Cardiology class on interesting cases

1. DR.R.SPANDANA
MODERATOR: DR.G SENGOTTUVELU & DR SENTHIL RAJ

2. TAVI IN PRESENCE OF AF IN A
POST CABG PATIENT

3.  Mr. KANDASAMY R, 79 years old gentleman presented with complaints of
BREATHLESSNESS ON EXERTION SINCE 1 WEEK.
 On evaluation ECHO done showed SEVERE AS (PG- 59mmHG, MG- 35mmHg), MILD
INCREASE IN GRADIANT ACROSS MV, NORMAL LV FUNCTION, AF WITH CVR. CT
CAG done on 24/11/22 showed PATENT SVG TO LAD, 70-80% MID RCA, 70-80% IN
OSTIOPROXIMAL LEFT RENAL ARTERY.

4. TYPE 2 DIABETES MELLITUS
PARKINSON'S DISEASE (NEWLY DIAGNOSED)
RHEUMATIC HEART DISEASE
CAD - SINGLE VESSEL DISEASE (2012)
S/P CABG SVG TO LAD (2012)
S/P MVR (EDWARDS PERIMOUNT PLUS PERICARDIAL BIOPROSTHETIC VALVE
27mm)-17/10/12
PERMANENT ATRIAL FIBRILLATION
SEVERE SYMPTOMATIC AORTIC STENOSIS
NORMAL LV FUNCTION
S/P TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)- 5/12/22 with MYVAL
OCTACOR 24.5MM DONE
POST TAVI ATRIAL FIBRILLATION WITH INTERMITTENT COMPLETE HEART BLOCK
EMERGENCY TPI (7/12/22)
SINGLE CHAMBER PERMANENT PACEMAKER IMPLANTATION (LBBP)- 8/12/22

9.  Both SAVR and TAVR are safe for patients with prior CABG surgery at
intermediate operative risk.
 Treatment modality influenced the postoperative course, with TAVR
facilitating faster improvement in quality of life and more robust exercise
tolerance, which persisted at 1-year follow-up.

10.  Intermediate-risk patients - symptomatic, severe AS and prior CABG surgery, TAVR
using the self-expanding valve and SAVR are both safe.
 The rate of all-cause mortality and disabling stroke as well as the individual
components of this primary end point were similar at 30 days and 1 year.
 Complications of the procedures differed, with those receiving SAVR having more
transfusions, acute kidney injury, and atrial fibrillation.
 Transcatheter aortic valve replacement led to a higher pacemaker rate but also to
significantly better aortic valve area and mean gradient and a more rapid
improvement in symptoms, exercise capacity, and quality of life.
Comparison of Outcomes After Transcatheter vs Surgical Aortic Valve
Replacement Among Patients at Intermediate Operative Risk With a
History of Coronary Artery Bypass Graft SurgeryA Post Hoc Analysis of
the SURTAVI Randomized Clinical Trial
Michael J. Reardon, MD1; Robin H. Heijmen, MD2; Nicolas M. Van
Mieghem, MD, PhD3; et al

11.  Reoperation in patients with prior CABG surgery carries increased risk both because
these patients tend to be older and have more comorbidities and because of the risk
of cardiac or graft injury during sternal re-entry.
 Previous CABG surgery treated with TAVR or SAVR had similar short-term and long-
term survival, but TAVR resulted in a shorter hospital stay and a greater need for
post procedure pacemakers.
 TAVR’s superior hemodynamics may have facilitated increased transvalvular flow
needed for exercise.
 Atrial fibrillation increases the risk of all primary and secondary outcomes after
TAVR/TAVI.
Comparison of Outcomes After Transcatheter vs Surgical Aortic Valve Replacement
Among Patients at Intermediate Operative Risk With a History of Coronary Artery
Bypass Graft SurgeryA Post Hoc Analysis of the SURTAVI Randomized Clinical Trial
Michael J. Reardon, MD1; Robin H. Heijmen, MD2; Nicolas M. Van Mieghem, MD, PhD3; et
al

13.  A substantial number of patients requiring aortic valve replacement have previous
undergone CABG “because similar risk factors are responsible for the pathogenesis
of coronary artery disease and aortic stenosis”.
 The preference for TAVI over surgery in this context is because the “risks of re-
operative surgery are much higher than the initial surgery”. He adds: “The patients
have already had a median sternotomy and are older at the time of the potential
second surgery.

