This document discusses coronary artery perforation during percutaneous coronary intervention (PCI). Some key points:
- Coronary perforation can occur during or after PCI and is defined as extravasation of contrast or blood from the coronary artery. Proximal or mid vessel perforations are more severe while distal perforations often have a benign course.
- Perforations are classified based on their severity. Treatment depends on the severity and location of the perforation. Conservative measures often suffice for minor perforations while techniques like prolonged balloon inflation or stenting may be needed for more severe perforations to stop bleeding.
- Factors like the use of atherectomy or laser devices, complex lesions, small vessels, and guide
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Based on the principle that the distal coronary pressure measured during vasodilation is directly proportional to maximum vasodilated perfusion.
FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow in the same artery if there were no stenosis.
FFR is simply calculated as a ratio of mean pressure distal to a stenosis (Pd) to the mean pressure proximal stenosis, that is the mean pressure in the aorta (Pa), during maximal hyperaemia.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Based on the principle that the distal coronary pressure measured during vasodilation is directly proportional to maximum vasodilated perfusion.
FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow in the same artery if there were no stenosis.
FFR is simply calculated as a ratio of mean pressure distal to a stenosis (Pd) to the mean pressure proximal stenosis, that is the mean pressure in the aorta (Pa), during maximal hyperaemia.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
What is a SCAD (spontaneous coronary artery dissection)?Laura Haywood-Cory
PPT presentation I created to educate people about how SCAD survivors use social media to support each other and organize. Katherine Leon had input on this as well, and the two of us presented a slightly different version of this in the WomenHeart "Champions Educating Champions" webinar series back in November of 2011.
Spontaneous coronary artery dissection (SCAD) is an infrequent and often missed diagnosis among patients presenting with acute coronary syndrome (ACS). Unfortunately, SCAD can result in significant morbidities such as myocardial ischemia and infarction, ventricular arrhythmias and sudden cardiac death. Lack of angiographic recognition from clinicians is a major factor of under-diagnosis. With the advent of new imaging modalities, particularly with intracoronary imaging, there has been improved diagnosis of SCAD. The aim of this paper is to review the epidemiology, etiology, presentation, diagnosis and management of SCAD.
SCAD is a rare, sometimes fatal, traumatic condition with approximately eighty percent of cases affecting women. The coronary artery can suddenly develop a tear, causing blood to flow between the layers which forces them apart, potentially causing a blockage of blood flow through the artery and a resulting heart attack. The condition may be related to female hormone levels, as it is often seen in post-partum women, or in women during or very near menstruation, but not always. It is not uncommon for SCAD to occur in people in good physical shape and with no known prior history of heart related illness. It is also not uncommon for SCAD to occur in people in their 20's, 30's, and 40's, as well as older.
Coronary CTO is characterized by heavy atherosclerotic plaque burden within the artery, resulting in complete (or nearly complete) occlusion of the vessel. Although the duration of the occlusion is difficult to determine on clinical grounds, a total occlusion must be present for at least 3 months to be considered a true CTO. Patients with CTO typically have collateralization of the distal vessel on coronary angiography, but these collaterals may not provide sufficient blood flow to the myocardial bed, resulting in ischemia and anginal symptoms. CTO is clinically distinct from acute coronary occlusion, which occurs in the setting of ST-segment–elevation myocardial infarction, or subacute coronary occlusion, discovered with delayed presentation after ST-segment–elevation myocardial infarction. Clinical features and treatment considerations of these entities differ considerably from CTO.
Among patients who have a clinical indication for coronary angiography, the incidence of CTO has been reported to be as high as 15% to 30%. Patients with CTO are referred for angiography because of anginal symptoms or significant ischemia on noninvasive ischemia testing. Patients who are symptomatic will have stable exertional angina resulting from a limitation of collateral vessel flow to meet myocardial oxygen demand with stress. Of patients referred for PCI in clinical trials of CTO PCI, only 10% to 15% of patients are asymptomatic. It is likewise uncommon for patients with CTO to present with an acute coronary syndrome caused by the CTO itself.
A review of the approach and necessary equipment for the endovascular treatment pf Coronary Chronic Total Occlusions including guide catheters, guide wires, micro catheters, snares, balloons, stents and new devices
Chronic Total Occlusions: The Road Less TraveledAllina Health
By M. Nicholas Burke, MD. The use of pioneering percutaneous treatments for chronic total occlusions: indications, limitations, outcomes and current research.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
2. Coronary Perforation
• Coronary artery perforation is defined as evidence
of extravasation of contrast medium or blood from
the coronary artery, during or following
percutaneous intervention.
