CASE OF THE WEEK
BY
DR. M. ZARRAR ARIF
PGR CARDIOLOGY
HISTORY
PATIENT DATA
Name: Babar Abbas
Age / Gender : 45 y / Male
MOA : Medical Emergency
DOA : 11-03-2011
Address: 149 F ...
HISTORY
PRESENTING COMPLAINTS
Chest pain for last 2 hours
HOPI
Patient was in usual state of health when
he developed comp...
HISTORY
Past History
Patient gives history of admission with
chest pain 2 days back for which he was
admitted in Ittefaq h...
HISTORY
Drug History
Patient has been taking following
medications since last 2 days
Asprin 75 mg OD
Clopidogrel 75 mg OD
...
HISTORY
Personal History
Patient has no history of smoking or any
other addiction
Occupational History
Patient is a school...
GPE
A middle aged man sitting in bed well
oriented in time place and person with
vitals
Pulse : 72 / min, regular, normal ...
SYSTEMIC EXAMINATION
Cardio Vascular System
On pre-cordial examination inspection
normal, on palpation apex beat in 4th
in...
SYSTEMIC EXAMINATION
Gastro Intestinal System
Normal findings on inspection with no
palpable visceromegally and no area of...
Provisional Diagnosis
• Acute Coronary Syndrome
INVESTIGATIONS
Investigation Result
Hb 14.3
B/Urea 30
S/Creatinine 0.9
S/Na+ 138
S/K+ 4
Troponin T (Kit Method) -ve
ECG
ECG findings are as below
It showed regular sinus rhythm with rate of
80/min, normal axis with normal PR, and
QT inter...
FINAL DIAGNOSIS
UNSTABLE ANGINA
TREATMENT
Emergency management was done with
S/L angisid 0.5 mg stat
Asprin 300 mg stat
Clopidogrel 300 mg stat
Morphine 3...
TIMI RISK SCORE
CORONARY ANGIOGRAM
• Patient was offered coronary angiogram
as it was Class I A indication according to
AHA guidelines
• R...
REVISED TIMI RISK SCORE
DECISION
Patient was advised PTCA for his disease
and for the complete decision we will have
to review the type of lesion ...
How to define a bifurcation
lesion ?
• “A coronary artery narrowing occurring
adjacent to, and/or involving, the origin
of...
Difficulties of Bifurcation PCI
• Risk of peri-procedural complications
• Relatively high re-stenosis
• Not all lesions ar...
Factors to be considered for
PCI strategy
• Anatomical factors
– LMCA bifurcation
– Location of plaque (Anatomical classif...
Classification of
Bifurcation Lesions
• Plaque Location
• Plaque Extent
• Angle
Classifications of bifurcation
lesions
Medina
Classification
Limitations of
the Medina classification
• Does not take into account
1. Length of disease in the ostium of
the SB
2. Leng...
Plaque Burden at the SB
Ostium
Trifurcation
Angulation
Fractal geometry and QCA
How to name a bifurcation lesion
Medina
Classification
SIDE BRANCH LOSS
Simple
Stents and Dedicated Delivery
Systems
Drug-eluting Stents in Bifurcation
Lesions – Safety Data
The Technique Matters more than the
Number of Stent ?
CONCLUSION
In cases where there is no lesion in the
side branch or a purely ostial lesion,
stenting the main branch with a...
KEEP YOUR GOAL IN SIGHT
WORK HARD
SUCCESS WIL BE YOURS
THANK YOU !!!
a case of Bifurcation Stenting- Dr Zarrar
a case of Bifurcation Stenting- Dr Zarrar
a case of Bifurcation Stenting- Dr Zarrar
a case of Bifurcation Stenting- Dr Zarrar
a case of Bifurcation Stenting- Dr Zarrar
a case of Bifurcation Stenting- Dr Zarrar
a case of Bifurcation Stenting- Dr Zarrar
a case of Bifurcation Stenting- Dr Zarrar
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a case of Bifurcation Stenting- Dr Zarrar

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a case of bifurcation PCI with detailed review

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a case of Bifurcation Stenting- Dr Zarrar

