AR

A 45 year-old-male patient was referred for coronary evaluation prior to kidney transplant. He was asymptomatic with history of diabetes, hypertension and kidney failure on routine dialysis. He had a high blood pressure of 197 / 88 mmHg and apical systolic murmur and AV fistula (Cimino) on his left arm. His other examination was unremarkable. He was already on aspirin 80 mg, rosuvastatin 20 mg and fixed-dose hypertension medication amlodipin/valsartan 5 / 80 mg.

His ECG showed normal sinus rhythm 80 beats per minute, left axis deviation, incomplete right bundle branch block, LA enlargement, LV hypertrophy. Echocardiogram showed dilated LA and LV with low EF of 39 %, TAPSE 2.8 cm,global hypokinesia and mild MR. His pertinent laboratory results showed creatinine 9.5 mg/dL, hs-Troponin T 295 ng/mL, LDH 299 U/L, 6.74 mg/L, kalium3.9 mmol/L and hemoglobin 13 mg/dL.

Coronary angiogram showed normal right coronary artery, left main and left circumflex. Mid LAD had 90 % stenosis and distal LAD had 80 % stenosis which both were suspected to have caused by coronary spasm. Post intracoronary nitroglycerin injection, the angiogram showed borderline stenosis of 49 % and 60 % in mid and distal LAD, respectively.
RCA Angiogram.wmv
LCA angiogram - spasm.wmv
LCA Post Intracoronary Nitroglycerin.wmv

To confirm whether the borderline stenosis limit the flow, an iFR examination was performed. A Verrata pressure wire was inserted  through a 6F system with RU guiding catheter to LAD. Significant pressure gradients were observed with spot iFR of 0.84 and 0.79 in mid and distal LAD, respectively. Pullback iFR was 0.76 in LAD. Direct stenting PCI to mid and distal LAD was then decided. A BMW guidewire was inserted heading towards target lesion in mid and distal LAD. A 2.5 x 23 mm Xience Sierra drug-eluting stent (DES) was inserted to distal LAD lesion and deployed at 13 atm. Afterwards, a 3.0 x 28 mm Xience Sierra DES was inserted to mid LAD lesion and then deployed at 18 atm. Final angiogram showed good results with TIMI 3 flow. Patient was then put on dual anti-platelet for one month followed with single anti-platelet indefinitely.
3. Final LAD Angiogram.mp4
1. iFR.mp4
2. PCI distal and mid LAD with 2 DES.mp4

In a case of significant stenosis caused by coronary spasm with borderline stenosis on angiogram after intracoronary nitroglycerin injection, iFR was useful in evaluating the pressure gradient which in this case showed flow-limiting stenosis thus prompting necessary PCI to be done.