case_images: PMC11082483_01
case_images: Admission electrocardiogram: sinus rhythm / HR 80 bpm / QRS axis 20  / PR 160 ms / QRS 80 ms / QT 320 ms / QS V1-V2 / ST-segment elevation (1 mm) V1-V2 / biphasic T waves V1-V4.
case_images: 10.1177_20480040241248924-fig1.jpg
case_images: PMC11082483_01_10.1177_20480040241248924-fig1.jpg
case_images: fig1-20480040241248924
case_images: The electrocardiogram showed sinus rhythm with QS complexes and ST-segment elevation (1 mm) in V1-V2 leads associated with biphasic T waves in V1-V4 leads (Figure 1).
case_images: (a) Moderate stenosis in distal segment of Cx (white thin arrow), after the 1st marginal artery's birth. (b, d) Subocclusive ostial stenosis of the 2nd DG and severe stenosis in mid-segment of LAD at the bifurcation with 3rd DG (Medina 1-1-1) (blue thick arrow). (c) Severe ostial stenosis of LAD (blue arrowhead). (e, f) Anomalous birth of RCA (blue asterisk) without angiographically significant lesions.
case_images: 10.1177_20480040241248924-fig2.jpg
case_images: PMC11082483_01_10.1177_20480040241248924-fig2.jpg
case_images: fig2-20480040241248924
case_images: Coronary angiography (Video 1; Figure 2) showed severe ostial stenosis of the left anterior descending artery (LAD) and in its middle segment at the bifurcation with the 3rd diagonal (DG) (Medina 1-1-1), subocclusive ostial stenosis of the 2nd DG, mild stenosis in the proximal segment and moderate stenosis in the distal segment of the circumflex artery (Cx) (after the birth of the 1st marginal; Medina 0-1-0) and an anomalous birth of right coronary artery that did not present angiographically significant lesions.
case_images: Pre-PCI LAD IVUS shows severe stenosis in the middle segment of the LAD, posterior to 3rd DG birth, with lesion lumen area of 2.93 mm2 (c) associated with severe calcification throughout the proximal and mid segments (a, b) of LAD. C-CAT sign (b) describe a C typed eccentric lesion, approximately 270-degree, calcified plaque and contralateral thin plaque.
case_images: 10.1177_20480040241248924-fig3.jpg
case_images: PMC11082483_01_10.1177_20480040241248924-fig3.jpg
case_images: fig3-20480040241248924
case_images: IVUS corroborated the severe stenosis in the middle segment of the LAD (posterior to 3rd DG birth - lesion lumen area of 2.93 mm2) associated with significant calcification along its entire length (Figure 3(a)-(c)). IVUS ruled out the presence of significant lesions in the circumflex artery.
case_images: (a) Pre-angioplasty IVUS been performed. IVUS guidewire can be seen in the LAD (thin arrow). (b) Acute vessel occlusion seen after guidewire removal that did not response to intracoronary nitroglycerin, so emergency angioplasty was decided. (c)-(e) Predilatation of the mid and proximal segments of the LAD was performed and two overlapping Evermine 3.0  x  32 mm and Evermine 4.0  x  29 mm DES were implanted in these segments of the LAD. (f, g) Then, the proximal segment of the LAD and LMCA were predilatated and a 4.5  x  22 mm Resolute Onyx DES was implanted at the proximal LAD-LMCA. (h) LMCA's postdilatation with a 5.0  x  12 mm NC Emerge balloon was performed (asterisks). (i) Floppy guidewires were recrossed and KB was performed with a 3.0  x  12 mm NC Euphora and 4.0  x  20 mm NC Emerge balloons. (j, k) Angiographic control showed adequate DES expansion with TIMI III flow.
