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.