3. • Anatomically, perforation is categorized as –
• Proximal or mid vessel
• Usually more profound with greater likelihood of
significant sequelae
• Distal vessel
• There the aetiology is often the guide wire (WIRE
EXIT) and the clinical course is frequently benign
5. Other classifications
• Fukutomi1
• Type I: Epicardial staining without a contrast
extravasation
• Type II: Epicardial staining with a visible jet of contrast
extravasation
• Kini2
• Type I: Myocardial staining without contrast
extravasation
• Type II: Contrast extravasation into pericardium,
coronary sinus, or cardiac chambers
1.Fukutomi T, Suzuki T, Popma JJ, et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention. Circ J 2002;66:349-56.
2.Kini AS, Rafael OC, Sarkar K, et al. Changing outcomes and treatment strategies for wire induced coronary perforations in the era of bivalirudin use. Catheter Cardiovasc Interv 2009;74:700-7.
6. First data…
• Ellis and colleagues reported first large scale series derived
from data obtained from 11 centres, from 1990 and 1991.
• Of 12,900 procedures performed, 62 were complicated by
coronary perforation (0.5%).
• They observed that the use of ‘new devices’ increased risk
of perforation.
Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era: incidence, classification, management, and outcome. Circulation 1994;90:2725-30.
7. • Only 14 out of 62 perforations (23%) occurred following
POBA, others from debulking techniques.
• Complication rate –
• POBA - 0.1%
• Excimer laser - 1.9%
• Rotational atherectomy - 1.3%
• Predesposing patient characteristics –
• Female gender
• Increasing age
8. • Over sizing of the angioplasty balloon was one of the key
causes for perforation.
• The development of cardiac temponade was associated
with appreciable mortality (20%)
particularly if it occurred in catheter laboratory as a result of brisk
extravasation (Type III)
10. • The incidence of Coronary Artery Perforation (CAP)
has not changed significantly over two decades.
• It is reported between 0.2% and 0.9%.
11.
12. Sequelae of CAP
• Caused by CAP
• Blood loss
• Distal ischemia
• Pericardial Temponade
• Cardiogenic shock
• Death
• Caused by management strategies
• Myocardial Ischemia
• Acute vessel occlusion
• Myocardial infarction
• Operative morbidity and mortality
• Death
14. Diagnosis
• Not all perforations are immediately visible on coronary
angiography.
• Remarkable proportion of patients may develop temponade
more than 2 to 6 hours after procedure.
• The clinical manifestation may be non-specific, and the
patient may simply develop progressive hypotension.
• A high index of suspicion should be maintained in order to
secure the correct diagnosis in a timely fashion.
15. Outcomes
• In various studies, outcomes depend largely upon the
severity of perforation.
• The outcome is worse if the temponade develops abruptly
within the catheter laboratory, rather than in the delayed
fashion in the recovery room or ICU.
• Outcomes also depend upon associated co-morbidities.
• Chronic renal dysfunction
• Pre-procedural impairment of LV function
• Older patient
• Cavitary spilling type III perforation
17. • A study1 of 38559 patients with 72 perforations reported that more than
40% of perforations were seen in vessels of less than 2.5mm diameter.
• The authors describe that the device-lumen mismatch is more
important than the vessel reference diameter.
• Other study2 of 8932 patients with 35 perforations showed that balloon
induced perforation was more likely where the balloon to artery ratio
was 1.3±0.3 compared with a ratio of 1.0±0.3 where no problem
ensued.
1.Javaid A, Buch AN, Satler LF, et al. Management and outcomes of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2006;98:911-4.
2.Ajluni S, Glazier S, Blankenship L, et al: Perforations after percutaneous coronary interventions: clinical, angiographic, and therapeutic observations. Catheter
Cardiovasc Diagn 32:206– 212, 1994.
18. Use of GP IIb-IIIa inhibitors
• Studies comparing outcomes of CAP in patients with or without use of
GPI reported a modest adverse influence where GPI were used.
• In a study* of 16,298 patients with 95 perforations, GPI were used in 33
cases.
• When these 33 cases were compared with the other 62 cases (where
GPI were not used), they found no difference in
• Mortality and
• Myocardial Infarction
• But, GPI use was associated with
• Higher incidence of temponade and
• Greater requirement of emergency surgery
*Fasseas P, Orford JL, Panetta CJ, et al. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures.