case_images: 10.1177_20480040241248924-fig4.jpg
case_images: PMC11082483_01_10.1177_20480040241248924-fig4.jpg
case_images: fig4-20480040241248924
case_images: After removal of the guidewire of the LAD (Figure 4(a)), complete occlusion of the LAD was observed (Figure 4(b); Video 2), that did not response to intracoronary nitroglycerin. Two overlapping 3.0  x  32 mm and 4.0  x  29 mm Evermine drug-eluting stents (DES) were implanted in the mid and proximal segments of the LAD (Figure 4(c)-(e)), respectively. Then, the most proximal segment of the LAD and LMCA were predilated with a 4.0  x  15 mm NC Euphora balloon and, subsequently, a 4.5  x  22 mm Resolute Onyx DES was implanted at the LAD-LMCA (Figure 4(f) and (g)). Postdilatation was performed at the LMCA with a 5.0  x  12 mm NC Emerge balloon (Figure 4(h)). The Floppy guidewires were recrossed and kissing balloon (KB) was performed with a 3.0  x  12 mm NC Euphora and 4.0  x  20 mm NC Emerge balloons (Figure 4(i)). Angiographic control showed adequate DES expansion with TIMI III flow (Figure 4(j) and (k)).
case_images: Post-PCI LAD IVUS showed improvement (red thin arrows) in the CSA in the proximal (a, b) and middle (c) segments of the LAD, however, there was persistent DES underexpansion (stent CSA 4.94 mm2) (c) so postdilatation was opted for.
case_images: 10.1177_20480040241248924-fig5.jpg
case_images: PMC11082483_01_10.1177_20480040241248924-fig5.jpg
case_images: fig5-20480040241248924
case_images: However, post-procedural IVUS showed distal DES underexpansion (Figure 5(a)-(c)) so postdilatation was chosen.
case_images: (a) Angiographic control with a TIMI III flow, however, IVUS showed DES underexpantion, so postdilatation was decided. (b, c) Postdilatation was performed with a 3.0  x  15 mm NC Euphora balloon in the mid and proximal segments of LAD. (d, e) On angiographic control, a contrast extravasation jet (blue arrow) was seen through a > 1 mm orifice, making the diagnosis of an Ellis type III CP. Immediately, the CP was sealed by prolonged low-pressure insufflation and protamine was administered. (F) After awaiting 15 min, angiographic control showed complete sealing of the CP and absence of residual leak (blue arrowhead).
case_images: 10.1177_20480040241248924-fig6.jpg
case_images: PMC11082483_01_10.1177_20480040241248924-fig6.jpg
case_images: fig6-20480040241248924
case_images: Postdilatation, at nominal pressure, was performed with a 3.0  x  15 mm NC Euphora balloon in the mid and proximal segments of LAD (Figure 6(a)-(c)). CP was made (Figure 6(d) and (e); Video 3). TTE revealed pericardial effusion, without right cavities collapse. After 15 min, the CP was complete sealed without residual leak (Figure 6(f); Video 4). Then, the patient was moved to the coronary care unit (CCU) where he presented tachycardia as the unique alarm sign, however there were no other intercurrences reported.
case_images: Strain curves in 4-chamber, 3-chamber and 2-chamber views. Show differences in systolic and post-systolic strain of segments from different coronary territories. Global longitudinal left ventricular strain: -18%.
case_images: 10.1177_20480040241248924-fig7.jpg
case_images: PMC11082483_01_10.1177_20480040241248924-fig7.jpg
case_images: fig7-20480040241248924
case_images: LAD. LVEF was 55%; global longitudinal LV strain -18% (Figure 7).
case_images: (a) TTE, 4-chamber view. Evidence of pericardial effusion with apical-lateral well (12 mm) and adjacent to the right atrium (9 mm). (b) Mitral respiratory variability less than 25%. (c) TTE, subcostal view. Pericardial effusion with well anterior to the right ventricle (7 mm) and posterior to the left ventricle (10 mm). (d) Dilated inferior vena cava with collapsibility less than 50%.
case_images: 10.1177_20480040241248924-fig8.jpg
case_images: PMC11082483_01_10.1177_20480040241248924-fig8.jpg
case_images: fig8-20480040241248924
case_images: There was pericardial effusion with apical-lateral well, adjacent to the right atrium, anterior to the right ventricle and posterior to the left ventricle (Figure 8).