The fantastic and fatal Temptation! ; The. be Performed in Some AMI Patients?. CHOE SEONGIL

Transcription

1 Complete Revascularization in AMI!! The fantastic and fatal Temptation! ; The Complete Revascularization had better not be Performed in Some AMI Patients?. CHOE SEONGIL Hanyang University Kuri Hospital, KOREA

2 Male/57, Rest chest pain A 57 year-old male visited at ER due to rest chest pain for 1 hour. Cardiovascular risk factor: None ; traffic accident (+) Alcohol: None Vital Sign: BPM 162/106 mmhg Physical Exam: Regular heart beat without murmur Chest AP EKG I avr V1 V4 Cardiac biomarker Angiography ; 2 hours after Aspirin & Clopidogrel administeration.

3 Coronary angiogram Left coronary artery Right coronary artery acute total occlusion at first diagonal branch with TIMI 0 flow and significant stenosis at proximal LAD with TIMI 3 flow. At first heparin were IV injected.

4 PCI for proximal LAD & D1 lesion After engagement &wiring Balloon dilatation engaged with a 7 Fr Cordis XB 3.5 guiding catheter. ATW and Route coronary guidewire were passed Apollo 2.0 x 20 mm balloon through LAD and D1, respectively. (14 atm, Goodman)

5 PCI for proximal LAD & D1 lesion After Ballooning Stenting at D1 2.5 x 30 mm Endeavour Resolute Intergrity RX stent at D1.

6 PCI for proximal LAD & D1 lesion Stenting at plad High pressure ballooning 2.75 x 38 mm Promus Element stent at plad High pressure balloon (Apollo, 3.0 x 10 mm, 18 atm, Goodman) dilatation at plad.

7 PCI for proximal LAD & D1 lesion Final Angiogram g AP cranial Final Angiogram g LAO cranial

8 I V1 Recent EKG avr V4 Severe chest pain was recurred 4 hours after PCI. I V1 F/U EKG avr V4 ST segment elevation in diffuse anterior wall

9 Repeated Coronary Angiogram Left coronary a.-rao caudal Left coronary a.-rao cranial Acute total occlusion at D1 and plad stented site with TIMI 0 flow. At first Glycoprotein IIb/IIIa receptor antagonist and heparin were IV injected.

10 PCI for proximal LAD & D1 lesion Balloon dilatation at plad Balloon dilatation at D1 Post-Ballooning engaged g with a 7 Fr Cordis XB 3.5 guiding catheter. Route guidewire was passed through LAD and balloon dilatation was performed with Apollo 2.0 x 20 mm balloon. Another Route guidewire was passed through D1 and balloon dilatation was also performed with Apollo 2.0 x 20 mm balloon.

11 PCI for proximal LAD & D1 lesion Thrombus aspiration at D1, plad Aspiration at plad lesion 7F Export aspiration catheter

12 PCI for proximal LAD & D1 lesion High pressure Balloon dilatation Kissing Balloon Dilatation at bifurcation High pressure balloon dilatation at plad. (Apollo, 3.0 x 10 mm, 18 atm, Goodman) Kissing balloon dilatation at bifurcation with Apollo 3.0 X 10 mm and 2.0 X 20 mm balloon.

13 PCI for proximal LAD & D1 lesion Final Angiogram AP cranial Final Angiogram LAO cranial TIMI 3 flow in all coronary vascular beds. Remnant thrombi were planned to be treated medically.

14 I V1 Recent EKG avr V4 I V1 F/U EKG avr V4 Resolution of ST segment elevation in anterior wall leads.

15 Transthoracic Echocardiography Parasternal long axis view Parasternal short axis view LAD territory wall hypokinesia Apical 4-chamber view Apical 2-chamber view

16 I V1 Recent EKG avr V4 As the Glycoprotein IIb/IIIa receptor antagonist IV infusion was ended, patient complained of rest dyspnea. I V1 F/U EKG avr V4 new developed ST segment elevation in diffuse anterior wall leads.

17 Follow o up coronary o angiogram a Left coronary artery Right coronary artery No significant ifi interval change.

18 Follow up TTE immediately after CAG Parasternal long axis view Parasternal short axis view apicoseptal and apicolateral wall akinesia Apical 4-chamber view Apical 2-chamber view

19 T.P.R chart FU CAG Systolic I avr V1 BP; 90mmHg V4 Cardiogenic shock & ARF Dopamine Hypercoaguability study; Etiologies for stent thrombosis was unidentified. Protein C activity 158% CyP2C19 major polymorphism Extensive metabolizer Protein S activity 131% Prothrombin G20210A mutation Negative Anti-thrombin III activity 138% VerifyNow P2Y12 (PRU)/base 184/283 (35%) Lupus anti-coagulant Ab Negative VerifyNow Aspirin (ARU) 406 Anti-cardiolipine i Ab Negative Anti-Xa LMWH Negative CYP2C9 genotyping Wild type Heparin PF4 Ab Not check

20 After 3 days of discharge EKG at Discharge I avr V1 V4 Revisit for chest discomfort EKG at Revisit I avr V1 V4 Pathologic Q waves with 2 mm ST segment elevation in V2-V4 leads.

21 Follow o up coronary o angiogram a Left coronary artery Right coronary artery The normal coronary flow was noted in all coronary vascular beds. Medications; aspirin, plasugrel, statin, nitrate, nicorandil, ARB, β-blocker

22 Follow up TTE at 4 months later Parasternal long axis view Parasternal short axis view LAD territory wall hypokinesia with slightly wall thinning. Apical 4-chamber view Apical 2-chamber view

23 Self-reflection In Korean proverb ; burn the barn down to get rid of the mice. In the four-character Chinese idiom ; 小貪大失, penny-wise and pound-foolish; incurring a great loss by pursuing a small profit. I reflect on my intervention strategy that did harm.

24 Conclusion TCTAP 1. Although the complete revascularization is the ultimate goal in the PCI, the pursuit of ideal perfection can sometimes lead to the serious tragic results due to the unexpected challenges such as no flow phenomenon or stent thrombosis 2. Successful PCI does not always warrant the good prognosis. In AMI patients, 3. If possible, the complete revascularization had better not be performed in some AMI. April, 26, 2012