Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
Mrs. M 40 year-old, non-hypertensive, non-diabetic housewife admitted with compressive chest pain for 10 hrs. She mentioned there was an exertional chest pain for few weeks and it relieved on rest but this time pain was persisting even on rest. ECG showed T inversion in anterior leads and based on positive Troponin I. She diagnosed as a case of NSTEMI.
Relevant test results prior to catheterization
ECG – ST depression in anterior lead with slight ST elevation in aVR (01A JPG)
Echo – Anterior wall hypokinesia, EF- 55%
RBS – 7 mol/l
Trop I- positive
Relevant catheterization findings
1) Tight left main coronary stenosis from LM ostium to distal LM bifurcation (Fig 1)
2) LAD: 60-70 narrowing in Proximal segment involving the D1 (Fig 1,)
3) LCX : Origin 30-40% (Fig 1, )
4) RCA normal (Fig 2)
Aspirin 300 mg and Clopidogrel 600 mg before the procedure.
PCI LM- Placed 7F JL 3.5 Guide catheter non selectively into LM ostium. I/V bolus heparin. By keeping Guide catheter non-selectively one run through the wire was inserted into LAD and another run through a wire into LCX. (Fig MB 04). Pre-dilatation, DES 2.75 x 48 mm (LM-LAD),provisional, stent cross-over, (Fig MB 06).Post-dilatation.POT.There was plug shifting into LCX. Wire recrossing. Kissing balloon inflation.2nd POT in LM with 3.5 mm NC balloon@18 atm. The final result was excellent ( Fig MB 07).
Hospital stay uneventful, discharged with Aspirin 150 mg and Clopidogrel 75 mg,
Sometime PTCA wire may be inserted by keeping the guide catheter placed non-selective.
RAD caudal, AP Cranial, LAO Cranial views should be checked for proper coverage of LM ostium.
Single stent provisional strategies are to be preferred for the majority of left main bifurcation lesions.
By starting with a provisional approach, all (sensible) options remain open to you.