Good morning everyone. I Have no disclosures So this is a case of a 50 year old gentleman. He has had a cabbage in 2015 He has ischemic cardiomyopathy with a reduced ejection fraction at 36% He's a type 1 diabetic on an insulin pump and he has a history of ventricular tachycardia on low-dose Amiodarone who has had an ICD and was admitted with unstable angina He's optimized on aspirin Plavix, Co-rig, amiodarone, Lasix, rosuvastatin, intrestose, bronolactone and dapaglifazin His physical exam was not notable for really anything except that it was fairly normal His creatinine was normal. His creatinine platelets were reasonable. This is his presenting EKG So we brought him to the cath lab And Went left radial engaged the IMA first and This is the diagnostic of the IMA So you can see some distal disease at the anastomosis This is the left system. So lots of native disease Another view of that see the competitive filling into the LED This Is right Sort of a typical post cabbage patient in a type 1 diabetic This is his SPG to diagonal Being reasonably well seven years later SPG To his OM again another pretty reasonable graft So The status of his vein grass was actually fine and surprisingly this IMA seemed like it was causing him trouble So we engaged the IMA with a 90 cm guide and introduced an FFR wire And got an IFR measurement of 0.8 And we had an FFR measurement of 0.79 after three minutes of adenosine So we then performed IVS for vessel reference sizing And the distal reference was 2.5 and the proximal reference was 3.0 So as a result, we pre dilated with a 2 5 8 compliant balloon I'll just play the IVS here You can see we're coming into that stenotic area that actually looks a lot worse by IVS than to Our visual assessment on the diagnostic So based on the measurements we stented with a 2 5 15 des and wanted to optimize with post dilation We post dilated with a 3 o NC balloon And this was our angiogram after post dilation So reasonable, but not excellent. You can see there's continued stenosis there So we IVS again And the MLA was 3.1 and 3.4 in the proximal stent At 3.1 and and the proximal stent was well expanded so Because of that we took another balloon this time a 4 by 8 NC balloon Which is not a balloon I would have taken based on the angiogram and not a balloon I would have taken based on the baseline IVS And you can see the improvement in the final angiogram So a much better optimized result So That's just a simple case of using both Physiology and imaging but in a slightly different vessel than we're used to Thank you very much

Ischemic cardiomyopathy

Coronary artery bypass graft surgery

Unstable angina

Catheterization procedure

Stenosis