Decision Making Using with Fractional Flow Reserve after the Treatment of Left Main Bifurcation in Simple Cross-Over Technique

- Operator : Seung-Jung Park

Decision Making Using with Fractional Flow Reserve after the Treatment of Left Main Bifurcation in Simple Cross-Over Technique

- Operator: Seung-Jung Park, MD

Case Presentation

A 66 year-old man was admitted with effort chest pain for 4 months. His coronary risk factors were hypertension, diabetes mellitus, and ex-smoker. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal left ventricular function (EF=64%) without regional wall motion abnormality. Treadmill test and thallium test were not done.

Baseline Coronary Angiography

The left coronary angiogram showed diffuse and tight stenosis at LM to mLAD with TIMI grade 2 flow ( Movie 1, Movie 2). The right coronary angiogram showed diffuse stenosis at pRCA. Before left coronary artery intervention, we implanted Xience Prime stent 3.5 x 28mm at pRCA ( Movie 3, Movie 4).

Procedure

An 8 Fr sheath was inserted through right femoral artery, and the left coronary ostium was engaged with an 8 Fr JL 3.5 catheter with side hole. Three 0.014 inch BMW wires were inserted into the LAD, LCX, and diagonal branch. We examed lesions with IVUS to make a decision ( Movie 5; LAD IVUS). IVUS examination revealed relatively normal LCX ostium. So, we intended to treat the lesions with simple cross-over technique. Predilatation was performed with a 2.5 x 20mm Maverick balloon at LM (Figure 1). After predilatation, Two Xience Prime stents (4.0x28mm and 2.75x38mm) were implanted at LM to mLAD with overlapping (Figure 2, Figure 3). And then, postdilatation using a 3.5 x 15mm Ryujin balloon and 4.0 x 15mm Dura Star balloon was performed. The following angiogram showed well-expanded stents, but stenosis of LCX ostium was observed ( Movie 6). We checked LCX FFR, which was 0.83. Therefore, we finished the procedure. Final angiogram showed that the procedure was successful ( Movie 7, Movie 8).