Cath Conference 1 October 2002 Presentation Transcript
Cath Conference 1 October 2002 Todd Justice
Case #1 BM
53yo wf collapsed at her desk at work. Brought to ed by ems. Upon arrival was in extremis and required immediate intubation for respiratory distress.
History of type 2 dm and smoking
Exam: BP 40/palp, Pulse 150, intubated, af Chest clear, neck veins distended Heart tones distant, no murmur Abd benign Ext poorly perfused with absent pulses
Na 140, K 4.0, Hco3 17, bun 17, cr 1.1, glc 492, AG 21, ca 8.9, mg 2.4, phos 7.9
Wbc 11.6, hct 38.2, plt 307
Abg: 7.01/62/21/sat 17%/base def 16.8
Trop 5.98, CK 236, MB 10
CXR: nl heart, mediastinum; lung fields clear.
Taken emergently to cath lab for rhc, lhc, iabp
RA mean 19
PA 30/20 mean 24
PCW mean 19
CO/I = 3.1/1.4
LV: limited lateral apical AK, EF 50%, no mr.
LAD: mild diffuse noncritical disease
CCA: 30% ostial, occluded distally
RCA: dominant, mild luminal irreg’s.
IABP placed left femoral
PCI on CCA: occlusion was opened with PTCA, but “no reflow” observed. Small perfusion bed visualized on injection through balloon.
Of note, pt had chest pain episode several days prior to this event. Had been diagnosed with a “breast bone infection” by local MD and treated with azithromycin.
Echocardiogram and CT chest performed.
Echo results: Hyperdynamic lv, posterolateral akinesis. Small posterior and moderate anterior pericardial effusion not echo free. Cannot rule out clot . Collapse of RA during diastole.
CT chest: Small right pleural effusion with compressive atx. Moderate high density pericardial effusion consistent with hemopericardium. Focal bulge of left ventricle. No extravasation of contrast noted.
LV free wall rupture diagnosed, felt to be secondary to MI 3-5 days prior.
2 pericardial drains placed.
Pt went to OR for urgent repair/patch.
Pt did well post-operatively. Off all vasoactive agents by evening of 1 st POD. Extubated on POD #2 and eating/communicating.
Case #2: LS
63yo wm s/p 3 vessel CABG 6wks prior to admission, presented to outside hospital complaining of increasing dyspnea on exertion. Also had cp described as a “pull” lasting few seconds.
Post op course had been complicated by rt pleural effusion occuring 3 weeks post op for which he had needed thoracostomy tube.
PMHx: NQWMI, CABG, h/o AF, type 2 dm, cerebrovasc disease, gerd with esophageal stricture, HTN.
Exam: bp 143/54, p88, 90% on 4L O2 jvp 8cm…to angle of jaw with hjr heart rrr no mrg decreased bs at bases 1+ pitting edema of lower ext b/l
Cardiac enzymes negative
Catheterization Data (after 3L diuresis):
RA mean 7
PA 38/11 (23)
PCW mean 15
Cath data (cont’d):
SVG-ramus: occluded proximally
SVG-CCA: occluded proximally
LMCA: 60-70% distal
LAD: severe diffuse disease up to 70% mid vessel
CCA: 30% prox, 100% after OM3
RCA 70% ostial, diffuse up to 50% prox/mid
LV: AK of basal inf wall, EF 50%, no MR
Hospital Course: Medical regimen was optimized and heart failure symptoms improved. Pt underwent directional coronary atherectomy. He tolerated the procedure well and was discharged home the following day.
Case #3: SC
48yo WF with longstanding tobacco abuse and COPD requiring home O2, presented to OSH with hypercapnic respiratory failure with severe acidosis and hypotension. No chest pain. No history of CAD.
Transferred to UK MICU service intubated and on DA gtt.
Exam: 121/63, 131, 10/10, AF Wheezing Regular tachycardia, no mrg No edema
Initial studies/Hospital course:
ABG: 7.09/175/197; serum HCO3 58
EKG sinus tach with nonspecific ST/T abnormalities
Troponin peaked at 0.05
Could not be weaned from ventilator.
Had bilateral ptx due to barotrauma
Developed MRSA pneumonia
RA mean 18
PCW mean 19
Ao 122/82, LV 122/19
Angio 50-55% LMCA, FFR 0.80, Nl LVEF
Failure to wean continued. PCI of LMCA undertaken as last ditch effort to assist ventilator weaning.
