CASE20210729_005

Primary Angioplasty of Left Main with Cardiogenic Shock & Pulmonary Edema with IABP Support

By Hariom Tyagi
like off

Presenter

Hariom Tyagi

Authors

Hariom Tyagi1

Affiliation

Lokpriya Hospital, India1
High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk Intervention

Primary Angioplasty of Left Main with Cardiogenic Shock & Pulmonary Edema with IABP Support

Hariom Tyagi1

Lokpriya Hospital, India1

Clinical Information

Patient initials or Identifier Number

LK

Relevant Clinical History and Physical Exam

This 45 year old gentleman- a known case of old AWMI (post PTCA to LAD in 2011) presented to us with severe retrosternal chest pain & dyspnoea a/w sweating for last 3 hours. The patient was in Killip Class IV with cardiogenic shock and recurrent VT. 

Relevant Test Results Prior to Catheterization

Coronary angiography suggested critical LM stenosis with significant ISR of LAD stent in proximal part. 

Relevant Catheterization Findings

Patient was put on Intra-aortic balloon pump. JL 3.5- 7F guiding catheter was engaged in left cusp near LM ostium. After crossing the lesion & serial predilatation with semicompliant balloons, 4.0x 23 Xience Prime DES was implanted from LM to LAD covering the ISR segment. Post dilatation with proximal optimization was done using 4.5x 8 mm NC sprinter balloon. 

Interventional Management

Procedural Step

Patient was put on Intra-aortic balloon pump. JL 3.5- 7F guiding catheter was engaged in left cusp near LM ostium. After crossing the lesion & serial predilatation with semicompliant balloons, 4.0x 23 Xience Prime DES was implanted from LM to LAD covering the ISR segment. Post dilatation with proximal optimization was done using 4.5x 8 mm NC sprinter balloon. During hospital stay- inotropic support was gradually tapered & IABP was removed on day 4. The patient remained stable and was discharged on day 6. This case shows the importance of primary angioplasty of the Left Main in such critically ill cases where emergency CABG is not practically feasible. 

Case Summary

Percutaneous intervention with stent implantation for LMCA disease has become a standard procedure in contemporary practice with safety, expedited recovery, and durability. Precise selection of the strategy aided by intracoronary imaging, functional evaluation, and mechanical support when needed have improved the immediate and long-term results in this high-risk intervention. It is however important to have a team approach and operator expertise before embarking on LMCA interventions.