LCX was <4 mm 2.Ostial LCX lesion was predilated with the used GENOSS balloon 2.5 x 10mm up to 14 atm. Final kissing balloon inflation was performed (LCX-LM GENOSS 2.5 x 10 mm) & (LAD-LM NC EUPHORA 4.0 x 8 mm) at 10 atm. IVUS of LAD showed well-opposed stent edges with ostial LAD MLA about 6.4 mm2. Unfortunately, we did not have time to repeat IVUS of the LCX as the patient was becoming restless at this point of time but he remained hemodynamically stable. Final cine, showed TIMI 2 flow to distal LAD and TIMI 3 flow to distal LCX. There is about 20-30% residual ostial stenosis but we were happy to accept the final results.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Case Summary. Our initial plan was to proceed with provisional stenting of the proximal LAD up to the LMCA as the ostium/proximal LCX appeared relatively disease-free. However, PCI for an ostial LAD lesion is well known to be associated with plaque shift in LMCA or LCX, and it is not uncommon to end up with a 2-stent bifurcation PCI. Fractional Flow Reserve (FFR) in the non-infarct related LCX can be a useful asset in addition to IVUS in assessing the need for a complex LM bifurcation PCI. If the TIMI flow in LCX was compromised, we would have opted for a TAP bifurcation stenting strategy. Nonetheless, we were happy to have kept a potential complex procedure simple and the patient remains well until today.
S107
- Post-dilation with a non-compliant balloon with the good angiographic result.
TCTAP C-017 Delayed Stenting in Left Main Lesions in Young Patients with Acute Coronary Syndrome Clinical Cases Nazim Megherbi,1 Mohamed Abed Bouraghda,1 Redwane Nedjar,1 Said Benghezel,1 Wathik Takdemt,1 Mohamed Chettibi,1 Mohamed Tahar Chafik Bouafia1 1 Chu Frantz Fanon, Bilda, Algeria [CLINICAL INFORMATION] Patient initials or identifier number. patient 1: H.A / patient 2 : H.S Relevant clinical history and physical exam. Patient 1: 29 years old patient, smoker, consults for a typical chest pain evolving since 3 hours. Clinical examination: KILLIP II, patient agitated Patient 2: 38 years old patient, smoker, with a history of NSTEMI on 02/05/ 2016 the angiography at that time showed a sténosis on the circumflex, we did put an Ativ stent on it with good results. He consults on 17/10/2016 for typical chest pain evolving for 1-hour. Clinical examination was normal. Relevant test results prior to catheterization. Patient 1: EKG: acute anterior STEMI. Patient 2: The EKG highlighted subendocardial lesions in the anterior territory. Troponin T was elevated at 56 times the normal limit. The echocardiogram was unremarkable. The ejection fraction was approximate. Relevant catheterization findings. Patient 1: Large thrombus on the distal LM and ostial CX.TIMI 0 flow on the LAD. Patient 2: Very Severe heterogeneous stenosis of the left main, TIMI III flow on the LAD and the Cx.The right coronary was normal.The patient was stable without any pain, the blood pressure was about 140/70. [INTERVENTIONAL MANAGEMENT] Procedural step. Patient 1: - We placed the patient under intra-aortic counterpulsation. - We performed instrumental thrombectomy with perfusion of TIROFIBAN intra-coronary and intravenous. - We restored a TIMI III flow with sedation of chest pain. - The patient was observed for 48 hours in an intensive care unit under intravenous perfusion of TIROFIBAN for 24 hours. - At angiographic control after the 48 hours, we noticed the disappearance of the thrombus, the left coronary artery was free from the angiographically significant lesion. Patient 2: - We placed the patient in observation in intensive care unit during 48 hours, where he received a perfusion of TIROFIBAN for 24 hours. - At the angiographic control after the 48 hours, the lesions were identical to those observed during the first angiography. - We performed the angioplasty of the ostial left main. - Predilatation of the lesion with a semi-compliant balloon and then with a compliant balloon. We did found resistance at the lesion’s predilatation. - Placement of an active stent covering the LM ostium with persistence of an imprint on the middle segment at the deployment of the stent.
