Webinar 8 | Bifurcation Badness - Cases from South Asia-Dr. Seth case presentation slides

Dr. Seth case presentation slides

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This case report by Prof. Ashok Seth highlights the complex management of a severely calcified left main trifurcation coronary artery disease in a 65-year-old diabetic, hypertensive male with prior anterior wall myocardial infarction and severe left ventricular dysfunction (ejection fraction 30%). The patient presented with dyspnea and Class III angina, with PET scan showing non-viable distal anterior/apical territory but viable other regions. He was turned down for surgery due to high risk.<br /><br />The interventional approach involved a multidisciplinary consensus at the CHIP-CTO India meeting. Given the high complexity score and patient risk factors, an Impella-supported percutaneous coronary intervention (PCI) was chosen. The procedure utilized advanced imaging (IVUS) and multiple device strategies: cutting balloons, rotational atherectomy, intravascular lithotripsy (IVL), and high-pressure non-compliant balloons to safely prepare and optimally treat extensively calcified lesions in the left main and its branches.<br /><br />Minicrush stenting was performed in the left main to the left circumflex artery trifurcation, with adjunctive use of drug-coated balloons (DCB) in areas with diffuse disease to avoid the risks of extensive stenting. Final angiographic and IVUS results showed well-expanded stents and satisfactory minimum stent area, indicating optimal procedural success.<br /><br />At six months, the patient was asymptomatic with improved ejection fraction (45%) and mild mitral regurgitation. Two-year follow-up showed sustained clinical improvement, increased exercise tolerance, and only mild ischemia on nuclear scan, highlighting excellent long-term outcomes.<br /><br />This case underlines the importance of intravascular imaging-guided device synergy—including rotational atherectomy, lithotripsy, cutting balloons, and drug-coated balloons—in managing complex, calcified left main bifurcation/trifurcation lesions, especially when surgery is not an option. This strategic approach can achieve optimal results safely and improve patient prognosis in challenging coronary anatomy.

Keywords

calcified left main coronary artery disease

trifurcation lesion

Impella-supported PCI

rotational atherectomy

intravascular lithotripsy

cutting balloons

drug-coated balloons

minicrush stenting

intravascular ultrasound (IVUS)

complex coronary intervention