Case Summary: We present a case of a 61-year-old male patient who was transferred to our centre for an urgent CABG operation (EuroScore 30.6%). He initially presented with chest pain (CCS III), dyspnoea (NYHA II-III) and ST-segment depression in the leads V2-V5. The echocardiography showed an LVEF of 40% with apical akinesia. He underwent coronary angiography and was diagnosed with a 3-vessel disease with a heavily calcified stenosis of the left main (LM), left circumflex artery (LCX) and right coronary artery (RCA) (SYNTAX Score II 50.9) (Fig.1, Fig.2). During the transfer the patient deteriorated into CS needing high dose of vasopressors. At that point the CABG surgery was deferred due to an inacceptable high risk of mortality. We decided to treat the patient interventionally. Because of the CS and the severe multi vessel disease we inserted the Impella device (Abiomed, Aachen) over the left femoral artery first. Revascularization of the RCA (Fig.3) with two drug eluting stents (DES), was followed by percutaneous coronary intervention (PCI) of the LM, LAD und LCX. Adequate plaque modification with semi-compliant and non-compliant balloons failed (Fig.4). Due to the heavily calcified lesions we decided to further prepare the lesions using IVL. 80 cycles (4-6 atm) of IVL in LM, ostial LAD and ostial LCX (Fig. 5) resulting in an adequate lesion preparation (Fig.6) followed by DES implantation in LM, LAD and LCX in TAP technique (Fig.7, Fig. 8). After dosage reduction of the vasopressors and discussion in the heart team, we decided to postpone the treatment (CABG vs. PCI) of the remaining lesions. The MCS device was successfully weaned and removed after two days. At discharge the LVEF returned to normal and a myocardial scintigraphy showed a remaining 12% ischemia in the LCX area which is planned in 12/2022.
Discussion: With no option for CABG surgery the only alternative was an interventional approach. Considering the grade of calcification, plaque modification options include balloon-based strategies or RA devices. In our case a RA device was avoided due to the high risk of plaque shift and/or total occlusion of the non-RA vessel. With the need of two guidewires, like in this case, IVL is an alternative way to prepare heavily calcified lesions, especially of the LM. However, the need of multiple temporarily balloon occlusions of the LM in IVL puts the patient at a higher risk for further hemodynamical deterioration. Therefore, the hemodynamical support of the MCS device in combination with IVL of the LM made it possible to treat this patient under safe and stress-free conditions. Based on our experience the combination of the MCS with IVL, even in the LM, in patients with severe CS is a feasible and safe treatment option.
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