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Primary PCI in Anterior AMI in a Patient with Anomalous Origin of LMCA Arising Together with RCA from Right Anterior Valsalva Sinus: A Challenging Option
- Operator: I. Sheiban, MD
Clinical Presentation
A 65-year old man was admitted with ongoing chest pain for 1 hour. His coronary risk factor was hypertension, cigarette smoking, and hypercholesterolemia. His baseline ECG showed ST elevation in all anterior leads. Echocardiography showed an akinesia of LV anterior wall, interventricular septum, and the apex with mild to moderate LV systolic dysfunction (EF = 40%). Troponin was slightly increased.
Baseline Coronary Angiography

1. Right coronary angiogram showed discrete narrowing at posterolateral branch (Figure 1).
2. Left coronary angiogram showed the anomalous origin of LMCA originating together with RCA from right anterior Valsalva sinus (Figure 2). LMCA was long and tortuous with a distal total occlusion and proximal LCx was significant lesion (Figure 3).

Procedure
A 6Fr sheath was inserted through right femoral artery and the left coronary ostium was engaged with an 6Fr Amplatz L guiding catheter (Figure 4). OTW balloon catherter with Choice PT guide wire was firstly used to have an access to LM and LCx (Figure 5). Predilatation was performed with 2.75 x 15mm Maverick balloon both on proximal LCx and distal LM (Figure 6, Figure 7). Plaque shifting to LAD was observed (Figure 8). A 2.75 x 18 mm Cypher stent was placed at proximal LCx and deployed by 18atm (3.01 mm) (Figure 9). Then a 3.0 x 18 mm Cypher stent was placed at LM to LAD and deployed by 14atm (3.15 mm) (Figure 10). The LCx was rewired with Choice PT guide wire. And then simultaneous double kissing balloon dilatation was performed in LM to LAD with a 3.0 X 12 mm Maverick balloon and in LM to LCX with a 2.5 X 12 mm Maverick balloon. The final angiogram showed successful result (Figure 11). A 3.0 x 9 mm Driver stent was implanted at posterolateral branch of the RCA (Figure 12, Figure 13). Nine-month follow-up coronary angiogram showed a good result (Figure 14).
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