JR

74-year-old male, K/C/O DM, HTN. Previous IPWMI with RVMI 6 years back, treated with PTCA/Stenting to RCA elsewhere. Moderate to severe TR with Mod PAH. Fall with SDH 2/5/2020, treated by Fronto-temporal Craniotomy, post op gliosis with epileptiform attacks Admitted with episode of syncope at home Sep 2020, ECG: Atrial Flutter with 5:1 block with VR 35 to 40 bpm, RBBB, BP 60 to 70 sys, Improved after Atropine. SARS-CoV2 RT-PCR positive with CT severity score 4/25.

Complex Cardiac Issues74 years old Male DM / HTNOld IWMI/RWAMI, Mod-Severe TR with PAHRecent Fall with SDH needing Craniotomy, post op gliosis with epileptiform attacksSyncope with Bradyarrythmias (AFL with higher degree block /RBBB) suggesting AV block with infra-hisian blockSevere RCA ISR

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Coronary Angiography:Dominant RCA: Proximal severe ISRLMS normalLAD mid vessel 50%LCX non-dominant with distal OM 60%

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Holistic Approach: 4 procedures in a Single Stage in Hybrid OR Catheter Laboratory with fusion image

1. Image (OCT guided) PCI to RCA  First the critical lesion in the proximal RCA was successfully stented with OCT guidance, using a Xienxe expedition 3x38mm stent.

2. Atrial Flutter Ablation             next, successful atrial flutter ablation was performed with CT image fusion with fluroscopy guidance 

3. Left Atrial Appendage Occlusion             next, the LAA was closed using fluroscopy, TEE guidance and CT image fusion, using an Amulet device
4. RV septal pacing (infra-hisian block with prolonged HV) next, successful RV septal pacing was done with an active fixation lead with SJM DDDR MRI compatible pacemaker with mode switch capability.
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In a COVID 19 positive patient during this pandemic a complex cardiac issue with multiple problems was successfully performed in a single stage in a Hybrid OR cath lab with CT fusion image, TEE guidance minimizing the number of admissions to hospital, and exposure to staff.