Case Presentation
A 66-year-old male with past medical history of hypertension,
hyperlipidemia, coronary artery disease, systolic cardiomyopathy with an
ejection fraction of 25% and a primary prevention biventricular ICD
presented to outside facility with unstable angina and aborted sudden
cardiac death. He had been treated with several rounds of
anti-tachycardia pacing and at least 6 internal defibrillations. On
arrival he was the midst of incessant episodes of pace terminated
ventricular tachycardia. He was started on intravenous amiodarone and
transferred to the cardiac care unit at our hospital.
Peak troponin I level prior to arrival was 7.48 and under the
circumstances he was taken for emergent coronary angiography. We
identified >90% calcified stenosis of proximal left
anterior descending coronary artery, proximal right coronary artery and
ramus intermedius respectively with moderate distal left main tapering.
We also identified high grade mid left anterior descending bifurcation
stenosis involving the origin of the first diagonal (medina 0,1,1)
(Figure 1). The anatomic Syntax score was 41 (high). His angina and
arrythmias became more quiescent with medical therapy and he recovered
in the coronary care unit where the heart team was convened. On further
work up he was found to have left ventricular ejection fraction of
25-30%, moderate left ventricular dilation, stage 3 chronic renal
failure, and a heavily calcified ascending aorta. Given his age of only
67 years old, left ventricular systolic dysfunction, high anatomic
Syntax score and risk of acute renal failure with repeated contrast dye
exposures our team opted to offer OPCABG.