Patient Management Conference. John M. Lasala MD PhD Professor of Medicine and Surgery Washington University

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Earl Oliver
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1 Patient Management Conference John M. Lasala MD PhD Professor of Medicine and Surgery Washington University

2 Disclosures None

3 Case Patient SK 63 y/o man with history of: Atrial fibrillation with RVR, on xarelto Membranous glomerulonephritis, CKD stage 3 Initially diagnosed in 2002, treated since 2010, currently on prednisone, acyclovir, and multiple anti-hypertensives HTN (poorly controlled) HLD TIA OA Chronic back pain

4 Case Patient SK June 2015: SK presents to BJH with CP and palpitations, found to have afib with RVR Admitted overnight, spontaneously converted to SR, sent home on PO diltiazem and xarelto in addition to home medications Discharge labs: Hgb = 13.5 Creatinine = 1.88 July 2015: While at home, SK develops sudden onset of substernal CP Pain sharp, constant, pleuritic, associated with dyspnea Called EMS, went to BJH ED Given ASA and NTG by EMS

5 Case Patient SK Initial presentation (730am): Vitals: HR: 108 BP: 133/83 RR: 22 O2 sat: 94% RA T: 36.7 ED exam: NAD other than mild chest discomfort, irregularly irregular and tachycardic, clear lungs, minimal LE edema, abdomen NT/ND, neuro nonfocal Troponin: <0.03 Cholesterol: 78 Triglycerides: 200 HDL: 21 LDL:

6 Initial EKG

7 CXR comparison Current CXR Prior CXR (1-2 months earlier)

8 Case Patient SK At 8:50am (~1.5 hour later) patient develops worsening chest pain Vitals: HR: BP: 68/49 RR: 22 O2 sat: 95% RA Given IVF bolus with minimal improvement With increasing afib with RVR, thought that patient might have worsening hypotension due to tachycardia Diltiazem 10mg IV given

9 Case Patient SK Management discussion: What is the appropriate workup and treatment at this point? What is your working diagnosis?

10 Case Patient SK Management discussion: What is the appropriate workup and treatment at this point? What is your working diagnosis? ED plan: IVF and vasopressors (levophed) for hemodynamic support STAT CT C/A/P Emergent cardiology consult STAT bedside TTE

11 CT Chest

16 CT chest Impression: 1.Ruptured circumflex artery aneurysm or pseudoaneurysm with active extravasation and moderate hemopericardium. 2. New 4.2 cm heterogenously enhancing mass involving the inferior pole of the left kidney. This should be considered a renal cell carcinoma until proven otherwise. Given the multiple other renal lesions, likely representing cysts and hemorrhagic cysts, further evaluation with renal ultrasound may be considered. 3. Mild basilar atelectasis with a superimposed airspace consolidation favored to represent aspiration pneumonitis.

17 SK ED course (continued) While CT images were being interpreted, cardiology asked for emergent evaluation and bedside echocardiogram

18 Bedside TTE

19 Bedside TTE

20 Bedside TTE Tricuspid Valve Mitral Valve

21 Bedside TTE

22 Bedside TTE

23 Bedside TTE

24 SK ED course (continued) Returning to SK s current admission: ED reviews findings of CT chest and TTE Prothrombin Complex Concentrate (Kcentra) given PCC = a combination of blood clotting factors II, VII, IX and X, protein C and S, prepared from fresh-frozen human blood plasma CT surgery consulted (at bedside ~10:15am) Vitals: (on norephinephrine at 15 mcg/min) HR: 91 BP: 98/67 RR: 18 O2 sat: 92% on 4L

25 CT surgery consultation IMPRESSION: This is a 63 year-old male with multiple comorbidities including immunosuppression, chronic renal insufficiency, stage III end stage renal disease who presents with a likely ruptured coronary circumflex artery. I have discussed with Dr. John Lasala, Cardiologist, a possible interventional approach with either a covered stent or at least a diagnostic left heart catheterization so that we can determine possibilities for coronary artery bypass graft if a covered stent is not possible. A percutaneous pericardial drain could be placed at that time. If not possible, then he will either undergo a pericardial window for effective drainage management of his large bloody tamponade plus or minus coronary artery bypass grafting with intervention on the ruptured circumflex artery. This may entail a bypass patch ligation or coronary if it becomes necessary. I have discussed with the patient the risks, benefits, and alternatives to all of these procedures. He is amenable to attempt at left heart catheterization with percutaneous intervention, but if not possible, then proceed with a coronary artery bypass graft.

26 SK ED course After discussion, patient taken to cardiac catheterization lab for further evaluation

27 SK ED course After discussion, patient taken to cardiac catheterization lab for further evaluation Management discussion: Patient with known effusion, evidence of hemodynamic compromise Also with evidence of ruptured coronary artery on CT How do you proceed in the cath lab? How to prioritize tamponade vs. ruptured coronary artery aneurysm?

