PCI in Octogenarian with multivessel disease - Operator: Bambang Budiono, MD Clinical Presentation A 86 year-old female with a past medical history of hypertension and dyslipidemia presented with a two weeks of history of resting chest pain radiating to right arm which was getting worse in the last 24 hours. Initial EKG showed ST depression and T wave inversion in the anterior and lateral leads, and serum cardiac markers were elevated. Echocardiography revealed hypokinesia of the anterior wall, anterior septum and apical wall with preserved left ventricular systolic function (LV ejection fraction=63%). Baseline Coronary Angiogram 1. Left coronary angiogram demonstrated 75% tubular stenosis in proximal LAD, and diffuse chronic total occlusion in the mid segment of LAD with heavy calcification and 90% stenotic lesion involving the first septal branch, and first diagonal branch. Left circumflex artery also showed subtotal stenosis in the mid segment (Figure 1, Figure 2). 2. Right coronary angiogram revealed discrete lesion with 90% diameter stenosis in the far distal RCA, and collaterals to the left system which was coming from distal PL and RV branch (Figure 3). Procedure The decision was made to perform PCI to the far distal RCA, middle LCX, and chronic total occlusion of middle LAD and first septal branch. A 7Fr sheath was inserted into the right femoral artery, and the right coronary ostium was engaged with a 7Fr Hockey stick guiding catheter. A 180cm 0.014 inch BMW wire was inserted into the distal RCA. A Voyager monorail 1.5 mm X 15 mm balloon was used to pre-dilate the distal RCA lesion (Figure 4). Next, a Tsunami 3.5 mm X 15 mm stent was positioned to cover the lesion (Figure 5). The stent was then deployed up to 16atm and angiogram showed a satisfactory result (Figure 6). For the left coronary intervention, a 7 Fr UBS guiding catheter was used to. The same BMW wire was used to wire the LCX. An ALEX 2.0 mm X 15 mm balloon then was used to pre-dilate the LCX lesion (Figure 7). And then, Tsunami 4.0 mm X 15 mm stent was positioned in the middle LCX, then deployed up to 16atm (Figure 8). Angiography showed satisfactory angiographic result (Figure 9). Next target were the chronic total occlusion in the middle LAD and tight septal lesion. A 180 cm Cross-It wire was successfully crossed the total occlusion (Figure 10). A previous Voyager 1.5 mm X 15 mm balloon was used to pre-dilate the whole middle LAD lesion. A 0.014 inch BMW wire then was inserted into the first septal branch (Figure 11). Kissing balloon technique was performed in order to modify the plaque (Figure 12). Because an ALIS 2.5 mm X 29 mm paclitaxel-eluting stent was unable to be positioned in the middle LAD, pre-dilation with an ALEX 2.0 mm X 15 mm balloon was done. The stent finally could be delivered easily to cover the middle LAD lesion, and deployed up to 12atm (Figure 13, Figure 14). And then, another ALIS 3.0 mm X 12 mm paclitaxel-eluting stent was positioned in the proximal LAD with a minimal gap (     1mm) between it and the previously dilated distal stent (Figure 15). The stent was then deployed up to 14atm (Figure 16). Final angiogram revealed excellent angiographic result (Figure 17).

Emergency PCI in a Patient with Multi-Vessel Disease and Bradyarrhythmia - Operator: Bambang Budiono, MD Clinical Presentation A 72-year old woman was transferred from a private hospital, presented with recurrent syncope, seizure, and apnea. She had brady-arrhythmia which was not respond with sulfas atropine. CPR was done in the ambulance during the transfer. Blood pressure was 60 mmHg, and the heart rate was 30bpm when she reached the emergency room. The ECG showed total AV Block with wide QRS complex. The patient was sent to the cath-lab for emergency temporary pacemaker insertion (Figure 1). Blood pressure arised spontaneously up to 100/60 mmHg after pacemaker insertion. Procedure PCI was done using trans-radial technique. Lesions in the proximal and mid LAD was firstly targeted. The left coronary was engaged with a 6Fr Ikari Left guiding catheter. A 0.014 inch BMW wire was inserted into the 1st diagonal branch (Figure 2) and a 0.014 inch Pilot 50 wire was inserted into the LAD (Figure 3). The LAD lesions were predilated using a 2.0x12 mm Maverick balloon (Figure 4, Figure 5). A 2.5 x 23 mm Taxus stent was positioned at mid LAD and deployed by 16 atm (2.74 mm) (Figure 6, Figure 7). The BMW guide wire then was took out. Another 2.75 x 25mm Taxus stent was positioned at proximal LAD, 1mm overlapped with previous stent and deployed by 16 atm (3.12 mm) (Figure 8, Figure 9). Additional balloon was performed with stent balloon distal to the overlapped segment (Figure 10). Final angiogram showed well-expanded stents with TIMI 3 flow (Figure 11). Lesion in the mid RCA was next targeted. A 6Fr Tiger Kim catheter was used to engage the RCA (Figure 12). A 0.014 inch Pilot 200 wire successfully crossed the lesion (Figure 13). The lesion was predilated using a 1.5x1.5 mm Maverick balloon (Figure 14). A 3.0 x 23 mm Tsunami Gold stent was positioned at distal RCA and deployed by 16 atm (3.26 mm) (Figure 15). Then a 3.5x19 mm Invastent was positioned at mid RCA and deployed by 16 atm (3.81mm) (Figure 16). Final angiogram showed satisfactory results (Figure 17).