Introduction: Coronary heart disease is one of the leading causes of death and morbidity in the world. With the advancement of new treatment options, increasing emphasis is being placed on less invasive approach of treating coronary disease, i.e. percutaneous coronary interventions (PCI) (1). A certain population still benefits most from surgical treatment - coronary artery bypass grafting (CABG) (2). Cardiac surgery carries a certain risk of peri- and post-procedural bleeding and the need for blood transfusions.

Case report: 64-year-old woman patient with long-term arterial hypertension, diabetes, a previous heart attack and PCI of the right coronary artery and ischemic cardiomyopathy with reduced systolic function of the left ventricle, was hospitalized for non-ST-elevation myocardial infarction. Coronary angiography verified three-vessel coronary disease with significant narrowing of the left main coronary artery (LMCA), left anterior descending artery (LAD), chronic occlusion of the circumflex artery, and significant narrowing of the right coronary artery (RCA). Considering the recent guidelines (three-vessel coronary disease and diabetes), the patient was referred to a cardiac surgeon and accepted for CABG. As the patient refused to receive blood transfusions for religious reasons, cardiac surgery was abandoned considering the high risk of periprocedural bleeding. The case was presented to the Heart team, considering the wishes of the patient, and it was recommended to do PCI LMCA/LAD and RCA. It is a complex high-risk procedure with a CHIP (Complex High-Risk Indicated PCI) score of 7. As there was no hemodynamic instability and cardiac output were maintained, we did not decide to use mechanical circulatory support in advance. PCI of the ostial RCA with the placement of a drug eluting stent (DES) and then PCI of the LMCA/LAD with the placement of 2 DES was performed. During the intervention, intravascular ultrasound was used to confirm good apposition of the stented segment. The patient was discharged with the recommendation of medications and further monitoring.

Conclusion: It is necessary to follow professional recommendations, but always keeping in mind patient’s wishes. Refusal of transfusion treatment presents a difficulty in deciding about the most optimal treatment modality.