Case Presentation #1 SCAI Fellows Course December 7, 2013 Barry F Uretsky, MD University of Arkansas for Medical Sciences Central Arkansas Veterans Health System Little Rock, AR
Case Presentation #1 65 yo M s/p CABG PDA and OM 2007 with both grafts known to be occluded, EtOHism, HTN, DM, LV dysfct (EF 20%). Spent 5 of last 6 months in hospital with resp infection progressing to ARDS. Discharged from hosp 5 weeks PT current admission. Presented with heart failure after 5 wk hx of CCS III angina.
Catheterization Findings 95% ostial left main 100% RCA 100% OM 100% SVG to PDA and OM SYNTAX score= 41 STS score= 9.6%
Aortography performed in preparation of possible PCI with Impella
Treatment Plan Reviewed by Heart Team. Surgeons refused to operate primarily because of co morbidities and relative malnutrition.
Treatment Plan Reviewed by Heart Team. Reviewed by Heart Team. Surgeons refused to operate primarily because of co morbidities and relative malnutrition. Plan was to perform stenting of left main under LV assist (Impella) support.
Impella Insertion Preclose technique utilized for percutaneous closure. Device would not pass easily through iliac artery despite previous angiogram showing patent vessel.
Impella Insertion Preclose technique utilized for percutaneous closure. Device would not pass easily through iliac artery despite previous angiogram showing patent vessel. Short 14Fr sheath exchanged for 30 cm 14 Fr sheath and Impella passed followed by aortogram from right femoral access to assure no vascular trauma.
LM BA under Impella Support
3.0x12 mm BA 4.0x12 mm BA 4.0x12 mm EES LM Stenting IVUS: MLA 12.6 mm 2 MLD 4.1 mm
Final Result
Follow Up 4 mos post PCI: Feeling great! No chest pain, increasing daily activities.
Lessons from Case Study CAD patients often have PVD. Prior to Impella insertion, angiography should be used to assure reasonable chance of placement. Be prepared to intervene if there are peripheral complications. Maximize safety net even with easy LM lesions.
Case Presentation # 2 SCAI Fellows Course December 7, 2013 Barry F Uretsky, MD University of Arkansas for Medical Sciences Central Arkansas Veterans Health System Little Rock, AR
Case Presentation #2 43 yo military veteran with 3 wk hx of exertional CP with minimal exertion. Hx of somatoform pain disorder, requiring cane, for ambulation and use of wheel chair at times. Nuclear stress test : large anteroseptal reversible defect
Catheterization Findings 95% bifurcation left main 80% RCA SYNTAX Score= 14 STS Score= 0.2%
Treatment Plan Reviewed by Heart Team. Surgeons agreed to operate. Pt had LIMA to LAD, SVG to OM, and RIMA to RCA.
Follow up Pt was asymptomatic for first 6 mos after CABG but then developed angina for past one month. Meds: ASA 81 mg Metoprolol 50 mg bid ISMN 30 mg qd Simvastatin 40 mg qd Methadone 10 mg tid prn pain
Catheterization Findings 95% bifurcation left main 80% RCA LIMA to D1: patent SVG to OM: patent RIMA to PDA: occluded
Treatment Plan? a) PCI of LM b) PCI of RCA c) PCI of RCA and LM d) Increase Med Rx e) Other
Rx Plan: FFR guided PCI
FFR = 0.84
FFR 0.86
FFR 0.72
Final Result
Final Result FFR post PCI= 0.98
Lessons from Case Study Patent grafts do not ensure complete revascularization. FFR valuable to determine culprit lesion post CABG.
Case Presentation # 3 SCAI Fellows Course December 7, 2013 Barry F Uretsky, MD University of Arkansas for Medical Sciences Central Arkansas Veterans Health System Little Rock, AR
Case Presentation #2 58 yo man without med hx. Recreational cocaine user, last time 3 d PTA. 30 min of severe chest pain. ECG in ambulance showed ST elevation in ant leads. Transmitted to ED. Cath Lab activated. PE: BP 120/100; HR 120/min RR:30/min. Wheezing, in pulm edema. Time sequence: 6:00 ECG in ambulance 6:07 Cath team activated 6:12 Arrival in ED ED Care including intubation 6:57 Arrival in Cath Lab 7:08 Access 7:16 First balloon inflation
First Fluoroscopy (7:14)
What to Do? Right coronary angiography Immediate balloon angioplasty IABP Impella CABG Other
Immediate balloon angioplasty (7:16)
After Stenting (LM to Circumflex)
Final Result (after FKS and IVUS)
RCA
ECG in Cath Lab Immediately before PCI 48 min after PCI
Follow Up Echo later the same day estimated ejection fraction at 10% Patient maintained BP; in fact, became hypertensive requiring diuretic (then became hypotensive) Heart rate gradually decreased to normal range. Patient extubated 24 hours later
Lessons from Case Study 30 50% of patients with ACS from LM die during hospitalization but..
Lessons from Case Study 30 50% of patients with ACS from LM die during hospitalization but.. 50% or so can be salvaged.
Lessons from Case Study 30 50% of patients with ACS from LM die during hospitalization but.. 50% or so can be salvaged. Time is crucial. Plan strategy to utilize the small window most effectively.