  1. 1. CASE OF THE WEEK BY DR. M. ZARRAR ARIF PGR CARDIOLOGY
  2. 2. HISTORY PATIENT DATA Name: Babar Abbas Age / Gender : 45 y / Male MOA : Medical Emergency DOA : 11-03-2011 Address: 149 F Model Town, Lahore
  3. 3. HISTORY PRESENTING COMPLAINTS Chest pain for last 2 hours HOPI Patient was in usual state of health when he developed complaints of sudden chest pain, central in location, radiating to left arm and neck, severe in intensity and was associated with sweating. No complaints of nausea, vomiting, palpitations or dyspnoea.
  4. 4. HISTORY Past History Patient gives history of admission with chest pain 2 days back for which he was admitted in Ittefaq hospital and he was advised stay for evaluation after an ECG but he was discharged on his request. No previous history of any other hospital stay, surgical interventions etc
  5. 5. HISTORY Drug History Patient has been taking following medications since last 2 days Asprin 75 mg OD Clopidogrel 75 mg OD Atorvastatin 20 mg HS Metoprolol 25 mg BD Lisinopril 5 mg HS No history of drug allergy.
  6. 6. HISTORY Personal History Patient has no history of smoking or any other addiction Occupational History Patient is a school teacher by profession Family History No history of DM, IHD in the family
  7. 7. GPE A middle aged man sitting in bed well oriented in time place and person with vitals Pulse : 72 / min, regular, normal character with no radio-radial and no radio-femoral delay. B.P : 160/100 mm Hg Temp : 980 F R/R : 16 / min -ve for Pallor, clubbing, cyanosis. JVP not raised.
  8. 8. SYSTEMIC EXAMINATION Cardio Vascular System On pre-cordial examination inspection normal, on palpation apex beat in 4th intercostal space with normal character, on auscultation first and second heart sounds normal with no added sound. Respiratory System Normal findings on inspection palpation and percussion with normal vesicular breathing bilaterally and no added sounds on auscultation.
  9. 9. SYSTEMIC EXAMINATION Gastro Intestinal System Normal findings on inspection with no palpable visceromegally and no area of tenderness on palpation, normal bowel sounds on auscultation. Central Nervous System Grossly intact HMF with no motor or sensory loss
  10. 10. Provisional Diagnosis • Acute Coronary Syndrome
  11. 11. INVESTIGATIONS Investigation Result Hb 14.3 B/Urea 30 S/Creatinine 0.9 S/Na+ 138 S/K+ 4 Troponin T (Kit Method) -ve
  12. 12. ECG ECG findings are as below It showed regular sinus rhythm with rate of 80/min, normal axis with normal PR, and QT intervals with normal QRS. STT changes were present in anterior chest leads from V1-V4 in form of ST segment depression and T wave inversions, no ST elevations seen in any leads.
  13. 13. FINAL DIAGNOSIS UNSTABLE ANGINA
  14. 14. TREATMENT Emergency management was done with S/L angisid 0.5 mg stat Asprin 300 mg stat Clopidogrel 300 mg stat Morphine 3mg stat Metoprolol 25 mg stat Infusion of isoket @ 10 u drops/min Clexane 80 mg S/C Stat Chest pain improved with medication and ECG also showed improvement
  15. 15. TIMI RISK SCORE
  16. 16. CORONARY ANGIOGRAM • Patient was offered coronary angiogram as it was Class I A indication according to AHA guidelines • Recommendations for Coronary Angiography in Unstable Coronary Syndromes Class I High- or intermediate-risk unstable angina that stabilizes after initial treatment. (Level of Evidence: A)
  17. 17. REVISED TIMI RISK SCORE
  18. 18. DECISION Patient was advised PTCA for his disease and for the complete decision we will have to review the type of lesion we r facing
  19. 19. How to define a bifurcation lesion ? • “A coronary artery narrowing occurring adjacent to, and/or involving, the origin of a significant side branch" • A significant SB is a branch that you don't want to loose in the global context of a particular patient
  20. 20. Difficulties of Bifurcation PCI • Risk of peri-procedural complications • Relatively high re-stenosis • Not all lesions are the same :  - Size of vessels (Meaningful SB size ≥2.25mm)  - Variable plaque distribution  - Extent of SB disease  - Variable angulations • Higher risk of stent thrombosis • PCI techniques are mainly based on personal experiences from skilled operators
  21. 21. Factors to be considered for PCI strategy • Anatomical factors – LMCA bifurcation – Location of plaque (Anatomical classification) – Plaque or carina shift – Angle between SB and MB – Dynamic change in bifurcation anatomy • Modalities for objective anatomical evaluation – QCA, IVUS, FFR • Selection of devices and strategies – DES vs. BMS – Single vs. Double stent techniques – Kissing balloon or not – Dedicated bifurcation stents
  22. 22. Classification of Bifurcation Lesions • Plaque Location • Plaque Extent • Angle
  23. 23. Classifications of bifurcation lesions
  24. 24. Medina Classification
  25. 25. Limitations of the Medina classification • Does not take into account 1. Length of disease in the ostium of the SB 2. Length of the LMCA before the bifurcation 3. Trifurcation 4. Vessel angulation • The LMCA differs from many other bifurcation lesions due to the importance of the SB (LCx)
  26. 26. Plaque Burden at the SB Ostium
  27. 27. Trifurcation
  28. 28. Angulation
  29. 29. Fractal geometry and QCA
  30. 30. How to name a bifurcation lesion
  31. 31. Medina Classification
  32. 32. SIDE BRANCH LOSS
  33. 33. Simple
  34. 34. Stents and Dedicated Delivery Systems
  35. 35. Drug-eluting Stents in Bifurcation Lesions – Safety Data
  36. 36. The Technique Matters more than the Number of Stent ?
  37. 37. CONCLUSION In cases where there is no lesion in the side branch or a purely ostial lesion, stenting the main branch with a jailed wire in the side branch followed by provisional T-Stenting of the side branch after guide wire exchange appears to be the most rational and successful strategy, provided that final kissing-balloon inflations are systematically performed.
  38. 38. KEEP YOUR GOAL IN SIGHT
  39. 39. WORK HARD
  40. 40. SUCCESS WIL BE YOURS
  41. 41. THANK YOU !!!
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