Complex left main bifurcation PCI in a patient with dual positivity: A unique interventional approach - A case report

Human immunodeficiency virus (HIV) affects over 38 million people worldwide, with 26 million receiving combined antiretroviral therapy (CART). People living with HIV (PLWH) have a 1.5- to 2-fold increased risk of cardiovascular disease, yet data on coronary revascularization remain limited. The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), further complicates the management of acute coronary syndrome (ACS) in PLWH. We present a case of an HIV-positive, COVID-19-positive patient with recurrent ACS, requiring urgent percutaneous coronary intervention (PCI) due to hemodynamic instability (systolic BP < 90 mm Hg) and ongoing chest pain despite optimal medical therapy.

A 41-year-old male, positive for SARS-CoV-2 on RT-PCR, presented with effort angina for two months and recurrent acute chest pain for one day. The electrocardiogram (ECG) showed ST-segment elevation. Despite initial medical management, persistent chest pain and hemodynamic instability (BP 86/60 mm Hg, heart rate 110 bpm) necessitated urgent coronary angiography (CAG), revealing significant stenosis. The SYNTAX Score I for our patient was 12, which is favorable for PCI over CABG. The SYNTAX Score II predicted a 4-year mortality risk of 15.3 % for PCI vs. 5.8 % for CABG. A multidisciplinary heart team discussion favored PCI over CABG. The patient underwent double kissing crush (DK crush) bifurcation stenting with drug-eluting stents (DES), achieving TIMI III flow and resolution of symptoms.

Coronary revascularization in PLWH is challenging due to a 2- to 3-fold increased risk of myocardial infarction, chronic inflammation, and drug interactions. Additionally, COVID-19 further elevates thrombotic risk. The SYNTAX Score II favored PCI, and considering the patient's unstable condition, PCI was the preferred strategy over CABG to reduce perioperative risks and hospital stay. The DK crush technique is well-documented for complex bifurcation lesions, with studies showing significantly lower target lesion failure rates (4.8 %) than other techniques (10.5 %).

Managing ACS in PLWH with concurrent COVID-19 requires a multidisciplinary approach. Given the limited surgical data, PCI remains a feasible and effective strategy, particularly in hemodynamically unstable patients. Until randomized trials provide definitive guidance, PCI remains the preferred approach for urgent coronary revascularization in PLWH.