++
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).
++++