Am Heart J 2004;147:140-5.
19. GPI and perforations
• Great caution should be exercised if any perforation is identified, even if
seemingly trivial, where GPI is used.
• Abciximab binds irreversibly to platelet receptors, rendering platelet
activity almost negligible for 24 – 36 hours.
• In case of perforation with Abciximab, unlike the small molecules
Tirofiban and Eptifibatide, simply discontinuing the infusion of
Abciximab will not reverse its effect.
• Platelet transfusion may be required to restore bleeding time.
• The strategy should be case based, balancing the stoppage of life
threatening haemorrhage with the importance of maintaining crucial
revascularization in a given case.
21. BIVALIRUDIN
• This study compared the consequences of CAP in patients who
underwent anticoagulation with bivalirudin to those in patients who
underwent anticoagulation with heparin at time of CP.
• From 33,613 procedures, 69 patients (0.2%) had CAP, Bivalirudin was
used in 41 patients, while Heparin in 28.
• The primary end point for this analysis was the composite of in-hospital
death, cardiac tamponade, or emergency cardiac surgery.
• The primary composite end point was similar between groups.
• However, there was a lower rate of cardiac surgery requirement in BIV-
treated patients.
• The study suggests that choice of procedural anticoagulant agent does
not influence outcome when CP occurs.
22.
23. BIVALIRUDIN
• A pooled analysis of patients treated with PCI in three randomized trials
including REPLACE-2, ACUITY, and HORIZONS-AMI.
• Among a total of 12,921 patients, CAP occurred in 35 patients (0.27%).
• Baseline creatinine clearance was the only independent predictor of CA
perforation.
• Patients assigned to BIVALIRUDIN versus UFH plus a GPI had
• non significantly lower rates of death,
• similar rates of MI,
• significantly lower rates of TVR, and
• similar rates of the composite end-point of death/MI/TVR.
• In three PCI trials, treatment of patients experiencing CA perforation
with bivalirudin monotherapy was not associated with worse outcomes
compared to treatment with UFH plus GP IIb/IIIa inhibitors.
24. Atherectomy
• Use of either atherectomy or laser ablative technology is
associated with a higher incidence of perforation than in
convention balloon and stent PCI.
• However, the increased complication rate using these
devices is strongly influenced by the complexity of the
coronary disease being treated.
• Ellis1 and colleagues reported that the incidence of
perforation with balloon angioplasty was 14 out of 9080
cases (0.1%), whereas that of debulking techniques
collectively was 48 out of 3820 cases (1.3%).
• Later reports suggested CAP rate of 0.4% (1990)2 and 0.3%
(2002)3 for rotablation.
1.Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era: incidence, classification, management, and outcome. Circulation 1994;90:2725-30.
2.Gruberg L, Pinnow E, Flood R, et al. Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2000;86:680-2, A8.
3.Fejka M, Dixon SR, Safian RD, et al. Diagnosis, management, and clinical outcome of cardiac tamponade complicating percutaneous coronary intervention. Am J Cardiol 2002;90:1183-6.
25. Guide Wires
• Several authors have clearly pin-pointed the hydrophilic
wire as a more risky equipment for perforation.
• Javaid et al1 found that 13 out of 15 wire associated
perforations had hydrophilic coating.
• Ramana el2 at found that the majority of 25 perforations
were caused by guide wires and these were usually
hydrophilic and stiff.
• Witzke3 and group found that 51% of perforations were wire
mediated
1.Javaid A, Buch AN, Satler LF, et al. Management and outcomes of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2006;98:911-4.
2.Ramana RK, Arab D, Joyal D, et al. Coronary artery perforation during percutaneous coronary intervention: incidence and outcomes in the new interventional era. J
Invasive Cardiol 2005;17:603-5.
3.Witzke CF, Martin-Herrero F, Clarke SC, Pomerantzev E, Palacios IF. The changing pattern of coronary perforation during percutaneous coronary intervention in the
new device era. J Invasive Cardiol 2004;16:257- 301.
26. Guide Wires
• Wires are much less likely to cause a breach in the proximal
or mid vessel, but more likely to do so distally, in the
terminal sub branches.
• They are also less likely to cause frank rupture of the vessel
than a high pressure balloon barotrauma.
• Hence, the appearance of angiography is more subtle when
the wire is the culprit.
• Fasseas classified 86% of guide wire mediated ruptures as
Ellis type I or II on angiography.
