This patient was a 50-year-old woman having a history of heart transplantation 9 years ago. A coronary angiogram according to the scheduled follow up protocol for heart transplant patients revealed critical stenosis of distal LMCA and bifurcation with 80% stenosis. ECG showed non-specific finding, and echocardiogram showed normal LV systolic function without regional wall motion abnormality. She did not complain of specific symptoms but thallium scan showed large reversible perfusion defect in LAD territory.

A 7Fr JL4 guiding catheter was engaged into LMCA and obtained coronary angiogram. At the first sight, the tight stenosis at the bifurcation site was definite but the exact anatomy among distal LMCA, LCx ostium and LAD ostium was ambiguous (Figure 1, Figure 2). After a 0.014 inch BMW wires were inserted into the LAD and LCx respectively, firstly intravascular ultrasound (IVUS) examination was performed, showed that tight stenosis was located at the distal LMCA with cross sectional area of 3.5mm2, LCx ostium was quiet normal, and pLAD had mild athersclerosis extending to first diagonal artery (Figure 3, Figure 4, Figure 5). As there is no disease at LCX ostium, operator decided to perform the simple stenting at LMCA to pLAD crossing LCX ostium. Xience 4.0*23mm with 12atm up to 15atm without predilatation was implanted and post-balloon dilatation using Quantum 4.5*15mm with 20 atm (Figure 6, Figure 7) was appplied. Final angiogram showed the perfect results without compromising LCx ostium (Figure 8).