14.  The rate of in-hospital mortality was similar between TAVI and surgery patients.
Furthermore, the lower incidence of myocardial infarction, stroke, bleeding, and
acute kidney injury were all lower in the TAVI patients.
 However, the need for a permanent pacemaker was almost two-fold higher in TAVI
patients
 TAVI procedure may be ‘an attractive option in the population of high-risk patients
with aortic stenosis and previous CABG’.
 Patients with previous heart surgery often present with reduced left ventricular
function.
 Paravalvular insufficiency will influence their late mortality.

15. NEW AF AFTER RECENT PCI

16.  MRS VASANTHA, 72 Year old came with chest pain on exertion which was retrosternal
compressive type (GRADE-II) subsides with rest and non radiating,
 TYPE 2 DIABETES MELLITUS
SYSTEMIC HYPERTENSION
DYSLIPIDEMIA
DEGENERATIVE MODERATE CALCIFIC AORTIC STENOSIS
MILD AR
CAD-ACS-NSTEMI
CAG (O7/12/2022): TRIPLE VESSEL DISEASE
NORMAL LV FUNCTION WITH LVEF-62%
SUCCESSFUL OCT GUIDED PCI TO RCA DONE WITH 2 DES AND PCI TO LCX WITH
2 DES AND FFR TO LAD DONE(BORDERLINE)

17.  Discharged on 9/12/22
T ECOSPRIN 75MG 1-0-0
T BRILINTA 90MG 1-0-1
T ROZAVEL 40MG 0-0-1
T CONCOR 5MG 1-0-0
T CILACAR 10MG 1-0-1
T TAZLOC CT 80MG 0-0-1
T MINIPRESS XL 2.5MG 1-0-1
T PAN 40MG 1-0-0 TO CONTINUE BEFORE FOOD
CAP.HAEMUP 1CAP 1-0-0
 Readmitted on 11/12/22 with complaints of chest pain radiating to arm, ECG showed AF with FVR.

18.  The management of atrial fibrillation in patients who have undergone percutaneous coronary
intervention (PCI) for the treatment of coronary-artery disease is a common and difficult
challenge.
 In patients with atrial fibrillation, oral anticoagulation is administered to reduce the risk of
stroke. In patients who have undergone PCI, dual antiplatelet therapy is administered to
prevent major adverse cardiovascular events and stent thrombosis.
 One in four older patients with atrial fibrillation who have had an acute myocardial infarction
receives triple therapy.
 A risk of intracranial hemorrhage that is two times as high as the risk with dual antiplatelet
therapy.

19.  Shortening the course of triple therapy does not substantially reduce the bleeding risk.
 Triple therapy may prevent ischemic events, it also has the potential to cause considerable
harm in many patients.
 In the PIONEER AF-PCI trial, dual therapy with rivaroxaban was associated with lower risks
of Thrombolysis in Myocardial Infarction (TIMI) major and minor bleeding than was triple
therapy with warfarin.
 Duration of triple therapy and the anticoagulants used in each study (warfarin in the WOEST
trial, rivaroxaban in the PIONEER AF-PCI trial, and dabigatran in the RE-DUAL PCI trial)

21. Clinical Significance of Atrial Fibrillation Status in Patients
With Percutaneous Coronary Intervention
 Approximately 5%-10% of patients who underwent percutaneous coronary intervention (PCI)
or had acute coronary syndrome (ACS) have concomitant AF.
 Concomitant AF is associated not only with hemodynamic compromise, but also other
multifactor comorbidities.
 these patients typically require both anticoagulation and antiplatelet therapies.

