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Relevant clinical history and physical exam
A 79 year-old male patient with diabetes, hypertension and dyslipidemia presented to an outside hospital with chest discomfort of CCS class II. Upon the angiographic diagnosis of LM and 3VD, the attending physicians recommended CABG surgery according to the clinical guidelines. However, the patient refused to undergo surgery and visited Seoul National University Hospital, seeking a second opinion.
Relevant test results prior to catheterization
Coronary CT angiography revealed multifocal calcified plaques with significant stenosis in distal LM, proximal to mid LAD, LCX ostium, and proximal RCA. There was no significant abnormality in myocardium, and the coronary artery calcium score was 255.45.
Relevant catheterization findings
A coronary angiography (CAG) revealed discrete 50-60% stenosis of distal LM (a), 60% stenosis of LCX ostium (b), tubular 80% stenosis of proximal LAD (c) and 70%stenosis of mid LAD (d), and tubular 70% stenosis of proximal RCA (e), resulting in a SYNTAX score of 45.
Rather than referring the patient to CABG surgery or performing a percutaneous intervention to the stenotic lesions immediately, we measured fractional flow reserve (FFR) for each lesion. In contrast to the angiographic assessment (LM and 3VD, SYNTAX score = 45), proximal LAD and mid LAD lesions were the only‘functionally-significant’ lesions with low FFR values (FFR = 0.70), whereas the LCX and RCA lesions showed FFR values higher than 0.80. The IVUS in LM showed a luminal area of 6.10 mm2, indicating that the LM lesion is functionally insignificant. According to the FFR measurement and IVUS imaging,this patient was diagnosed as 1VD with a functional SYNTAX score of 12. We performed the FFR-guided PCI with DES to the proximal and mid LAD lesions but did not perform revascularization to LM, LCX and RCA lesions. Until 2 years after the successful PCI to LAD, this patient remained asymptomatic, and follow-up echocardiography showed no evidence of myocardial ischemia.
In this patient with LM and 3VD with a high angiographic SYNTAX score, the LAD lesions were the only functionally significant lesions as assessed by FFR measurement and IVUS imaging. This case suggests that the angiographically complex coronary disease does not always require surgery, and that the physiologic assessment can provide a crucial information for determining the optimal treatment strategy and may improve the overall prognosis by reducing unnecessary procedures.