Case of Reverse CART (RCA opened from left side)

in Max Super Speciality Hospital, Shalimar Bagh

Apr 18 , 2023

A chronic smoker male was admitted to Max Super Speciality Hospital, Shalimar Bagh, with complaints of chest pain on exertion. The patient was first admitted to another hospital, where he was diagnosed with LM-TVD (LM=90% stenosis, LAD proximal CTO, LCX proximal 80% stenosis, RCA-CTO). The patient’s 2D echo showed LVEF=23%, and then he was referred to Max Hospital, Shalimar Bagh, for CABG.

As the patient’s LVEF was 23%, it was a high-risk case for CABG. So, it was planned to do OCT-guided Multi-Vessel Percutaneous Coronary Intervention (MVPCI). As it was an unprotected LM, there was a requirement for a temporary ventricular assist device. But because of limited finances, the doctors went ahead without an assist device.

The right femoral route was chosen for the procedure. First, LM-LAD stenting was done because retrograde entry into RCA through LM-LAD was not possible with 90% LM stenosis, followed by RCA stenting, which was done through the reverse CART technique. The procedure was completed uneventfully. Total of three stents were put in, LCX FFR was done, and it showed a 0.93 (negative) value, so stenting was not done in LCX, LAD territory was non-viable, so revascularisation was not attempted.

The patient was discharged on the second day of the surgery and followed up after after 7 days, 1 month and 3 months. The patient was angina-free and had a normal lifestyle.

Dealing with cases of LM-TVD (LAD-CTO, RCA CTO) with HFrEF (LVEF=23%) is very challenging, as both CABG and MVPCI are high-risk procedures. And because of economic constraints in a country like India, doctors have to take daring decisions to go ahead with single-sitting MVPCI to achieve nearly total revascularisation. In such patients, achieving nearly total revascularisation by percutaneous coronary intervention is quite challenging and satisfactory too.

In today’s world, LM-TVD with HFrEF, satisfactory results with MVPCI can be achieved by an expert team in a highly-equipped centre.