Case Summary. Stable TIMI3 flow is the aim of primary PCI which can be performed with thrombectomy combined to anti-GP IIb, IIIa without stenting for the first step to avoid distal embolization and stent downsizing in young patients who sometimes have not significative coronary lesions, this is true for many of them, but not all. It is difficult to identify those likely to receive a deferred strategy. Nevertheless, this strategy must be adopted only when we are sure to ensure the safety of our patients.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
TCTAP C-016 Left Main Coronary Artery to Left Anterior Descending Artery Percutaneous Coronary Intervention in Acute Anterior Myocardial Infarction Complicated by Ostial Left Circumflex Artery Plaque Shift: Make it Complex or Keep it Simple Jiyen Kam,1 Benjamin Leo Cheang Leng,1 Hou Tee Lu,1 Chuey Yan Lee1 1 Hospital Sultanah Aminah, Malaysia [CLINICAL INFORMATION] Patient initials or identifier number. HMS Relevant clinical history and physical exam. Mr. HMS was a 65-year-old gentleman who presented with intermittent chest pain for 10 hours. His cardiovascular risk factors were Diabetes Mellitus and 20-pack years of cigarette smoking. BP 152/90 mmHg, pulse rate 72 bpm, SpO2 96% breathing room air and blood glucose 7.4 mmol/l. Cardiovascular examination was unremarkable. Chest auscultation revealed fine basal crackles bilaterally. Relevant test results prior to catheterization. ECG showed ST segment elevation and pathological Q wave in leads V1-V4. Transthoracic echocardiography revealed moderately impaired LV systolic function, LVEF 40-45% with hypokinesia in the anterior, septal and apical walls. Troponin T level was markedly elevated. A diagnosis of acute anterior STEMI Killip class II was made. He received immediate fibrinolysis with IV Tenecteplase, but rescue PCI was performed later for persistent ST elevation and chest pain. Relevant catheterization findings. Coronary angiogram was performed via right transfemoral approach: 1. Mild distal left main coronary artery (LMCA) disease. Tight ostial and proximal left anterior descending (LAD) artery stenosis of 80-90%. Intermediate mid LAD disease. TIMI 2 flow to distal LAD. 2. Dominant left circumflex (LCX) artery with intermediate-mid segment disease and 70-90% stenosis of the obtuse marginal (OM) branch. 3. The right coronary artery was recessive, small and diffusely diseased. [INTERVENTIONAL MANAGEMENT] Procedural step. The LCA was engaged with 6Fr XB 3.5 guiding catheter. Runthrough NS Hypercoat wire (Terumo) was placed in LCX. PT2 moderate support wire (Boston Scientific) was advanced into distal LAD. Ostial and proximal LAD was predilated with GENOSS 2.5 x 10 mm balloon up to 12 atm. IVUS (Boston Scientific) of mid LAD to LMCA showed heavy plaque burden in proximal LAD with MLA of 3.3 mm2. Xience Prime DES (Abbott) 4.0 x 23 mm was deployed at proximal LAD-mid LMCA at 10 atm. Post-dilatation was performed with NC EUPHORA balloon (Medtronic) 4.0 x 8 mm up to 16 atm. Subsequent cine showed severely pinched ostium of LCX but perfusion remained TIMI 3. Run through wire recrossed into LCX. IVUS of LCX showed MLA of ostium LCX was <4 mm 2.Ostial LCX lesion was predilated with the used GENOSS balloon 2.5 x 10mm up to 14 atm. Final kissing balloon inflation was performed (LCX-LM GENOSS 2.5 x 10 mm) & (LAD-LM NC EUPHORA 4.0 x 8 mm) at 10 atm. IVUS of LAD showed well-opposed stent edges with ostial LAD MLA about 6.4 mm2. Unfortunately, we did not have time to repeat IVUS of the LCX as the patient was becoming restless at this point of time but he remained hemodynamically stable. Final cine, showed TIMI 2 flow to distal LAD and TIMI 3 flow to distal LCX. There is about 20-30% residual ostial stenosis but we were happy to accept the final results.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
Case Summary. Our initial plan was to proceed with provisional stenting of the proximal LAD up to the LMCA as the ostium/proximal LCX appeared relatively disease-free. However, PCI for an ostial LAD lesion is well known to be associated with plaque shift in LMCA or LCX, and it is not uncommon to end up with a 2-stent bifurcation PCI. Fractional Flow Reserve (FFR) in the non-infarct related LCX can be a useful asset in addition to IVUS in assessing the need for a complex LM bifurcation PCI. If the TIMI flow in LCX was compromised, we would have opted for a TAP bifurcation stenting strategy. Nonetheless, we were happy to have kept a potential complex procedure simple and the patient remains well until today.
