Cardiologic history. Anamnesis. Female BD Risk factors HTN, DM, Dyslipidaemia. Cardiologic Long history. Last admission Heart failure

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2 Anamnesis Cardiologic history Female BD Risk factors HTN, DM, Dyslipidaemia Cardiologic Long history Last admission Heart failure 2004 NSTEMI CX stenosis DES on CX 2012 Acute Pulmonary Oedema 2013 Unstable Angina 2014 Acute Pulmonary Oedema 2015 Acute Heart Failure Severe Aortic Valve Stenosis Ostial RCA stenosis Ostial LM stenosis RCA restenosis Severe Mitral valve regurgitation Hospitalization Aortic Valve Bioprosthesis Ostial RCA DES CABG LIMA>LAD; RIMA >RCA Mitral Valve Bioprosthesis Coronarography

3 Coronary angiography Right femoral 6F Diagnostic angiography: Tight stenosis of LM and ostial instent occlusion of RCA of native coronaries and distal anastomosis stenosis of by-pass LIMA>LAD; RIMA>RCA LM Ostial stenosis FFR LAD 0,70 FFR CX 0,72 RCA Ostial instent occlusion LIMA-LAD Distal anastomosis stenosis RIMA-RCA Distal anastomosis stenosis Fig.1.a Fig.1.b Fig.1.c Fig.1.d

4 Coronary angiography Right femoral 6F Diagnostic angiography: Tight stenosis of LM and ostial instent occlusion of RCA of native coronaries and distal anastomosis stenosis of by-pass LIMA>LAD; RIMA>RCA LM Fig.2.a Fig.1.b Fig.2.b Ostial stenosis FFR LAD 0,70 FFR CX 0,72 RCA Ostial instent occlusion LIMA-LAD Distal anastomosis stenosis RIMA-RCA Distal anastomosis stenosis

5 Procedure on LM Same day 7F right femoral Implantation of bifurcation dedicated self-expandable DES AXXESS on LM after adequate predilatations POBA LM-LAD Acrostak GRIP 3,0x12 at 16 Atm POBA LM-CX Acrostak GRIP 3,0x12 at 16 Atm Bifurcation DES LM Axxess 3,5 x 11 Axxess kissing balloon LM-LAD 3,5x11 LM-CX 3,5x11 Axxess post dilatation LM 4,0 x 8 IVUS FFR Fig.3.a. Axxess navigation Fig.3.c. Axxess point of no return Fig.3.b. Axxess initial opening Fig.3.d. Axxess final opening

6 Procedure on LM Same day 7F right femoral Implantation of bifurcation dedicated self-expandable DES AXXESS on LM POBA LM-LAD Acrostak GRIP 3,0x12 at 16 Atm POBA LM-CX Acrostak GRIP 3,0x12 at 16 Atm Bifurcation DES LM Axxess 3,5 x 11 Axxess kissing balloon LM-LAD 3,5x11 LM-CX 3,5x11 Axxess post dilatation LM 4,0 x 8 IVUS FFR Fig.4.a. Kissing balloon Axxess Fig.5.a. Final result LAO_CAUD Fig.4.b. Axxess post-dilatation Fig.5.b. Final result RAO_CAUD

7 Procedure on LM Same day 7F right femoral Implantation of bifurcation dedicated self-expandable DES AXXESS on LM POBA LM-LAD Acrostak GRIP 3,0x12 at 16 Atm Fig.6.a FFR LM-LAD with Acist RXi POBA LM-CX Acrostak GRIP 3,0x12 at 16 Atm Bifurcation DES LM Axxess 3,5 x 11 Axxess kissing balloon LM-LAD 3,5x11 LM-CX 3,5x11 Fig.6.b. FFR LM-CX with Acist RXi Axxess post dilatation LM 4,0 x 8 IVUS FFR

