Precision PCI in the era of AI and multimodality imaging

#CardioTwitterCase originally published on Twitter

This case was originally published on Twitter by @FBardooli

Case description

This is the case of a 55 years old lady, known to have dyslipidemia, diabetes mellitus type 2 and hypertension on medical therapy. She presented with progressively worsening dyspnoea for the last 3 months. Her 2D ECHO showed preserved left ventricular function with no significant valve disease. 

Coronary CT angiogram revealed severe proximal LAD discrete lesion, but an ambiguous proximal zone at the ostium of LAD, with regards to involvement of the LMCA involvement (Figure 1).

The challenge is to locate a healthy landing zone at the ostium of LAD with no disease extension to LM. Furthermore, as to proceed with the strategy to position the stent at the ostium with no strut protrusion into the LMCA. 

Utilising the data from the CTCA, the best angulation to visualize the ostium of LAD was selected. Subsequently, both LAD and LCX were wired, and the OCT run into LAD done showed significant lipid rich atheroma in the proximal LAD (Figure 2) with healthy ostial segment of LAD without involvement of the distal LMCA or OS of LCx.

The lesion was 15 mm in length, with a vessel diameter of 4 mm in distal and 4.74 mm at proximal segment (Figure 3).

Utilising AI & co-registration in OCT, a 4.0 x 15 mm stent was placed in position (Video 1) & subsequently post dilated with a non-compliant 4.5 x 12 mm balloon.

Post PCI OCT run showed good expansion > 90 % of the stent, no edge dissection and, importantly, a good coverage of the ostial LAD (including the atheromatous plaque) with no major protrusion in the LM (Figure 4).

Final remarks

Nailing ostial lesions can be performed if indicated! Imaging modalities predict pre- and post-intervention outcomes.