Fasseas P, Orford JL, Panetta CJ, et al. Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures.
Am Heart J 2004;147:140-5.
27. Guide Wires
• A proportion of such patients may go on to develop
pericardial temponade.
• In some instances this only becomes manifest late (between
2-26 hours post procedure)
• One way to minimize distal trauma is to create loop at the
end of the wire, rendering it less likely to inadvertently
puncture the vessel wall.
• The adjunctive use of GPI may potentiate prolonged
bleeding from a seemingly minor blemish in the vessel.
28. Chronic Total Occlusions
• In CTO intervention, there is always a high risk of coronary perforation,
and more so with the heavy weight, stiff tipped wire.
• If there is no balloon inflation where the wire is incorrectly positioned,
there is minimal extravasation of contrast and blood.
• Use of GPI should be withheld until the occlusion is safely crossed and
the operator is confident that the distal tip of the wire is seated
intraluminally.
• Shimony* and colleagues studied 9568 procedures and compared 57
patients having CAP with 171 patients who had no CAP and found that
CTO intervention is the strongest independent predictor of CAP,
followed by calcified lesions and NSTEMI.
*Shimony A, Zahger D, Van Straten M, et al. Incidence, risk factors, management and outcomes of coronary artery perforation during percutaneous coronary intervention.
Am J Cardiol 2009;104:1674-7.
30. • Most important step is to recognize and identify
presence of a perforation.
• High index of suspicion
• Subtle signs: Unusual migration of wire tip, dye
staining, unexplained hypotension
31. Strategy
• Strategy depends upon –
• Site of the perforation
• Severity of the insult
• Hemodynamic stability of patient
• Persistent bleeding
33. • Type I perforations usually respond to conservative
measures.
• In any case, indispensable measures are:
• Fastidious post-procedural care
• Cautious monitoring of hemodynamic parameters
• At least one, and if required, serial echocardiographic
assessment.
Javaid A, Buch AN, Satler LF, et al. Management and outcomes of coronary artery perforation during percutaneous coronary intervention.
Am J Cardiol 2006;98:911-4.
34. • Type II or III perforations
• Initial management is similar.
• First objective is to stop bleeding.
• Immediate step is to inflate a balloon at the site of bleeding
if it is in the mid or proximal vessel, and more distally for a
remotely situated wire perforation to buy the time for
further strategy making.
• This prevents the development of temponade, and
favourably alters the outlook of the situation.
35. • In significant proportion of cases, prolonged balloon
dilatation is all that is required.
• Balloon inflation for upto 30 min is required.
• If the patient can not tolerate ischemia, then perfusion
balloon, if available may be helpful.
• Fukotomi reported excellent results using perfusion balloon
for Ellis type III rupture
Fukutomi T, Suzuki T, Popma JJ, et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous
coronary intervention. Circ J 2002;66:349– 356.
36. • A number of authors advocated deployment of standard
intracoronary stents to secure perforation site.
• This may involve the deployment of a number of layers of
stent over the point of rupture before it can be sealed off.
37. Anticoagulant therapy and
platelet inhibitors
• Important question –
• Whether dealing with the perforation signals the end of the
procedure or the operator wants to continue the procedure
after control of bleeding is achieved.
• If the case is to be discontinued, reversal of the heparin with
protamine has been shown to be effective alongside other
measures.
• But this should be deferred till balloons and wires are still in
the artery.
38. GPI
• Intravenous GPI should be discontinued in majority of cases
where perforation is identified.
• Even seemingly trivial blush of extravasation may progress
to severe problems if these agents are ongoing.
• Abciximab counteraction with fresh platelets transfusion, as
earlier discussed, should be executed with precaution on
case by case base.
39. ACT
• There is no clear recommendation regarding which level of
the heparin anticoagulant effect should be maintained after
CAP.
• Because intervention devices remain in the patient, the
heparin effect should not be completely reversed, and it
might be acceptable to maintain the ACT at 150–250 s.
• The ACT should be measured immediately after CAP.
• Further treatment is dependent on the bleeding level and
hemodynamic status.
40. Cardiac Temponade
• Immediate Echocardiography, urgent drainage by
pericardiocentesis is must.
• Drainage not only alleviates hemodynamic problem, but
also allows for an active evaluation of the rate of ongoing
bleeding from the perforation site.
• Sometimes, accumulation of very small amount of
pericardial blood may result in profound hemodynamic
suppression or cardiac arrest.
• Deploying a drain in such situation is very difficult.
