Author + information
Patient initials or identifier number
Mrs. NGUYEN T.A.
Relevant clinical history and physical exam
A Female 56 years old, NYHA II-III, admitted due to exertional chest pain. Her CVD risk factor included: hypertension, hypercholestemia. Her stable angina become relevant 1 year ago but recently more angina episodes happened without any reliefs by antiangina medications. Her ECG showed Q wave of old infarction in inferior and anterior wall. Echocardiography results showed severely reduced LVEF of 25% with hypokinesia in all wall motion and moderate MR.
Relevant test results prior to catheterization
After discussed with heart team, patient refused bypass and would like to have PCI. Attempt to open mLAD CTO was decided.
Relevant catheterization findings
After crossing mLAD CTO lesion with Gaia 3 wire, the micro catheter very difficult to pass through the lesion. After predilatation with 1.25 mm balloon, the micro catheter can pass through the lesion, however tip injection through microcatheter showed perforation at mLAD lesions.
Face to coronary perforation at mLAD CTO due to wrong wiring at night.
Use deflation with negative pressure to suck the micro catheter in the false lumen
Put second wire into septal branch and inflation from proximal LAD to septal 1 with 2.5 balloon to stop perforation. However, the tricky situation is the septal to inflate was the main source of collaterals for distal RCA vessels and BP will go down if balloon inflated too long. Deflation and inflation should be consequently to avoid hemodynamic deteriotation.
Check bedside echocardiography showed mild effusion without any hemodynamic deterioration.
No protamin was used.
After long balloon inflation at septal branch, selective angiogram showed no more perforation, repeated bedside echo did not show expanded effusion, and patient was transferred to CCU to monitor closely when the hemodynamic was stable.
On CICU few hours later: BP come down with moderate effusion in bedside echocardiography and elevated level of blood lactate. Pericardiostomy was done at CICU and clinical manifestation improved immediately.
Pericardial drainage was less next morning and finally, patient discharged well 5 days later
Challenging case of coronary perforation at mLAD CTO due to predilatation/guide wire sealing partially with long deflation of balloon at septal branch. Take home message: “So called simple CTO” images still need carefully approach ! Always optimize small preceding steps to prevent the late big complications ! Think creative when there is no way to deal with.