Conquering the obstacles during the intervention of a proximal chronic total occlusion of right coronary artery with a concurrent significant ostial stenosis: a case report.

Percutaneous coronary intervention (PCI) on a proximal chronic total occlusion (CTO) of the right coronary artery (RCA) with concurrent ostial stenosis can be challenging because of the significant difficulty in properly engaging the catheter and providing stable support during the procedure. We report the case of a 57-year-old man with chronic coronary syndrome who underwent an elective PCI at the Dr. Soetomo General Hospital in Surabaya, on April 13th, 2022. At the beginning of the procedure, there was difficulty in intubating the RCA, which required the guide catheter replacement. The angiography revealed a significant lesion at the ostium, a CTO at proximal to mid- RCA with bridging collaterals, and a significant distal lesion. Several strategies to improve guiding catheter support during PCI are using large and supportive shape guide catheters, deep guide catheter intubation, extra support wire, microcatheter and guide catheter extension. The risk of pressure dampening and ischaemia upon engagement should always be kept under consideration.

Intra-aortic balloon pump still has a role in late-onset myocardial infarction complicated by ventricular septal rupture with intractable heart failure: a case report.

BACKGROUND: The current guidelines have discouraged the routine use of intra-aortic balloon pump (IABP) in cardiogenic shock complicating acute coronary syndrome (ACS). Since then, the trend of IABP utilization in ACS has been declining. Nevertheless, the guidelines still preserve the recommendation of IABP use in hemodynamic instability or cardiogenic shock caused by post myocardial infarction (MI) ventricular septal rupture (VSR). CASE PRESENTATION: A 46-years-old diabetic Southeast Asian female was referred from a peripheral facility with intractable heart failure despite treatment with vasoactive agents and diuretics for five days. The ECG suggested a recent anteroseptal myocardial infarction with normal high-sensitivity troponin-I value. The echocardiography detected a regional wall motion abnormality and a 10 mm wide ventricular septal defect. Invasive coronary angiography revealed a severe two-vessel coronary artery disease. We planned a delayed surgical strategy with preoperative optimization using IABP as a bridge to surgery. IABP implantation followed by significant hemodynamic improvement and rapid resolution of heart failure without any inotrope support. Afterwards, coronary artery bypass grafting (CABG) and VSR surgical repair were performed. We safely removed IABP on the third postoperative day with proper weaning and minimal vasoactive support. CONCLUSION: We report a case where IABP still provided benefits for a patient with intractable heart failure caused by undetermined onset MI complicated by VSR. The use of IABP in such a case is in accordance with the recommendation of the current guidelines. Several studies showed that IABP use during preoperative optimization in the case of post-MI VSR was associated with survival benefits.