Case
A 73-year-old man with a history of diabetes mellitus was referred to our hospital for treating coronary artery disease. Coronary artery angiography showed severe diffuse stenosis of the left anterior descending artery (LAD) and old MI of the left circumflex artery (LCx), with a collateral flow from the LAD to the LCx (Figure 1a, b). We performed percutaneous coronary intervention (PCI) for the LAD and LCx that led to coronary LAD perforation (Figure 1c). To repair this, we implanted a covered stent in the LAD and jailed the septal and two large diagonal branches (D1, D2) (Figure 1d). The patient experienced cardiac shock, was intubated, and the Impella CP (Abiomed, Danvers, Massachusetts, USA) was inserted. One week later, the patient was weaned off the Impella CP and it was removed, with moderate MR being present; however, 2 days later, it was re-inserted because of pulmonary congestion and low output syndrome due to the worsening of MR. Echocardiography under Impella CP support showed a low ejection fraction (EF) of 31%, severe MR with tethering, and global hypokinesis, compared to an EF of 57%, trivial MR, and only basal infero-posterior mild hypokinesis before PCI (Figure 2). Mechanical support was difficult to remove due to severe IMR and, therefore our heart team considered a surgery.