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Patient initials or identifier number
Relevant clinical history and physical exam
The patient was 85 years-old female.
She had a history of hypertension, dyslipidemia, aortic regurgitation, mitral regurgitation, hypothyroidism, and no dementia. She came to our hospital by ambulance because of worsening chest pain at the night. She was alert and conscious but blood pressure was 90/51 mmHg and heart rate was 77 bpm.
Relevant test results prior to catheterization
The electrocardiogram showed ST elevation in aVL and aVR, and mirror image in inferior leads.
The chest X-ray showed significant pulmonary vascular congestion and cardiothoracic ratio was 63.4%.
Relevant catheterization findings
We performed emergent coronary angiography and found that both LAD ostium and LCX ostium had 99% stenosis with severe delayed flow (Fig.1).
Remarkably, LAD and LCX were bifurcated at the angle of almost 180 -degree.
Furthermore, LAD had an aneurysm near the ostium.
Immediately we started PCI to LAD ostium and LCX ostium.
At first, we inserted intra-aortic balloon pump (IABP) to keep her hemodynamic status stable. Next, we put guide wires to both LAD and LCX and dilated alternatively with semi-compliant balloons.
There was another severe stenosis at the distal site of LAD, so we also dilated the lesion and deployed Ultimate stent (terumo) 2.5/15 mm. Finally, we performed V stenting with two Ultimaster stents (terumo) (3.5/15 mm to LAD ostium and 2.5/15 mm to LCX ostium)Moderate stenosis have remained at the side branches of LAD and the distal site of LCX but the coronary flow was reserved (Fig.2).
Therefore, we finished the procedure. About 12 hours later, we could weaned her off IABP. Peak CPK was 93IU/L. She had worsening anemia (minimum hemoglobin was 6.2 g/dl) and that was thought to be a cause of heart failure, so she needed a blood transfusion. After 20 days of treatment, she left the hospital and went home.
We treated an aged case of acute coronary syndrome with left main trunk bifurcation lesion by V stenting and had a good result. She and her family do not want follow up coronary angiography and she has no symptoms or cardiac events up to the present.