Pt remains on ventilator. Awaiting tracheostomy and transfer to permanent ventilator facility.
Case #4 LM
64 yo aaf with history of CAD, athsma, htn, type 2 dm, esrd admitted for increased dyspnea.
PMHx: CAD…nqwmi x 2, lad stent jan 00 required ptca for in-stent restenosis june 02; h/o tobacco abuse but quit 1993; previous ef 60%; remainder as above.
Exam: 121/60, 57, 20, af Heart rrr with S3 Wheezing bilaterally No peripheral edema
CXR: pulmonary vasc congestion
Underwent acute dialysis with UF
Cardiac enzymes followed: peak trop 8.34
Cath data: LMCA: 75% distal lesion LAD: 75% origin, long 60% D1 CCA: long 90% origin RCA: 75% ostial, 80-90-% mid-vessel LV: severe inferior hk, mod ant hk. EF now 40% with mod to severe MR, significant change from 6/02.
Pt unwilling to consider surgery, so underwent PCI of LMCA and proximal LAD and CCA.
Takagi et al
Circulation, 6 Aug 2002: “Results and Long-Term Predictors of Adverse Clinical Events After Elective Percutaneous Interventions on Unprotected Left Main Coronary Artery.”
Purpose: to evaluate outcomes of pci on left main disease in elective cases (most previous studies intermixed elective and emergent cases).
67pts with LM stenosis >50% that was suitable for pci, and either contraindication to CABG or patient and referring MD preferred percutaneous approach with full knowledge of procedural risks.
Takagi, et al
Procedures: balloon predilation, rotational atherectomy, directional atherectomy, ivus according to operator preference. Stent implantation encouraged in most lesions.
Pre and post-procedure ticlid and asa
Clinical f/u at 1, 3, and 6mos and then at latest f/u or telephone interview. Avg length of f/u 31 mos.
Angiographic f/u at 6mos or earlier if suggestion of ischemia.
Takagi, et al
Unstable angina 40%
Previous MI 34%
Triple vessel dz 45%
LvEF 57% +/- 13%
High risk (Parsonnet >15) 28%
Takagi, et al
Site of LM lesion: ostium 22%, mid 18%, distal bifurcation 60%.
Angiographic success 97%, procedural success 91% (defined as leaving hospital free from death, MI, or CABG).
Stents placed in 64 pts. 39 had balloon angioplasty, 16 had dca (13 of those stented), 12 had rotational atherectomy and stenting. Balloon pump in 58%, ivus performed in 46%, IIb/IIIa antagonists in 15%. 32% pci of another cor segment.
Mean stenosis decreased from 59 to 4%.
Takagi, et al
In hospital comlications: 2 emergent CABG, 2 q-wave mi, 3 nqwmi. No deaths.
Follow-up cardiac events: mean follow up 31 mos (range 5-94 mos). 11 deaths, 8 cardiac deaths. Total event rate including death, MI, any revascularization was 34%.
Angiographic f/u in 51pts after 5 +/- 2mos: 16 restenoses (31%), 13 of these were when the distal lmca was initially involved.
DCA debulking + stent not significantly better than stenting alone (36 vs 47% restenosis). Restenosis in debulked branch only 24%.
Takagi, et al
Cardiac mortality higher in pts with high surgical risk—21%. In the 72% of pts with low surgical risk (Parsonnet score <15) cardiac mortality only 4.2% throughout the f/u.
Hazard ratio of LVEF <40% was 8.6. Low ef was the covariate of cardiac death.
Covariate of all cardiac events was reference vessel diameter.
Takagi, et al
PCI feasible in variety of LM lesions with high immediate success and favorable hospital outcome.
Follow up affected by relatively high incidence of cardiac death, MI, and need for reintervention.
Finding that pts with LM disease and high surgical risk or low ef also are high risk for pci undermines value of pci as an alternative to surgery in these pts.
Tagaki, et al
The fact that 6/8 cardiac deaths occurred in first 6mos highlights the dramatic way restenosis could manifest in the LM. However, only 2 cardiac deaths occurred after the first 6mos. Thus a solution to the problem of restenosis would favorably affect the future use of LM pci.
Numbers too small to draw conclusions regarding atherectomy.
PCI of LM good long-term results in those with low surgical risk and large reference vessel diameter.