• At least a clear rim of fluid should be visible on
echocardiography before putting a drain, otherwise there is
a risk of puncturing RV free wall.
42. Pericardiocentesis
• Once the space is completely dry, the volume which is
further accumulated should be counted every minute to
know the success of local treatment at perforation site.
• If there is no resolution of bleeding at 30 minute, further
action is required.
• This may include Surgery.
• Pericardial temponade in this situation carries mortality of
20-50%.
43. Covered Stents
• Frank rupture of proximal or mid coronary artery often
constitute a tear in the vessel, upto 5 mm in length.
• Deploying a covered stent isolates the point of haemorrhage
from the circulation.
• The most widely used device is PTFE covered stent.
• Sandwich design
• Inflexible, difficult to deliver in certain areas
44. Covered Stents
• Briguori1 and colleagues reported 11 cases treated in this
fashion and compared them with other 17 cases treated
with BMS.
• In both groups, balloon temponade and reversal of
anticoagulation failed.
• MACE rate was 18% in covered stent group compared to
88% in BMS group.
• Stankovic2 reported reduction in MACE rate for TYPE III
perforations using PTFE covered stents but no benefit was
gained in type II perforations.
1.Briguori C, Nishida T, Anzuini A, Di Mario C, Grube E, Colombo A. Emergency polytetrafluoroethylene-covered stent implantation to treat coronary
ruptures. Circulation 2000;102:3028 –3031.
2. Stankovic G, Orlic D, Corvaja N, Airoldi F, Chieffo A, Spanos V, Montorfano M, Carlino M, Finci L, Sangiorgi G, Colombo A. Incidence, predictors, in-
hospital, and late outcomes of coronary artery perforations. Am J Cardiol 2004;93:213–216.
45. Covered Stents
• On the other side, Ly and colleagues achieved successful
seal of the perforation using PTFE in 71% of cases, but there
was no statistically significant reduction in the development
of temponade, nor the requirement of emergency surgery
when it was compared to prolonged balloon dilatation.
• Difficulty in delivery of this inflexible device is most
troublesome in the calcified, tortuous vessel which is usual
substrate in the perforated vessel.
46. Covered Stents
• Additional late concern is of in-stent restenosis.
• Although poorly quantified, a small number of patients
undergoing angiographic follow-up showed 29% restenosis
rate.
Briguori C, Nishida T, Anzuini A, Di Mario C, Grube E, Colombo A. Emergency polytetrafluoroethylene-covered stent implantation to treat coronary ruptures.
Circulation 2000;102:3028 –3031.
47. Distal Perforation
• Covered stents are of no benefit.
• Most of them are caused by angioplasty guide wire.
• Objective is to seal off the leaking branch.
• Little concern for ischemia to the small region of
myocardium supplied by it.
• If conventional measures fail, vessel may be occluded by –
• Platinum microcoils (Trufill – Terumo)
• Injection of Thrombin
• Autologous clotted blood
• Subcutaneous adipose tissue
• Tris-Acryl gelatin microspheres
• Polyvinyl alcohol foam
48. Emergency Surgery
• Cases not responding to conventional measures are sent for
emergency surgery.
• These perforations are frank ruptures, and not modest distal
perforations.
• Ellis reports 63% of type III perforations had to go for
surgery, while very few of type I or type II underwent
surgery.
49. Surgical outcomes
• The results are disappointing.
• The mortality of emergency surgery in reports of
both Fejka and Witzke was 50%.
So, why is an operation such a poor option
for these cases?
50. Because….
• These are cases with
• Other treatment options failed
• Ongoing bleeding
• Hemodynamic compromise
• On inotropic support
• Coagulopathy
• Myocardial infarction
• Deterioration of renal function
51. No surgery…
• Some operators send remarkably few patients for an
operation, and their overall mortality figures are
impressively low.
• Fukutomi1 and colleagues reported 69 cases of CAP, 29
progressing to temponade.
• The mortality was zero.
• Only two of the 69 underwent surgery.
• Therefore, either conservative or percutaneous treatment
options were successful in vast majority of patients.
1.Fukutomi T, Suzuki T, Popma JJ, et al. Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous
coronary intervention. Circ J 2002;66:349– 356.
52. Surgery, when….
• But, it is always sensible to keep surgical team ready to take
patient on operative table at any moment.
• If the bleeding from pericardial tube is persisting at a rate
above 10mL per minute despite all other action being taken,
mechanical and pharmacological, it is prudent to call a
surgeon.
