CASE20210820_002

Coronary Intervention of Bifurcation Lesions by Novel Technique and ASD Device Closure-Hands on Hands

By Abdul Momen, Ashraf Ur Rahman
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Presenter

Dr. Abdul Momen

Authors

Abdul Momen1, Ashraf Ur Rahman2

Affiliation

National Institute Of Cardiovascular Diseases, Bangladesh1, National Institute of Cardiovascular Diseases (NICVD), Bangladesh2
Complex PCI - Bifurcation/Left Main Diseases and Intervention

Coronary Intervention of Bifurcation Lesions by Novel Technique and ASD Device Closure-Hands on Hands

Abdul Momen1, Ashraf Ur Rahman2

National Institute Of Cardiovascular Diseases, Bangladesh1, National Institute of Cardiovascular Diseases (NICVD), Bangladesh2

Clinical Information

Patient initials or Identifier Number

Mr. x

Relevant Clinical History and Physical Exam

Mr. X, a 55 years old cardiac OT boy, hypertensive and diabetic presented with progressively increasing dyspnoea (NYHA II/III), chest pain and palpitation. He is a known case of ASD (Secundum) for last 20 years. But he refused surgical closure of ASD several times due to phobia of cardiac surgery. Recently he developed worsening of his symptoms including sudden onset of palpitation and chest tightness. His S2 was splitted and a systolic murmer was present over pulmonary area. Vitals were normal.

Relevant Test Results Prior to Catheterization

ECG: Atrial Fibrillation later reverted to sinus rhythm
Trans thoracic Echocardiography: ASD (Secundum) about 22 mm with left to right shunt. Good LV systolic function (EF 60%)
Trans Oesophageal Echocardiography: ASD (Secundum) 22x 18x 16 mm with left to right shunt. Rims are adequate except the aortic rim.
FBS: 6.7 mmol
HbA1C : 7.3 %
S.  creatinine: 1.2 mg/dl
F. Lipid Profie:  S. Cholesterol 220 mg/dl, HDL 35 mg/dl, LDL 160 mg/dl, TG 340 mg/dl
TSH: 3.2
SGPT: 45 U/L

Relevant Catheterization Findings

1. Bifurcating lesion about 80-90% involving LCX and OM1 (Medina 1,1,1). OM1 is a large caliber  vessel.
2. LAD is free of significant disease.
3. LM is normal
4. LCX is dominant
5. RCA is non dominant and free of significant disease.

Final Diagnosis : SVD, Bifurcation lesion LCX, OM1 with ASD (Secundum) with left to right shunt.

Treatment options:
             i) Surgical closure of ASD with CABG
             ii) PCI of bifucation lesion of LCX followed by device closure of ASD

Interventional Management

Procedural Step

The patient was given option for surgery but he again refused.So we planned for Intervention. If we close ASD 1st, there would be risk of diastolic heart failure. So we planned for PCI 1st. We started with distal radial access. We took slender sheath 7. We proceeded with 7F guide catheter combo technique ( 7F guide catheter with 5F 125 cm multipurpose catheter).
Our plan was single stent strategy with provisional Side branch (SB) stenting protecting the SB osteum by modified jailed balloon technique (MJBT). We wired both LCX and OM1. The lesion at LCX was predilated by semicomplaint ballon. A DES 3x 24 mm was placed at LCX and a balloon (2x12 mm) was negotiated to the SB. The SB balloon was pulled
and the proximal marker was kept about 2-3 mm within the main vessel while distal marker covered the SB ostium lesion. The main vessel (MV) stent & SB balloon were inflated simultaneously in nominal pressure. Then the SB balloon was taken out and MV stent balloon was again inflated to optimize the unapposed part of the stent. Wires were
recrossed. POT was done by 3.5 x 8 mm NC balloon at proximal part of the stent above the SB. The SB osteum stenosis could be adequately reshaped and TIMI III flow was achieved.The pateint was kept in diuretics and ASD device closure was attempted after 2 weeks. LVEDP was measured by pig tail catheter and was about 8 mm. ASD device was deployed by RUPV approach. LVEDP was again measured and it was 10 mm (not significantly high).

Case Summary

PCI for true bifurcation lesions has high risk for adverse events. SB occlusion is one of the most serious complications and occurs in more than 7.0% of cases during bifurcation
stenting. Selection of the optimal interventional strategy for true coronary bifurcation lesions is controversial. Novel strategy MJBT is safe and effective in preserving SB patency for true bifurcation lesions.
Complete interventional solution avoiding the fear and pain of sternotomy makes patient comfortable.