28 SK ED course After discussion, patient taken to cardiac catheterization lab for further evaluation Management discussion: Patient with known effusion, evidence of hemodynamic compromise Also with evidence of ruptured coronary artery on CT How do you proceed in the cath lab? How to prioritize tamponade vs. ruptured coronary artery aneurysm? Updated information: Patient with stable BP (SBPs ~90s) on single pressor

29 Cardiac Cath

30 Cardiac Cath

31 Cardiac Cath

32 Cardiac Cath

33 Cardiac Cath

34 Cardiac Cath

35 Cardiac Cath

36 Cardiac Cath

37 Cardiac Cath

38 Cardiac Cath

39 Cardiac Cath

40 Cardiac Cath

41 Cardiac catheterization Impressions: 1. Spontaneous rupture of coronary artery (left circumflex) successfully sealed with 3.5 x 16mm JoMed GraftMaster PTFE covered stent 2. Successful angioplasty of 60-70% left circumflex disease 3. Successful pericardiocentesis Note: During pericardiocentesis, ml of blood was removed with restoration of blood pressure to SBPs s and discontinuation of vasopressor support Pericardial fluid: Bloody, >800,000 RBCs, 2730 nucleated cells (50% PMNs)

42 SK Hospital Course Admitted to CCU post-procedure Continued to have significant output from pericardial drain, slowly decreasing hemoglobin (nadir of 7.5 from admit Hgb of 11.8 over course of several days) Intermittent sharp chest pain Hemodynamically stable

43 SK Hospital Course Admitted to CCU post-procedure Continued to have significant output from pericardial drain, slowly decreasing hemoglobin (nadir of 7.5 from admit Hgb of 11.8 over course of several days) Intermittent sharp chest pain Hemodynamically stable Given persistent pericardial drainage and intermittent symptoms, patient taken for repeat LHC to evaluate covered stent the following week

44 Cardiac Cath (one week later)

Coronary Artery Aneurysms First described by Morgagni in 1761 1 st case report by Bougon in 1812 Can be saccular or

45 Coronary Artery Aneurysms First described by Morgagni in st case report by Bougon in 1812 Can be saccular or fusiform Single or multiple Giovanni Battista Morgagni ( ) Hiramori S., et al. Journ. of Card Cases : e119-e122.

Coronary Artery Aneurysms Definition: Localized dilation of coronary artery exceeding the diameter of adjacent normal segment by 50% Older reports occasionally used 2x vessel size Intact vessel wall

46 Coronary Artery Aneurysms Definition: Localized dilation of coronary artery exceeding the diameter of adjacent normal segment by 50% Older reports occasionally used 2x vessel size Intact vessel wall Pseudoaneurysm has loss of vessel wall integrity and damage to adventitia or perivascular tissue Giant coronary aneurysm >20mm diameter Giant coronary artery aneurysm of RCA Hiramori S., et al. Journ. of Card Cases : e119-e122.

47 Coronary Artery Aneurysms Incidence: Prior studies show ~1-5% incidence in patients undergoing coronary angiography, but varying criteria over time may influence these percentages Males appear to be more commonly affected Noted on CASS study

48 Coronary Artery Aneurysms Causes: Congenital causes: Connective tissue diseases (polycystic kidney disease, Ehlers- Danlos syndrome) Accounted for ~17% of CAAs in one postmortem study Acquired causes: Atheromatous disease Cause of ~50% of CAA in adults Increasingly common cause in patients as they age Arteritis in Kawasaki disease Most frequent case of coronary artery aneurysm in children More common cause in certain areas (i.e. Japan) Syphilis Takayasu arteritis Trauma Angioplasty or atherectomy

Coronary Artery Aneurysms Treatment: Optimal management of CAA unknown Generally agreed that management of incidental CAAs should be based on severity of coexistent CAD Medical management: Focuses on

49 Coronary Artery Aneurysms Treatment: Optimal management of CAA unknown Generally agreed that management of incidental CAAs should be based on severity of coexistent CAD Medical management: Focuses on risk factor reduction Consideration of anticoagulation or antiplatelet therapy given thrombosis and embolic risk Surgical intervention: Recommended in cases of enlarging aneurysm or aneurysm >30mm Involves resection of aneurysm and bypass grafting Particularly useful in atherosclerotic aneurysms or multivessel disease Percutaneous intervention: JoMed PTFE covered stent Placement of polymercoated stent at site of aneurysm Lima B., et al. Tex Heart Inst J. 2006; 33:

12 th Annual West Virginia ACC Meeting April 8, 2017

12 th Annual West Virginia ACC Meeting April 8, 2017 Rameez Sayyed, M.D., FACC, FSCAI Associate professor of Medicine Program Director for interventional cardiology Marshall University Joan C. Edwards