1. Case Presentation CRT
Sumith Aleti

2. History
66yo morbidly obese (BMI: 45), past smoker & no known medical history on a trip from Pennsylvania
Syncope in her car while at gas station
Immediate CPR by a bystander who is a paramedic
Received 4 shocks, amiodarone 300mg, Epinephrine x2, intubated and transferred to a near by ED
Labs: Na: 143; K:2.7; Cl: 100; HCO3: 19; BUN: 14; Creat:1.2, Troponin T 0.031
Hgb: 17; WBC: 11; Plt: 279

3. Initial Hospital Course
Transferred to our hospital
PEA arrest on arrival and regained pulse with Epi and CPR.
EKG: long QT and nonspecific ST/T changes.
CT chest: complete collapse of the left LL and partial collapse of the left UL along with possible pneumonia right LL and multiple rib fractures, no pulmonary embolism
Bronchoscopy performed for lung collpase.
Peak troponin T 1.6; CKMB 48.8
Bedside ECHO: limited by body habitus but grossly normal.

4. ECG

5. Coronary Angiogram Performed next day Right radial access
6Fr 13cm sheath
Tight distal LM stenosis
Occluded mid LCx
Collaterals to LAD and OM from right
LVgram (RAO and LAO): normal wall motion with LVEF 60%

6. Decision to intervene CT surgery urgently consulted.
Patient was felt to a poor candidate for surgery due to:
Respiratory issues
Fractured Ribs
Collapsed lung
Pneumonia
Morbid obesity
Proceeded with unprotected LM PCI

7. Preparation for PCI
Femoral access for unprotected LM, possible balloon pump.
Difficulties in obtaining access due to morbid obesity
Unable to advanced 7Fr sheath
4Fr sheath was placed
Femoral angiogram was obtained.
Exchanged for 7Fr 23cm

8. Access Problems Noticed right groin hematoma and increasing in size
Angiogram performed

9. Access site bleeding Closed with 8Fr angioseal
No active bleed was evident
Right iliac angiogram performed via right radial access via a balloon catheter to confirm hemostasis

10. Management of Bleed 8 x 20mm RIVAL balloon 135cm catheter
Asahi prowater wire
Balloon tamponade proximal to bleeding site
4 inflations
5 min each
4 atm max pressure
Post tamponade result

11. LM stenting
Given patient’s clinical presentation, proceed with LM stenting using:
Rt radial route
EBU 3.75 guide
Asahi Prowater wires into LAD and OM1
IVUS pre and post PCI

12. IVUS Diffusely diseased proximal LAD MLD of LM: 0.3mm
LM vessel diameter: 4.8mm
LM stented into LAD and another stent in proximal LAD

13. LM Stenting Predilated with 3.0 x 12mm Apex
4.5 x 20mm x 140cm VERIFLEX BMS
Post dilated with 4.5 x 08mm NC TREK RX

14. LAD Stenting Proximal LAD stented with 4.0x15mm Integrity BMS
Post dilated with 4.0x8mm NC Quantum Apex.
Post PCI IVUS showed well expanded and apposed LM and LAD stents

15. Further hospital course
Duplex right lower extremity
Thrombosed pseudoaneursym of right distal EIA
2.7cm x 3.9cm
1 cm wide neck
Follow up duplex stable
Failure to wean off ventilator
BAL grew Cryptococcus and patient was treated for it.
Tracheostomy and PEG tube performed
Transferred to nursing home for long term care