57 years old HTN & DM Male, history of exertional angina for 5 months back . ECG ST depression in precordial leads, 2D Echo mildly hypokinesia of LAD territory with LVEF of 55%. BP - 130/80 , PULSE - 86 BPM,CVS - S1 S2 NORMAL , CHEST CLEAR
CAG revealed DVD Ostial LAD CTO, ostial circumflex 90% lesion & 40% proximalRCA lesion referred for CABG .CABG done with graft LIMA to LAD & RSVG to PLVB (surgeon discretion) symptomatic again check CAG -- adviced
MOVIE-0003.mp4 MOVIE-0004.mp4 MOVIE-0006.mp42D Echo
(At admission ) Lcx territory hypokinetic , LAD and RCA territories normal mild lv systolicdysfunction LVEF – 45 %, RVSP- 40 MM OF HG
(After6 hrs) severeLV dysfunction with LVEF 20%, Akinetic LAD and LCX territories with severe PAH(60mm of Hg).
Trop I was elevated > 4 times
CAG: Post CABG LMCA – Distal total occlusion with faintly filling LCx RCA – Proximal 50% lesion LIMA – LAD –anastomotic site 90% lesion . distal to the graft 80% lesion in native LAD
POST CABG CAG (GRAFT).mp4 POST CABG CAG.mp4Discussion -
• A challenging case of ACS with cardiogenic shock involving LMCA, LAD and LCX
• Needed urgent revascularization of LAD and LCX in view of rapidly deteriorating hemodynamics
• Distal LMCA minicrush bifurcation stenting with opening of flush LAD ostial CTO was successfully accomplished with hemodynamic support
• This case stresses the importance of early revascularisation in cardiogenic shock of ischaemic etiology
