PCI in patients with cardiogenic shock associated with acute occlusion of the left main coronary artery

Patient urgently transferred to the catheterization laboratory Current presentation 57 year-old man, chest pain > 2 hours and palpitation Risk factors Arterial hypertension Diabetes mellitus type 2 Active smoker Instrumental data BP – 70/40 mmHg ECG - ST depression in leads II, III, aVF, V2 – V6 Transthoracic ECHO - hypokinetic anterior wall , ejection fraction 30% Diagnosis NSTEMI, Cardiogenic shock, Killip IV. Patient urgently transferred to the catheterization laboratory Case 1

Angiographic data Retrograde filling of the left arteries Right femoral artery approach 6 Fr sheath 5 Fr diagnostic catheter Total occlusion of the left main LCx D 1 Distal LAD Anteroposterior caudal projection Anteroposterior cranial projection

Procedure XB 3.5 guiding catheter Runthrough NS floppy guidewire (hydrophilic) to the LAD Balloon predilatation with semi-compliante balloon catheter 2.0 × 10 mm (8 atm)

Procedure (cont.) Final result after stent implantation Stenting followed by the final kissing balloon postdilatation 3.5 × 18 mm BMS LM - LAD After balloon predilatation After balloon predilatation conducted second Runthrough NS floppy guidewire to the LCx Final result after stent implantation and postdilatation with 4.0 × 10 mm NC balloon

Follow up 6 months later

Comorbidities and bad habits Current presentation 64 year-old man, chest pain > 1 hours and palpitation Risk factors Arterial hypertension Active smoker Instrumental data BP – 80/30 mmHg ECG - ST depression in leads V4 – V6 Transthoracic ECHO - akinesia anterior wall and the apex, ejection fraction 33% Comorbidities and bad habits Aneurysm of the ascending aorta, d = 4.8 cm Chronic obstructive pulmonary disease Diagnosis NSTEMI, Cardiogenic shock, Killip IV. Patient urgently transferred to the catheterization laboratory Case 2

Angiographic data Right radial artery approach 6 Fr sheath 5 Fr diagnostic catheters LAD Total occlusion of the left main Aneurysmal right coronary artery and retrograde filling of the LAD Anteroposterior caudal projection RAO caudal projection

Angiographic data

Procedure XB 3.5 guiding catheter Runthrough NS floppy guidewire (hydrophilic) to the Ramus Multiple balloon predilatation with semi- and non-compliante balloon catheters 2.0 × 15 mm (8 atm) and 2.25 × 15 mm (14 atm) respectively

Procedure (cont.) After balloon predilatation conducted second Runthrough NS floppy guidewire to the LAD LCx Culprit lesion Ramus LAD Anteroposterior cranial projection

Procedure (cont.) Stenting followed by the final kissing balloon postdilatation Тhe patient has been stabilized and two weeks later was operated CABG BMS 3.0 × 15 mm LM-Ramus Final result after stent implantation

Final result