Left Main Case:


Left Main Case: Iatrogenic left main dissection is an infrequent but fatal complication of invasive coronary angiography.

Presentation

· A 72-year-old man with previous history of PCI to the right coronary artery in December 2017 and moderate left ventricular dysfunction presented with stable angina in November 2018.

· Comorbidities: chronic obstructive pulmonary disease, rheumatoid arthritis, hypertension, Barrett’s oesophagus.

· Current medications: Aspirin 75 mg daily, Clopidogrel 75mg daily, Atorvastatin 80mg daily, Bisoprolol 2.5mg daily, Candesartan 4mg daily, Folic Acid, Lansoprazole, Methotrexate 15mg every week, Iron Sulphate, and Salbutamol Inhaler.

· Coronary angiogram: patent right coronary artery stent, moderate left anterior descending artery and mild disease in the left main and circumflex artery.

· The left main coronary artery was engaged using an Extra back up(6F) 3.5 guide given the moderate left anterior descending artery and intention to perform a fractional flow reserve. This guide was not coaxial and resulted in a large left main dissection with an aortic dissection (Video 1) resulting in pulseless electrical activity arrest needing intubation and cardiopulmonary resuscitation with auto pulse (Zoll).

 

(Video 1)

How should I treat this iatrogenic left main dissection?

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***Experts: Shoaib Qayyum, Vinayak Nagaraja, Karim Ratib, Najeeb Azam

 

-Source: PCR