1. Intra-Aortic Balloon Pump For Complex Calcified Left-Main Bifurcation Lesion
Supawat Ratanapo, MD
Medical College of Georgia,
Augusta University

2. Supawat Ratanapo, MD 
I have no relevant financial relationships

3. Learning objectives Learning objective 1 Learning objective 2

4. Case
53-year-old male with PMH of CHF with EF 45% global hypokinesis 2 months ago, moderate to severe MR, HTN, COPD, chronic smoking, chronic alcohol abuse, cirrhosis who was initially admitted with unstable angina and decompensated heart failure for 1 day.
The patient had been scheduled for outpatient coronary angiography prior to admission.
TTE this admission : EF 40 % with new anterior wall hypokinesis and mod-severe MR.

5. Left dominant
LM: Distal 60%
LAD: Osital 90%, prox-mid 80-90%
LCx: Ostial 30-40%
OM1 ostial 80%,
Lt PDA - MLI
RCA: non-dominant with mid 90%
LV gram: LVEF 40%, LVEDP 24 mmHg.
RHC:
Fick CO: Fick CI: 1.42
PCW: 24
PA: 80/38 (54)
RV: 66/7
RA: 20
PVR: 769 SVR: 1538

7. Hospital Course SYNTAX score 37
CT Surgery was consulted for revascularization
The patient was declined for CABG due to cirrhosis, COPD and pulmonary hypertension.
High risk multi-vessel PCI was performed 3 days later after HF optimization

8. LCx was performed IVUS-guide PCI.
IVUS showed severe calcification of LM/LCx
Plan for Rotational Atherectomy

9. Rotational Atherectomy to LM/ LCx ostium.

10. The patient developed bradycardia followed by PEA arrest after starting rotational atherectomy.
IABP was placed emergently followed by temporary pacemaker
Dopamine IV drip was started
The patient regained consciousness after 1 min of CPR
No intubation needed.

11. PCI was resumed and LAD was wired

12. Rotational Atherectomy to LAD with IABP support

13. PCI with IVUS-guided DES to mid LAD

14. Simultaneous kissing stents (SKS) technique for LM bifurcation

15. Successful PCI to LM bifurcation lesion

16. Result The patient was awake and alert post procedure.
Dopamine was weaned off overnight.
IABP and temporary pacemaker removed the following day.
No acute vascular complications.
The patient did very well and was discharged home 3 days later.

17. Take Home Messages
Prophylactic IABP will allow adequate time to complete the complex procedure and may reduce peri-procedural complications.
IABP can be used safely to facilitate rotational atherectomy and simultaneous kissing stents to LM bifurcation.

18. Take Home Messages
IVUS should be used to guide rotational atherectomy in complex coronary lesion especially in tortous coronaries.
Rotational atherectomy can be use carefully in vessel with severe tortuosity.