S107
- Post-dilation with a non-compliant balloon with the good angiographic result.
TCTAP C-017 Delayed Stenting in Left Main Lesions in Young Patients with Acute Coronary Syndrome Clinical Cases Nazim Megherbi,1 Mohamed Abed Bouraghda,1 Redwane Nedjar,1 Said Benghezel,1 Wathik Takdemt,1 Mohamed Chettibi,1 Mohamed Tahar Chafik Bouafia1 1 Chu Frantz Fanon, Bilda, Algeria [CLINICAL INFORMATION] Patient initials or identifier number. patient 1: H.A / patient 2 : H.S Relevant clinical history and physical exam. Patient 1: 29 years old patient, smoker, consults for a typical chest pain evolving since 3 hours. Clinical examination: KILLIP II, patient agitated Patient 2: 38 years old patient, smoker, with a history of NSTEMI on 02/05/ 2016 the angiography at that time showed a sténosis on the circumflex, we did put an Ativ stent on it with good results. He consults on 17/10/2016 for typical chest pain evolving for 1-hour. Clinical examination was normal. Relevant test results prior to catheterization. Patient 1: EKG: acute anterior STEMI. Patient 2: The EKG highlighted subendocardial lesions in the anterior territory. Troponin T was elevated at 56 times the normal limit. The echocardiogram was unremarkable. The ejection fraction was approximate. Relevant catheterization findings. Patient 1: Large thrombus on the distal LM and ostial CX.TIMI 0 flow on the LAD. Patient 2: Very Severe heterogeneous stenosis of the left main, TIMI III flow on the LAD and the Cx.The right coronary was normal.The patient was stable without any pain, the blood pressure was about 140/70. [INTERVENTIONAL MANAGEMENT] Procedural step. Patient 1: - We placed the patient under intra-aortic counterpulsation. - We performed instrumental thrombectomy with perfusion of TIROFIBAN intra-coronary and intravenous. - We restored a TIMI III flow with sedation of chest pain. - The patient was observed for 48 hours in an intensive care unit under intravenous perfusion of TIROFIBAN for 24 hours. - At angiographic control after the 48 hours, we noticed the disappearance of the thrombus, the left coronary artery was free from the angiographically significant lesion. Patient 2: - We placed the patient in observation in intensive care unit during 48 hours, where he received a perfusion of TIROFIBAN for 24 hours. - At the angiographic control after the 48 hours, the lesions were identical to those observed during the first angiography. - We performed the angioplasty of the ostial left main. - Predilatation of the lesion with a semi-compliant balloon and then with a compliant balloon. We did found resistance at the lesion’s predilatation. - Placement of an active stent covering the LM ostium with persistence of an imprint on the middle segment at the deployment of the stent.
Case Summary. Stable TIMI3 flow is the aim of primary PCI which can be performed with thrombectomy combined to anti-GP IIb, IIIa without stenting for the first step to avoid distal embolization and stent downsizing in young patients who sometimes have not significative coronary lesions, this is true for many of them, but not all. It is difficult to identify those likely to receive a deferred strategy. Nevertheless, this strategy must be adopted only when we are sure to ensure the safety of our patients.