Case 7 – LM/LAD PCI

Case Presentation

A 77-year-old woman with medical history of CAD s/p PCIs, severe aortic stenosis s/p TAVR (29 mm Evolut Pro) presented with angina like chest pain for last few days. Ruled in as NSTEMI with peaked troponin of 29.95 ng/ml.
EKG showed T wave inversion in antero-septal leads. ECHO showed normal LVEF with normal gradients across aortic valve.

Prior coronary angiogram was done by JL4 For Left Coronary System and AR2 for right coronary artery.

First, JL 3.5 catheter was used but not able to do selective engagement. Then, FL 3.0 and Ikari right 1.0 were changed to engage LCA without success. Left coronary angiogram was done by using Ikari right 1.5 and showed significant disease in distal left main and proximal LAD.

Selective catheter engagement was performed with the help of the guidewire support. Two coronary wires were advanced into LCx and LAD. Then, successful PCI was performed by using DES to left main and proximal LAD.

Learning Points

In post TAVR cases, it is helpful to have step by step guide catheter selection for coronary angiogram, like in this case. (JL 3.5> FL 3.0> Ikari 1.0> Ikari 1.5)
Operator should expect that it could sometimes require multiple catheters to engage coronary artery in post TAVR patient.
Railing the guide catheter towards the ostium (for selective engagement) using guide wire or J wire is particularly useful in post TAVR case.