55. Special measures
• A case report of LAD CTO intervention complicated
by Type III perforation with Conquest pro wire over
Finecross Microcatheter.
• Immediate removal of wire and applying negative
pressure of 2-3 mmHg for 3-5 minutes through
microcatheter while preparing the fat emboli
sealed the perforation successfully.
TCTAP C-031, Case from Indonesia
56.
57. Dual guiding catheter technique
• Retrieving the balloon and inserting a covered stent may
require some time and it is possible that the stent will not
reach or cross the lesion.
• Hence, the perforation may be without sealing for an
unpredictably long period of time.
• Use of a dual guiding catheter approach reduces the
duration of uncontrolled hemorrhage through the
perforation.
58. Dual guiding catheter technique
• After placing a second guiding catheter and guide wire, the
covered stent can be advanced and placed immediately
proximal to the sealing balloon.
• In a rapid maneuver, the sealing balloon can be retracted
and the covered stent advanced and implanted.
• If initial delivery of the covered stent fails, re-insertion of
the blocking balloon can be performed quickly which
provides time to consider options for a second attempt
(smaller covered stent, additional guide wire, upsizing the
guiding catheter, etc.).
60. Persistent Complete Occlusion
• More than 20 min – unacceptable
• Heparin can not be reversed with protamine at the
perforation place
61. Persistent Partial Occlusion
• Controlled Hypotension
• Severity of stenosis with Pressure drop with FFR
with Distal pressure with TIMI flow
• Short length, highly compliant balloon inflation at
the location of CAP
62. Intermittent Complete Occlusion
• An intermittent, nonfatal complete ischemic model is found to improve
tissue tolerability to reperfusion injury after long-term ischemia and to
delay cell death.
• This phenomenon is known as “ischemic preconditioning (IPC)”
• A 10 min ischemia/1 min reperfusion model is optimal.
• If necessary, this procedure can be repeated three or four times.
• Notably, IPC can attenuate ischemia reperfusion injury during cardiac
surgery, which is the ultimate method to treat CAP.
• However, this model may not be satisfactory for patients with
preexisting cardiac dysfunction.
• To avoid cardiac function deterioration, a shortened ischemic time or
prolonged reperfusion time (such as 5 min/5 min) model should be an
alternative in these patients.
63. Intermittent Partial Occlusion
• To verify whether a CAP has been sealed during partial occlusion, a
balloon must be deflated for angiography, which results in reperfusion.
• If the perforation is not sealed, further occlusion is needed (i.e., the
intermittent partial occlusion model).
• This process can also induce ischemia reperfusion injury, in which the
ischemic myocardium shifts from stunned to hibernating.
• Because of the heavy total ischemic burden, hibernating cardiomyocytes
are damaged more severely than stunned cardiomyocytes are;
therefore, the remarkably prolonged recovery time is usually a few days
to several months.
64. Cunclusion
• It is favourable that CAP remains a rare complication.
• High index of suspicion.
• Immediate diagnosis and localization of perforation
• Urgent and serial echocardiographic monitoring
• “Stop the bleeding” first
• Prolonged balloon dilatation always
• May need covered stent
• Quick Pericardiocentesis
• Worse outcomes if emergency surgery is warranted
Thus, the clinical spectrum ranges from mere puncture of the vessel by guide wire, leading to dye staining but no adverse hemodynamic consequences, through to vessel rupture, resulting in brisk extravasation of blood and contrast, and abrupt hemodynamic collapse.
New devices were atherectomy and excimer lased ablation.
Temponade – 4 to 46%
CABG – 3 to 39%
MI – 5 to 34%
Death – 5 to 17%
There are number of other explanations for a fall in blood pressure following intervention.
Associated DM HTN Renal, Long standing CAD. Calcification by itself, irrespective of use of atherectomy device, was related to more incidence of CAP.
Tortuosity - 39-46%
More than 40% CAP were in vessels of <2.5 diameter. Devise-Vessel mismatch more than diameter.
However, Platelet transfusion goes against the objective of maintaining patency of the stent by inhibiting this arm of clotting process.
Nearly 1/2 of CPs in each group was managed with prolonged balloon inflation alone. Protamine was used in 46% of HEP-treated patients. Covered stents tended to be used more frequently in the BIV group (p 0.061).
The type of the lesion and lesion characteristics like total occlusion, calcification or tortuosity were not assessed, and they had no control group with heparin only, considering the fact that Heparin has benefit of reversal with protamine.