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PATIENT CASE

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An 85-year-old man with a history of tobacco use, hypertension, paroxysmal atrial fibrillation, insulin-dependent diabetes mellitus, prior cerebrovascular accident, previous myocardial infarction (MI), coronary artery disease (CAD), and ischemic cardiomyopathy presented with high-risk non–ST-segment elevation myocardial infarction (NSTEMI) associated with heart failure symptoms (New York Heart Association [NYHA] class IV). Cardiac exam revealed bibasilar rales, a laterally displaced point of maximal impulse, a regular rhythm with normal heart sounds, and trace bilateral lower extremity pitting edema. His electrocardiogram revealed normal sinus rhythm and left axis deviation, along with ST depressions and T-wave inversions in the lateral leads suggestive of ischemia. Chest x-ray showed diffuse pulmonary edema and an enlarged cardiac silhouette. Laboratory values were notable for an initial serum troponin T of 0.08 ng/mL that peaked at 0.13 ng/mL, a serum brain natriuretic peptide level of 1700 pg/mL, and serum creatinine level of 0.7 mg/mL. Echocardiography showed severely reduced left ventricular systolic function with severe global hypokinesis, severe mitral regurgitation, and a left ventricular ejection fraction (EF) of 20% to 25%. Of note, 6 months prior to this admission, his left ventricular systolic EF was 45%. He was initially treated with aspirin and ticagrelor and anticoagulated with unfractionated heparin. Coronary angiography revealed a 99% heavily calcified bifurcation lesion in the proximal left anterior descending (LAD) coronary artery involving the origin of a large first diagonal branch, with Thrombolysis in Myocardial Infarction (TIMI) 1 flow. The Medina classification of the lesion was 1,1,1 (Figure 18-1). The left circumflex coronary artery was a diffusely diseased vessel with a moderate lesion in the distal segment. The right coronary artery (RCA) was a dominant vessel with a severe, long, diffuse, eccentric, and heavily calcified lesion in the mid segment and a second calcified, focal lesion in the posterolateral branch. There was extensive collateral circulation from the RCA to the distal LAD via septal branches (Figure 18-2). The calculated Society of Thoracic Surgery predicted risk of mortality was 11.7%. The case was discussed among the multidisciplinary heart team, including cardiothoracic surgeons and interventional and noninvasive cardiologists. Based on his age and comorbidities, the patient was deemed to be a poor candidate for coronary artery bypass graft surgery (CABG) and was therefore referred for high-risk percutaneous coronary intervention (HR-PCI).

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Figure 18-1

Baseline angiographic images of the left coronary artery. Caudal views of the left coronary system demonstrating a complex, heavily calcified, long, subtotally occluded bifurcation lesion involving the proximal LAD and the origin of a large first diagonal branch (arrow).

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Figure 18-2

Baseline angiographic images of the right coronary artery (RCA). Right anterior and left anterior oblique views of the RCA demonstrating significant and heavily calcified lesions in the mid segment of the right coronary segment and the posterolateral branch (arrows). Note the collateral flow through septal branches of the posterior descending ...

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