I Blew It

60 years old male with history of hypertension, hyperlipidemia, ESRD on HD, CAD with CABG in 2006 (LIMA to LAD, SVG to RCA), PCI to LCx in 2012 and ISR in LCx stent with PCI to LCx and OM1 by TAP technique.

He was admitted for NSTEMI. Echo EF 50-55%, no RWMA, ECG showed reversible ST depression over lateral leads, TNT 0.11 to 1.78.

Cath showed patent LIMA to LAD, patent SVG to RCA, LM diffuse 60%, pLAD subtotal occlusion, competitive flow with LIMA, LCx-OM1 medina 1:1:1 95% bifurcation lesion (Figure 1, Movie 1, Movie 2). Patient was seen by surgeon and he opted for PCI.

8Fr JL4 guide to LM, no pressure damping noted but 2nd injection was complicated with left main dissection and perforation (Movie 3). Patient went into cardiac arrest immediately. CPR started and ET tube was inserted by anesthesiologist. BMW wires were inserted to LCx and OM1 with some difficulty. At the same time, temp wire and impella CP were inserted for hemodynamic support (Movie 4). Pre-dilatation was done with 2.5mm balloon (Movie 5). Then DES 3.0×26 deployed at ostial LM to LCx (Movie 6). Post dilated with 3.5mm NC balloon.

After successful stent deployment, there is restoration of blood pressure. Subsequent TEE showed hematoma at cusps with no evidence of dissection (Figure 2, Movie 7). Patient regained full conscious on the cath lab table with ET tube in-situ.