Decision Making Using Fractional Flow Reserve after Left Main disease Treatment with Simple Cross-Over Stenting

- Operator : Seung-Jung Park

Decision Making Using Fractional Flow Reserve after Left Main disease Treatment with Simple Cross-Over Stenting
- Operator: Seung-Jung Park, MD
Case Presentation
A 55 year-old gentleman was admitted with effort chest pain developed one month ago. His coronary risk factors were hypertension and dyslipidemia. The physical examination was normal. The ECG and cardiac enzymes were unremarkable. The echocardiography showed normal LV systolic function (EF=57%) without regional wall motion abnormality. Treadmill test was positive at stage 3.
Baseline coronary angiogram
The left coronary angiogram showed significant diffuse narrowing of LM shaft to LAD ostium and left dominant system ( Movie 1, Movie 2, Movie 3).
The right coronary angiogram showed diminutive RCA ( Movie 4).
Procedure
An 8 Fr JL 4 SH guiding catheter with side hole was engaged into left coronary artery through right femoral approach. Two 0.014 inch BMW wires were inserted at LAD and LCX, respectively (Figure 1). Firstly, we performed intravascular ultrasound (IVUS) evaluation from LM to pLAD and pLCX, respectively. LCX ostium relatively preserved at IVUS examination ( Movie 5). So, we planned to deploy a stent at LM to pLAD with simple cross-over technique. A Promus Element stent 4.0x20mm was deployed and post-stenting adjunctive balloon dilatation was done by using a Quantum balloon 5.0x15mm (Figure 2). The following angiogram showed well-expanded stent but LCX ostium looked like significantly compromised ( Movie 6). So we checked the FFR value of LCX to determine whether to treat or not. The FFR value of LCX was 0.92 (Figure 3). Therefore, we finished the procedure. Final angiogram showed that the procedure was successful ( Movie 7, Movie 8).

Comments

  • Guanghui Chen 2012-06-30 If an episode of IVUS evaluation from pLCX to LM was presented, and the result shows the compromised osmium of LCX is also unremarkable anatomically, it will then be convinced better to finish the procedure. Doesn't the operator think so?
  • Bing Liu 2012-07-01 The osLCX was jailed 50% at most angiographically after the LM-LAD cross-over stenting! And the pLCX was 4.5mm vessel actrually, so was the FFR reasonable for the jailed osLCX!? It was exessive evaluation£¬I think. It will take pt.10000RMB in CHINA.
  • Arash Gholoobi 2012-07-02 I believe that opening up the struts with KBI is reasonable in case of such a large dominant side branch.

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