8 Procedure on LM Same day 7F right femoral Implantation of bifurcation dedicated self-expandable DES AXXESS on LM POBA LM-LAD Acrostak GRIP 3,0x12 at 16 Atm POBA LM-CX Acrostak GRIP 3,0x12 at 16 Atm Bifurcation DES LM Axxess 3,5 x 11 Axxess kissing balloon LM-LAD 3,5x11 LM-CX 3,5x11 Axxess post dilatation LM 4,0 x 8 IVUS FFR Fig.7.a. IVUS LM-LAD Fig.7.b. IVUS LM-CX

9 Procedure RCA 6F right radial Next day Retrograde RIMA>RCA reopening of RCA CTO and through the same introducer anterograde RCA stenting IM 6F GC Engagement of RIMA Retrograde RIMA-RCA Filder XT CTO balloon Retrograde HS 5F GC Engagement of RCA Anterograde Stenting RCA Post-dilatation IVUS and FFR Fig.8.a. Filder XT and OTW Fig.8.b. Retrograde POBA 2,0 mm Fig.8.c. Retrograde POBA 3,0 mm

10 Procedure RCA 6F right radial Next day Retrograde RIMA>RCA reopening of RCA CTO and through the same introducer anterograde RCA stenting IM 6F GC Engagement of RIMA Retrograde RIMA-RCA Filder XT CTO balloon Retrograde HS 5F GC Engagement of RCA Anterograde Stenting RCA Post-dilatation IVUS and FFR Fig.9.a. Anterograde 0,35 wire Fig.9.b. Anterograde 5F GC

11 Procedure RCA 6F right radial Next day Retrograde RIMA>RCA reopening of RCA CTO and through the same introducer anterograde RCA stenting IM 6F GC Fig.10.a. POBA 3,0 mm Fig.10.b. POBA 3,5 mm Fig.10.b. POBA 4,0 mm Engagement of RIMA Retrograde RIMA-RCA Filder XT CTO balloon Retrograde HS 5F GC Engagement of RCA Anterograde Stenting RCA Post-dilatation IVUS and FFR

12 Procedure RCA 6F right radial Next day Retrograde RIMA>RCA reopening of RCA CTO and through the same introducer anterograde RCA stenting IM 6F GC Fig.11.a Ostial RCA DES Fig.11.b Result DES Fig.11.c Mid RCA DES Engagement of RIMA Retrograde RIMA-RCA Filder XT CTO balloon Retrograde HS 5F GC Engagement of RCA Anterograde Stenting RCA Post-dilatation IVUS and FFR

13 Procedure RCA 6F right radial Next day Retrograde RIMA>RCA reopening of RCA CTO and through the same introducer anterograde RCA stenting IM 6F GC Engagement of RIMA Retrograde RIMA-RCA Filder XT CTO balloon Retrograde HS 5F GC Engagement of RCA Anterograde Stenting RCA Post-dilatation IVUS and FFR Fig.12.a. POBA 3,5 HP Fig.12.b. POBA 4,0 HP Fig.13. Final result

14 Procedure RCA 6F right radial Next day Retrograde RIMA>RCA reopening of RCA CTO and through the same introducer anterograde RCA stenting IM 6F GC Fig.14.a FFR RCA with Acist RXi Engagement of RIMA Retrograde RIMA-RCA Filder XT CTO balloon Retrograde HS 5F GC Engagement of RCA Anterograde Stenting RCA Post-dilatation IVUS and FFR Fig.14.b IVUS RCA Fig.14.c IVUS RCA

15 Follow up 6 months Myocardial scintigraphy Clinical Asymptomatic Functional No heart failure Scintigraphy No ischemia Program after 12 m Scintigraphy Angiography IVUS or OCT

16 CONCLUSIONS TAKE HOME MESSAGES In case of a patient with two previous cardiac surgeries the demonstration of ischemic evidence is important New rapid exchange Acist RXi with NAVUUS catheter for FFR Makes easy the measurement of FFR in all vessels before and after the procedure as it scores over any coronary wire In such complicated and complex case Percutaneous approach is preferable as third surgery is accompanied with higher risk Dedicated self-expandable DES for the LM ostial stenosis When the anatomy and the angle are suitable is acceptable and feasible Retrograde approach through by-pass graft RIMA-RCA Is possible for RCA ostial CTO reopening and stenting

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