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Relevant clinical history and physical exam
A 66-year-old man, who had been implanted cardiac resynchronization therapy defibrillator in 2008, was admitted to our hospital because of persistent chest pain. His coronary risk factors were hypertension, diabetes mellitus, dyslipidemia, smoking history, hyperuricemia and chronic kidney disease.
Relevant test results prior to catheterization
Coronary angiography in 2008 demonstrated significant stenosis in the right coronary artery and the diagonal branch. His electrocardiogram revealed all pacing. Echocardiogram showed ejection fraction of 16.4% and diffuse left ventricular hypokinesis with apical akinesis.
Relevant catheterization findings
Left coronary angiogram showed a severe stenosis in the proximal left anterior descending artery, which was apparently progressed in comparison with the previous finding, and moderate stenotic lesions in the diagonal branches. Right coronary angiogram showed significant lesions in the proximal and mid segment.
We engaged a 6Fr Ikari left type 3.5 guiding catheter at the left coronary artery via the right radial artery, and crossed the lesion with the Run through NS Extra floppy wire. Intravascular ultrasound showed convex shape of the luminal surface with acoustic shadow. In addition, optical coherence tomography showed protrusion of the calcified nodule (C-N) toward the lumen with thrombus. We dilated the lesion using a 2.5 x 10 mm Score flex balloon catheter and deployed a 2.75 x 12 mm Xience Alpine stent. After that, we dilated the lesion with a 3.0 x 8 mm Hiryu Plus balloon catheter because the stent expansion was not enough. The final angiographic and Intravascular ultrasound results were so good.
Although the pathophysiology of calcified nodule remains unclear, our case indicated that the calcified nodule could develop to cause acute coronary syndrome at an apparent normal lesion in eight years.