Chronic Total Occlusion of Left Main Stem with Multi-vessel Disease

Abstract

Background: Chronic total occlusion (CTO) of the left main stem (LMS) presents a challenging scenario in the management of coronary artery disease. We present a case highlighting the successful intervention and long-term outcomes in a 70-year-old male with CTO of the LMS and multi-vessel disease, complicated by non-ST-segment elevation myocardial infarction (NSTEMI) and severely impaired left ventricular (LV) function.

Case Presentation: A 70-year-old hypertensive male presented with NSTEMI, severe LV dysfunction, moderate mitral regurgitation, and hypotension. Despite initial hesitation towards intervention, recurrent chest pain necessitated urgent coronary angiography. Diagnostic assessment revealed electrocardiographic changes suggestive of ischemia and echocardiographic evidence of LV dysfunction.

Management & Results: Therapeutic intervention involved meticulous pre-dilatation of the occluded LMS followed by angioplasty and stenting, with attention to avoid bifurcation stenting. Additional interventions included balloon angioplasty and stenting of proximal lesions in the left anterior descending (LAD) artery and ramus, and direct stenting of the distal right coronary artery (RCA) lesion. Long-term follow-up demonstrated significant improvements in clinical symptoms and LV function, emphasizing the efficacy of revascularization.

Conclusion: This case underscores the importance of timely intervention, tailored therapeutic approaches, and long-term medication adherence in optimizing outcomes in patients with complex coronary artery disease and impaired LV function. A simplified approach to multi-vessel percutaneous coronary intervention may offer favorable long-term outcomes, warranting further investigation.