Mrs T

Patient female 67 years old, was admitted with worsening of dyspnea on effort few months prior to admission. She denied chest pain and hospitalization due to myocardial infarction. She has history of hypertension and diabetes mellitus type 2. Patient also with chronic kidney disease stage V on routine hemodialysisand scheduled for kidney transplant.

ECG shown sinus rhythm, 80 bpm, normal axis, left atrial enlargement and left ventricular hypertrophy, inverted T wave in inferior leads. Echocardiography found concentric LV hypertrophy, dilated RA and RV, hypokinetic in inferior LV wall with estimated ejection fraction 37%, mild mitral and pulmonary regurgitation.

Coronary angiography shown normal left main coronary and left circumflex artery, mild 30% stenosis lesion in mid right coronary artery, and 70 – 80% stenosis lesion in mid left anterior descending artery.
LAD 1.wmv
LAD 2.wmv
RCA.wmv

BMW guidewire inserted through JL3.5-6F guiding catheter into target lesion in mid left anterior descendingartery. Instant wave-free ratio was performed and shown estimated pressure gradient 0.77, so we decided to continue with coronary stenting. Predilatation in target lesion was performed with Across HP balloon 2.0-15mm, followed by stenting with DES BioFreedom 3.0 – 24mm with pressure around 10 -12 atm. Post stenting evaluation shown normal blood flow TIMI 3 in distal of left anterior descending artery.
iFR procedure.wmv
PRE DILATATION.wmv
STENTING 2.wmv

Instant wave-free ratio improve accuracy in decision for coronary stenting, particularly in borderline stenosis lesion. In this case, coronary angiography shown borderline coronary stenosis lesion, particularly in female patient without significant clinical symptoms of ischemia, other than decreased ejection fraction. iFR guided catheterization provided information whether stenotic lesion is flow limiting and coronary stenting is needed. Thus, patient cardiac function will improved and stable prior to her schedule for kidney transplant.