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.