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Relevant clinical history and physical exam
The 53-year-old man suffered from chest tightness on exertion for several weeks. He was admitted for acute decompensated heart failure, NYHA Fc IV 3 months ago. During that admission, he was accidentally found to have severe left ventricular systolic dysfunction (diffuse hypokinesia to akinesia of LV) with LVEF of 26%. He felt dyspnea on mild exercise (NYHA Fc III) despite adequate medical treatment.
Relevant test results prior to catheterization
Echocardiography showed 1. Mildly dilated left ventricle (LV), 2. Diffuse hypokinesis to akinesis of LV with severe left ventricular systolic dysfunction, LVEF: 26%, and 3. Severe functional mitral regurgitation. Cardiac PET was done and showed that the mid-anterior wall of the left ventricle is viable and the lateral and inferolateral walls of the left ventricle are non-viable. Cardiac MRI was also arranged and showed diffuse late gadolinium enhancement at LV transmurally.
Relevant catheterization findings
Coronary angiography was done via right radial artery and showed double vessel disease (LM: patent; LAD: -M to -D: diffuse lesion up to 40%; LCX:-M: 80% stenosis; RCA: -P: chronic total occlusion with heavy calcification, RV collaterals to RCA-D and other collaterals from LCX-AM branch). LVG showed diffuse hypokinesia of LV with severe LV systolic dysfunction, LVEF: 25%.
For RCA lesion, a 7Fr AL 1 GC was engaged at RCA via a right femoral artery. A Fielder FC GW with a support of sprinter legend 1.25 x 6 mm OTW balloon failed to advance. We then changed the wire to Progress 200TGW and advanced it to RCA-D. A Trek 1.2 x 12 mm balloon was inflated at RCA-P to D with pressure up to 10 barr. With a support of 6Fr Guideliner, a Sprinter legend 2.0 x 12 mm balloon was pushed further to RCA-M to -D and was inflated with pressure up to 22 barr. However, balloon rupture was noted. We then used an NC Trek 2.5 x 20 mm and an NC Quantum 2.5 x 20 mm BC balloon to inflate at RCA-P to M up to high pressure (26 barr) due to no full-dilatation. Both balloons ruptured. An NC Empira 2.75 x 15 mm BC was inflated at RCA-P to M with pressure up to 26 barr. However, the balloon was not fully inflated at the stenotic lesion. After discussion with the family, they agreed to use the rota-ablation (self-paid). A Prowler microcatheter and extension wire was used for an exchange of Rota floppy wire. The rota-ablation with a 1.75 mm burr was done at RCA-P to M for 3 times. Then we used the NC Empira 2.75 x 15 mm BC to inflate at RCA-P to M with pressure up to 22 barr. An Integrity 2.5 x 30 mm BMS was deployed at RCA -M to D and another Integrity 2.75 x 30 mm BMS was deployed at RCA-P to M. A NC 2.75 X 15 mm Empira was inflated at RCA-P to M in-stent site for post-dilatation with pressure up to 24 barr. The final result of RCA was good with TIMI 3 flow.
The support of the systemic is crucial for PCI success. We used several techniques to enhance our system support, including AL guiding catheter, 6 in 7 Fr mother-and-son catheter, distal balloon anchoring technique, to overcome the tortuous and calcified chronic total occlusion lesion.