P39 MANAGEMENT OF A CASE OF LAST REMAINING PATENT VESSEL

Abstract

Abstract A 72–year–old hypertensive, dyslipidemic and smoker (20 cig/day) gentleman was admitted to the emergency department for pulmonary edema. Past medical history included COPD, anterior MI treated with PCI and stenting of proximal LAD 5 years back, recent TIA. He was admitted to cardiac intensive care unit and treated with CPAP, IV furosemide and norepinephrine. Echocardiogram showed severe ventricular dysfunction (LVEF 20%) and severe functional mitral regurgitation; lab tests pointed out mild troponin elevation (50 ng/L) and high levels of BNP (1300 pg/mL). After stabilization, he underwent coronary angiography: in–stent CTO of LAD, critical stenosis of distal LM and ostio–proximal LCX (last remaining patent vessel, LRPV); hypoplastic RCA. At the end of angiography, new episode of pulmonary edema that required treatment with inotropes, CPAP and diuretics. Considering hemodynamic instability and high surgical risk (combined STS 37%), the Heart Team decided to proceed to PCI with mechanical circulatory support with Impella CP. From left radial access we achieved advancement of JR4 guiding catheter with guide extension in right common iliac artery. We performed angiography and then put a coronary guidewire in superficial femoral artery to facilitate right femoral access (angio–guided). From this femoral access we implanted Impella CP device. From left radial access we performed PCI: cannulation with JL 3 guiding catheter, wiring with Sion Blue ES guidewire, pre–dilatation with NC balloons until 3.0 mm diameter, stenting of LM–LCX with 1 DES 4.0/32 mm, post–dilatation with NC balloons (4.5 and 5.0 mm diameter). Good angiographic result; IVUS examination revealed good expansion and apposition of stent. Femoral access was closed with 2 Perclose Proglide. Patient was then monitored in cardiac intensive care unit, with clinical improvement and without complications. 10 days after PCI the patient, asymptomatic, was discharged. The echocardiogram displayed betterment of contractile function (LVEF 28%) and of mitral regurgitation (now moderate). At 4–month follow–up visit, patient is paucisymptomatic (NYHA class II), without angina episodes, with good quality of life in guideline–directed optimal medical therapy. Critical disease of LRPV is a severe condition, with unpredictable evolution and poor prognosis. PCI of LRPV in HFrEF patients is an high–risk PCI scenario in which mechanical circulatory support with Impella can prove to be essential.