False or True? That is a Question
Dr. Ling-ling CHEUNG
United Christian Hospital, Hong Kong
A 42 year old lady who enjoyed good past health was admitted through emergency department because of sudden onset of retrosternal chest pain associated with shortness of breath, dizziness, nausea and vomiting in the middle of the night. Upon admission, the blood pressure was 100/59. Electrocardiogram showed sinus tachycardia, 110/min. Blood test including complete blood picture, liver and renal function test were all normal. However, the Troponin I was raised to 13 (mcg/L). Bedside echocardiography showed good left ventricular systolic function of 60%, there was anteroseptal wall hypokinesia and mild mitral regurgitation. The working diagnosis was non ST elevation myocardial infarction. In view of the excruciating chest pain, she was scheduled for urgent coronary angiogram. It showed linear spiral dissection in distal left main artery LM which extended into mid left anterior descending artery mLAD resulting in TIMI 0 flow beyond. The ostial left circumfex artery LCx was also involved by the dissection, however TIMI 3 flow was maintained (Movie 1, Movie 2). The right coronary artery was relatively normal. In view of extensive dissection, aortogram was performed via left femoral artery access which showed a normal caliber aorta with no dissection flap.
Following joint discussion with the patient, her husband and the cardiac surgeons, the decision was for percutaneous coronary intervention.
The left coronary artery was cannulated with a 6F Judkin left 3.5 guiding catheter. A Runthrough Hypercoat guidewire was advanced into the distal LCX artery whilst another guidewire Fielder FC was advanced into the distal LAD. IVUS interrogation with a 40mHz Atlantis Pro catheter confirmed extensive nature of coronary dissection with a false lumen extending from the ostium of the left main up to the mid LAD (Movie 3, Figure 1, Figure 2). There was also intramural haematoma in the mid LAD, but there was no obvious atheroma in the arterial segments interrogated. A 3x20mm Ottimo Ex balloon was used to dilate the mid LAD segment. A 4x28mm SYNERGY stent was first deployed from the ostium of the left main artery to the proximal LAD. Repeat angiography showed no improvement of flow in the mid LAD (Movie 4). A second SYNERGY stent 3x32mm was then deployed across mid LAD proximally overlapping with previous stent (Movie 5). The LCX artery was rewired through the LM stent struts. A NC Quantum Apex balloon 4x15mm was used to postdilate the proximal segment of the stent. Repeat IVUS study showed some stent malapposition in the mid LAD as well as distal LM, therefore further postdilatation was performed using a 4.5x20mm NC Quantum Apex balloon to mid LAD and a 5x15mm NC Quantum Apex balloon to distal LM. No further dissection plan was visible in the LCX artery angiographically after LM stenting (Movie 6, Movie 7) and therefore no further intervention was deemed necessary. The patient was haemodynamically throughout the procedure and she was discharged home two days after procedure.
