Grim to Glim: A LMCA Total Occlusion in NSTEMI

A.M. Thirugnanam
A.M. Thirugnanam, MD., FSCAI, PhD. Sr. Interventional Cardiologist
Ipcard Cardiac Care Center, Hyderabad, India
Facility / Institute
Ipcard Cardiac care Center, Hyderabad, Andhra Pradesh, India
Clinical History
A 56 year old male with type II diabetes for 7 years and hypertension for 5 years presented with crescendo angina for more than 45 min. He had intermittent chest discomfort for the past 15 days, but did not see a physician. He was a non-smoker and did not use ethanol. He has epilepsy for 3 years, is a vegetarian, and is a school teacher by profession. At the time of admission his ECG (Figure 1), showed ST depression >2mm in V4-V6, ST elevation in aVR, and borderline changes in all other leads. LVEF measured 40-45%. TnI measured 56ng/dl, resting blood sugar measured 254mg/dl, and Creatinine measured 1.2mg/dl; HR was 136/min and BP was 80/100mmhg; and oxygen saturation was 93% in room air. Chest X-ray was clear. Angiography was performed via the radial route; during angiography the patient developed epilepsy and was given IV phenytoin.
LMCA: proximal total occlusion (Figure 2), filling retrograde from RCA faintly (Figure 3).
RCA: dominant with mild disease in the mid and distal segments (Figure 4).
A loading dose of clopidogrel 900mg, aspirin 325mg, and atorvastatin 80mg were given. Bolus and infusion of bivalirudin were given according to body weight. The LMCA was engaged with a JL 7Fr guiding using the right femoral approach. First a BMW guidewire was engaged with some difficulty into the LAD, and second BMW guidewire was positioned in the LCX. A 1.5x10mm Maverick balloon was used to predilate the entire LM to mid LAD (Figure 5) followed by a 2.0x10mm Maverick balloon. The patient developed mild hypotension (70/90mmHg); and dobutamine 10mcg and noradrenalin 5mcg were started. First a 2.5x33mm Xience Prime stent was deployed in the distal LAD (Figure 6), followed by a 2.75x33mm (Figure 7) and a 3.0x33mm (Figure 8) Xience Prime stent in the mid and proximal LAD and LMCA. The entire stented segments were overlapped and post-dilated accordingly (Figure 9). The final result was good and no residual thrombus or dissection was found (Figure 10).
Conclusion(s) / Result(s)
Bivalirudin infusion was continued for 12 hours, and ECG changes decreased significantly. The patient was discharged on the 5th day with appropriate medications.
In high risk LMCA angioplasty, skill and meticulous planning are important. In this patient with crescendo angina and a highly elevated troponin and compromised LV function, the CT surgeon was reluctant to peform CABG.
Conflicts of Interest

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