22.  Kinjo et al. assessed the prognostic significant of AF and atrial flutter in patients with acute MI
that had been treated with PCI. In their study, patients with AF were older, were in higher
Killip classes, had higher rates of previous MI and previous cerebrovascular accident, had
systolic blood pressures of < 100 mmHg and heart rates ≥ 100 beats/min, were less likely to
smoke, and had higher prevalence of multivessel disease and poorer reperfusion of infarct-
related artery than those without AF.
 AF was a common complication in patients with MI who were treated with PCI and
independently influenced 1-year mortality.
 Cardiogenic shock, congestive heart failure, cardiac rupture, ventricular tachycardia and/or
ventricular fibrillation, and stroke occurred more often in patients with AF than in those
without AF

23.  Patients with AF had a greater incidence of death due to pump failure than those without AF.
 A higher risk of mortality; a deterioration in haemodynamics due to increased heart rate, loss of
atrioventricular synchrony, and progressive dysfunction of the left atrium and left ventricle;
and stroke and other embolic events resulting from atrial thrombi.
 Several kind of arrhythmias, especially ventricular arrhythmias and conduction disturbances,
can occur during PCI. These arrhythmias may result from excess catheter manipulation,
intracoronary dye injection, new ischaemic events, or reperfusion injury. Lethal ventricular
arrhythmias, including serious ventricular tachycardia and ventricular fibrillation, have been
reported to occur in 1.5–4.4% of patients undergoing coronary angioplasty.

24.  The frequency of these arrhythmias after primary PCI was analyzed in a study of
3065 patients.
 Ventricular arrhythmias occurred in 133 patients (4.3%).
 Smoking, lack of pre-procedural beta-blockers, shorter time from symptom onset to
emergency room arrival, initial TIMI flow grade 0, and infarct of the right coronary
artery were variables independently associated with a risk of serious ventricular
arrhythmias

28.  Both prevalent AF and incident AF were associated with worse crude outcomes and
complications during hospitalization.
 AF is increasing as the society ages and is associated with numerous risk factors, such as
smoking, alcohol consumption, obesity, hypertension, diabetes, and history of heart failure or
myocardial infarction. Therefore, AF was common in patients who underwent PCI, including
those with ACS, who represented a high-risk group.
 Patients with PCI were identified and classified into 3 groups according to AF status: no AF,
prevalent AF before admission, and incident AF after admission.

29. MULTIVESSEL PCI IN A METALLIC VALVE

30.  Mr. GUNAPANDIYAN V, 44 years old gentleman, Now admitted for CAG + PCI TO LAD/
LCX AND OM.

31.  TYPE 2 DIABETES MELLITUS – 7 years
SYSTEMIC HYPERTENSION - 7 years
RHD
SEVERE MS WITH PHT
S/P MVR(2013)- SJM MECHANICAL (27MM)
RECENT NSTEMI
S/P CAG (2/12/2021)- TRIPLE VESSEL DISEASE.
 CAD- S/P PCI TO CULPRIT LAD WITH RESOLUTE ONYX STENT/ POBA TO RAMUS AND
DISTAL LAD
MILD LV DYSFUNCTION, EF- 50%
CAG (10/12/22)- TRIPLE VESSEL DISEASE WITH 90% TSR ND LAD STENT, DISTAL CTO
OF CAD WITH TOTAL OCCLUSION.
ADHOC PCI (10/12/22)- WITH 3.0MM X 28MM XIENCE ALPINE DES TO LAD, 2.0MM X
28MM XIENCE ALPINE DES TO OM2 AND WITH 2.75MM X 18MM XIENCE ALPINE DES TO
LCX.

32.  Age : 45 Year old female

33.  Triple therapy (TT) indications:
 Atrial fibrillation at moderate to high thromboembolic risk, mechanical heart valves, previous
cardiogenic thromboembolism and recent deep vein thrombosis or pulmonary embolism
 Owing to the superior efficacy of VKA compared to dual antiplatelet therapy (DAPT)
 TT with VKA, aspirin and clopidogrel is regarded as the optimal antithrombotic regimen in
patients with an indication for VKA undergoing PCI-S.
 TT is associated with the lowest incidence of stroke compared to DAPT or the combination of
VKA and a single antiplatelet agent.

34.  Drug-eluting stents are generally not implanted, owing to the need for prolonged clopidogrel,
and hence TT, administration.
 When drug-eluting stent implantation is clinically necessary, the use of newer generation drug-
eluting stents (especially polymer-free) that exhibit accelerated re endothelization is preferred