Intravascular ultrasound-guided directional atherectomy and stent implantation of an unprotected main stem in a heart transplant patient with significant comorbidity

Following orthotopic heart transplantation (HTx), development of transplant vasculopathy (TVP) is the limiting medical entity leading to significant m orbidity and mortality beyond the first year after HTx. Selection of a suit able strategy for repeat revascularisation - transcatheter angioplasty, cor onary artery bypass grafting or repeat HTx - depends on various parameters including coronary morphology, left ventricular performance, comorbidity, a vailability of graft material and donor organs. Catheter-based intervention s on the main stem of the left coronary artery are feasible, but a relative ly lower primary success rate and a higher complication rate and significan tly increased mortality have to be expected. We report on a patient who und erwent HTx 9 years ago and developed severe transplant vasculopathy reveali ng significant main stem stenosis, making reintervention necessary. Due to age, coronary artery morphology and comorbidity the patient was not conside red for coronary artery bypass grafting or repeat HTx. We performed success ful IVUS-guided directional coronary atherectomy and stent implantation on a distal. stenosis of the unprotected main stem. Our case demonstrates a pr edictable procedural risk and favourable primary result of left main stem a ngioplasty procedures, thus providing a therapeutic option for patients who are poor candidates for operative revascularisation strategies.