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Decision Making Using with FFR (Fractional Flow Reserve) Guidance
- Operator: Antonio Colombo, MD
Case Presentation
A 74 year-old man was admitted with effort chest pain for 3 months. His coronary risk factors were hypertension, hyperlipidemia and ex-smoking. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=65%) without regional wall motion abnormality. Treadmill test is negative and thallium test showed reversible large perfusion defect of LCX territory.
Baseline coronary angiography
The left coronary angiogram showed tight stenosis of LM to proximal LAD, tubular stenosis of middle LAD, and diffuse narrowing of distal LCX ( Movie 1, Movie 2, Movie 3). The lesions at right coronary artery were not significant.
Procedure
A 7 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with a 7Fr XB 3.5 catheter with side hole. Two 0.014 inch BMW wires were inserted into the LAD and LCX. A 3.5 x 20mm Promus Element stent was directly implanted at LM to proximal LAD crossing LCX ostium without predilatation (Figure 1). A 3.0 x16 mm Promus Element stent was also implanted at middle LAD with predilatation and postdilatation using a 3.5 x 15mm Quantum balloon (Figure 2). After LAD stentings, we checked LCX FFR value using a pressure wire because of abnormal thallium result. LCX FFR value was 0.70. So we intended to treat LCX ostium using a kissing balloon angioplasty to improve LCX FFR value. A kissing balloon angioplasty was performed with a 3.5 x 15mm Quantum balloon for LAD and a 2.5 x 15mm Maverick balloon for LCX (Figure 3). After a kissing balloon angioplasty, rechecked LCX FFR value was 0.83. Final angiogram showed that the procedure was successful ( Movie 4, Movie 5, Movie 6).
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