Hybrid Revascularization in a Patient with Severe Ischemic MR and Cardiogenic Shock

¹, ¹

, Hong Kong, China¹

Clinical Information

Patient initials or Identifier Number

WSK

Relevant Clinical History and Physical Exam

68 year-old women presents with Cardiogenic shock and severe mitral regurgitation with inferior wall hypokinesia and posterior papillary muscle dysfunction. JVP elevated, acute pulmonary edema
She has previous history of PCI to LAD, LCx and RCA

Relevant Test Results Prior to Catheterization

ECG shows inferior and lateral STD-TWI, aVR ST elevationEcho: inferior/inferolateral Hypokinesia EF~35%. PMVL tethering with severe MR posteriorly directed. No pericardial effusion

Relevant Catheterization Findings

Coro: LAD patent stent. RCA 80% ISR. LCx 90% ds at stent inlet and long stent present. Tiny OM not suitable for grafting. Given inotrope IABP inserted at bedside in prior to coronary angiogram in view of cardiogenic shock with severe MR

Interventional Management

Procedural Step

Sent for emergency OT after emergency heart team meeting with Mitral valve annuloplasty and commissuroplasty and CABG with SVG to PDA doneSurgeon commented that the LCx could not be grafted due to presence of long stent and only a small OM branch and suggested hybrid approach revascularization to LCxPCI to LCX done after surgical repair done Left femoral access 6 Fr. XB 3.5 guiding Runthorugh hypercoat guidewire OCT done. LCX ostial 99% ISR with STO, AG TIMI 2 flowLCX crossed with Supercross 90 MC and Fielder XTA, switched to SION blue on Caraval MCLCX dilated with 2.0 balloon and OCT doneFurther balloon with NC scoreflex 3.0LAD dilated with NC 3.5 at 22 atm and LCX with NC 3.0 at 22 atmKBI (NC 3.5/NC 3.0 at 12 atm)Pantera Lux DCB 3.0/15 to LCXOCT showed satisfactory results. TIMI 3 flowLFA closed with 6Fr angiosealPuncture Site