Managing Dialysis-Associated Haemodynamic Instability in Critical Calcific Left Main Stem Disease With Tachycardia-Bradycardia Syndrome Using Intravascular Lithotripsy-Assisted Percutaneous Coronary Intervention and Permanent Pacemaker Implantation

Figures

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  Figure 1. Intradialysis ECG showing PAF (region marked by a purple curly brace with a purple star), ST depression in leads I–III, aVF, and V4–V6 (red arrows), and ST elevation in lead aVR (green arrow), indicating global subendocardial ischaemia. PAF: paroxysmal atrial fibrillation.

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  Figure 2. Intra-dialysis ECG showing severe sinus bradycardia at 43 bpm (encircled in red).

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  Figure 3. Intra-aortic pressure recording during angiography. Pulse pressure of 104 mmHg with elevated systolic pressure of 168 mmHg (blue arrow) and diastolic pressure of 64 mmHg (red arrow). Pulse pressure = systolic pressure - diastolic pressure.

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  Figure 4. OCT images of the LAD Minimal lumen diameter of approximately 1.5 mm before IVL-assisted stenting (A) and post-stenting minimum stent diameter of 3.5-3.75 mm after IVL-assisted stenting (B). In each pane, white text annotations correspond to the regions highlighted by white arrows. OCT: optical coherence tomography; LAD: left anterior descending artery; IVL: intravascular lithotripsy.

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  Figure 5. OCT images of the LAD Minimum lumen diameter of approximately 1.5mm before IVL (A) and fracture of the calcium plate after IVL (B). Post-stenting minimum stent diameter of approximately 3.75 mm after final stent implantation (C). In each pane, white text annotations correspond to the regions highlighted by white arrows. OCT: optical coherence tomography; LAD: left anterior descending artery; IVL: intravascular lithotripsy.

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  Figure 6. Angiographic LAO-caudal views Dry cine run of the LMS, LAD, and Cx arteries, which are heavily lined with parallel calcium deposits on both sides, i.e, tramtrack calcification (white arrows) (A). Severe stenosis of distal LMS, LAD, and Cx arteries (red arrows) (B). Post-PCI results with minimal residual stenosis of the ostial Cx (C). LAO: left anterior oblique; LMS: left main stem; LAD: left anterior descending artery; Cx: circumflex artery; PCI: percutaneous coronary Iintervention.

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  Figure 7. Angiographic RAO-caudal views Severe stenosis of distal LMS, LAD, and Cx arteries marked by red arrows (A). Deployment of LMS to LAD stent after successfully deploying the Cx stent, both stents marked by white arrows (B). Post-PCI results (C). RAO: right anterior oblique; LMS: left main stem; LAD: left anterior descending artery; Cx: circumflex artery; PCI: percutaneous coronary intervention.

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  Figure 8. DDDR pacemaker in-situ Notable heavy calcification of the aortic arch "Mönckeberg's sclerosis" (white arrow) was observed.