1. One patient, two years, three choices, four PCI ZHAO Peng Cardiology ， the Affiliated Hospital of Medical College of CPAPF, Tianjin, China

2. Case presentation Male ， 61 years old Chest pain for 4 hours ECG ： ST segment elevation on V1-V5 lead Smoking 、 hypertension 、 hyperlipidemia No diabetes mellitus Diagnosis: Acute myocardial infarction

3. Coronary angiography

7. Treatment strategy Open the culprit vessel as early as possible Use coil wire to avoid into the false lumen Crush the thrombus by balloon dilation Implant stent to restore the blood supply

8. Balloon : 2.5*14mm Pressure ： 8atm After nitro. bolus ， TIMI-3 flow

9. Stent 1: Cypher 3.0*18mm Pressure:12atm

10. Stent 2: Cypher 3.0*23mm Pressure:16atm

11. The final film

12. Patient condition The symptom of angina disappeared Vital sign were stable Echocardiograph showed LVEF 42%

13. 11 months later Intermittent chest pain for 5 days ECG on symptom: ST segment elevation on avR lead No drug terminate Stop smoking Blood pressure, glucose and lipoids were satisfactory So, WHY?

14. Recheck Coronary Angiography

15. LM ostial-proximal lesion

17. LCX ostial lesion

18. No lesion in RCA

19. Unstable plaque in LM and LCX IVUS check

20. What’s the next? CABG? PCI? Our determination ： PCI No calcification lesion, easily transport devices DES ， seldom restenosis Checked by IVUS ， perfect stent- adherent

21. LCX, Balloon dilation, 3.0*15mm ， 12atm

22. Stent location

23. Stent : Endeavor 4.0*24mm Pressure:16atm

24. Kissing balloon LM 4.0*24mm 16atm LAD 3.0*13mm 16atm

25. Stent implanted, checked by IVUS, perfect stent-adherent

26. Patient condition The symptom of angina disappeared again after PCI UCG: LVEF45% Take more drug, adding cilostazol No symptom for 1 year, recheck coronary angiography

27. Coronary angiography

28. What we can do? Clinical observation ？ CABG ？ PCI ？ After the communication with the patient’s kin, the final choice was PCI

29. LAD ostial lesion Cutting Balloon 3.5*6mm 8atm

30. LAD ostial lesion LCX ostial lesion

31. Cutting balloon 3.5*6mm 8atm

32. Cypher 3.5*23mm Located to LM ostium 18atm

33. Kissing balloon LAD 3.5*15mm 12atm LCX 3.5*15mm 12atm

34. LM, the stent’s corollas overlapped

35. The final film

36. 7 days later Chest pain exploded, cold sweat and shock ECG: ST segment elevation on avR lead and depression on V1-V6 lead Troponin T was elevated treatment ： IV tirofiban coronary angiography

37. The bulk of thrombus filled LM, proximal LAD and LCX, the blood of LAD was TIMI-2 grade

38. What we can do? We had no choice besides PCI IABP Thrombus suction anticoagulants Vasoactive agent

39. Sucking thrombus TIMI-3 flow

40. The final film

41. Present condition Persistent IABP for 4 days Twice acute heart failure 7 days in CCU UCG: LVEF 25% Underwent CABG after 4 weeks

42. Thanks !