Critical Left Main Coronary Stenosis During on-Call Hours: A Case for Delayed Revascularization?

ntroduction: Critical left main coronary artery (LMCA) stenosis is a life-threatening emergency that requires rapid but well-coordinated intervention. However, during on-call shifts, limited staff availability may necessitate stabilization strategies before definitive treatment. Case Report: We report the case of an 84-year-old woman with a history of ischemic heart disease and atrial fibrillation (CHA DS -VA = 4) who presented with acute chest pain and hemodynamic instability. ECG showed ST elevation in aVR, and diffuse ST depression in lateral and inferior leads. Emergency angiography revealed a 90–99% stenosis of the LMCA with extensive calcification, along with proximal LAD 70% stenosis and 90% circumflex stenosis. An intra-aortic balloon pump (IABP) was inserted for stabilization, and PCI was deferred to the next day. The patient improved clinically and electrocardiographically under IABP. Definitive PCI using a culotte technique was successfully performed the next day with favorable outcomes. Conclusion: In selected unstable patients with critical LMCA stenosis, early mechanical support with IABP may allow safe deferral of complex PCI until optimal team conditions are available. This case highlights the value of a staged strategy under specific emergency conditions.