Cath Conference 1 October 2002 Todd Justice

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Cath Conference1 October 2002Todd Justice
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Case 1 BM

• 53yo wf collapsed at her desk at work. Brought
  to ed by ems. Upon arrival was in extremis and
  required immediate intubation for respiratory
  distress.
• History of type 2 dm and smoking
• Exam BP 40/palp, Pulse 150, intubated, af Chest
  clear, neck veins distended Heart tones
  distant, no murmur Abd benign Ext poorly
  perfused with absent pulses

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BM (contd)

• Na 140, K 4.0, Hco3 17, bun 17, cr 1.1, glc
  492, AG 21, ca 8.9, mg 2.4, phos 7.9
• Wbc 11.6, hct 38.2, plt 307
• Abg 7.01/62/21/sat 17/base def 16.8
• Lactate 14.4
• Trop 5.98, CK 236, MB 10
• CXR nl heart, mediastinum lung fields clear.
• ECG
• Taken emergently to cath lab for rhc, lhc, iabp

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BM (contd)

• Results
• RA mean 19
• RV 36/19
• PA 30/20 mean 24
• PCW mean 19
• LVEDP 26
• CO/I 3.1/1.4
• LV limited lateral apical AK, EF 50, no mr.

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BM (contd)

• Results (contd)
• LMCA nsd
• LAD mild diffuse noncritical disease
• CCA 30 ostial, occluded distally
• RCA dominant, mild luminal irregs.
• IABP placed left femoral
• PCI on CCA occlusion was opened with PTCA, but
  no reflow observed. Small perfusion bed
  visualized on injection through balloon.

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BM (contd)

• Of note, pt had chest pain episode several days
  prior to this event. Had been diagnosed with a
  breast bone infection by local MD and treated
  with azithromycin.
• Echocardiogram and CT chest performed.

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BM (contd)

• Echo results Hyperdynamic lv, posterolateral
  akinesis. Small posterior and moderate anterior
  pericardial effusion not echo free. Cannot rule
  out clot . Collapse of RA during diastole.
• CT chest Small right pleural effusion with
  compressive atx. Moderate high density
  pericardial effusion consistent with
  hemopericardium. Focal bulge of left ventricle.
  No extravasation of contrast noted.

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BM (contd)

• Hospital Course
• LV free wall rupture diagnosed, felt to be
  secondary to MI 3-5 days prior.
• 2 pericardial drains placed.
• Pt went to OR for urgent repair/patch.
• Pt did well post-operatively. Off all vasoactive
  agents by evening of 1st POD. Extubated on POD
  2 and eating/communicating.

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Case 2 LS

• 63yo wm s/p 3 vessel CABG 6wks prior to
  admission, presented to outside hospital
  complaining of increasing dyspnea on exertion.
  Also had cp described as a pull lasting few
  seconds.
• Post op course had been complicated by rt pleural
  effusion occuring 3 weeks post op for which he
  had needed thoracostomy tube.

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LS (contd)

• PMHx NQWMI, CABG, h/o AF, type 2 dm, cerebrovasc
  disease, gerd with esophageal stricture, HTN.
• Meds Avandia, ASA, Lopressor, Dilt, Lipitor,
  amiodarone, insulin, isdn
• Habits chews tobacco
• Exam bp 143/54, p88, 90 on 4L O2 jvp 8cmto
  angle of jaw with hjr heart rrr no
  mrg decreased bs at bases 1 pitting
  edema of lower ext b/l

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LS (contd)

• EKG
• Cardiac enzymes negative
• Catheterization Data (after 3L diuresis)
• RA mean 7
• RV 38/12
• PA 38/11 (23)
• PCW mean 15
• Ao 108/48
• LV 106/24

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LS (contd)

• Cath data (contd)
• LIMA-LAD occluded
• SVG-ramus occluded proximally
• SVG-CCA occluded proximally
• LMCA 60-70 distal
• LAD severe diffuse disease up to 70 mid vessel
• CCA 30 prox, 100 after OM3
• RCA 70 ostial, diffuse up to 50 prox/mid
• LV AK of basal inf wall, EF 50, no MR

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LS (contd)

• Hospital Course Medical regimen was optimized
  and heart failure symptoms improved. Pt
  underwent directional coronary atherectomy. He
  tolerated the procedure well and was discharged
  home the following day.

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Case 3 SC

• 48yo WF with longstanding tobacco abuse and COPD
  requiring home O2, presented to OSH with
  hypercapnic respiratory failure with severe
  acidosis and hypotension. No chest pain. No
  history of CAD.
• Transferred to UK MICU service intubated and on
  DA gtt.
• Exam 121/63, 131, 10/10, AF Wheezing Re
  gular tachycardia, no mrg No edema

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SC (contd)

• Initial studies/Hospital course
• ABG 7.09/175/197 serum HCO3 58
• EKG sinus tach with nonspecific ST/T
  abnormalities
• Troponin peaked at 0.05
• Could not be weaned from ventilator.
• Had bilateral ptx due to barotrauma
• Developed MRSA pneumonia

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SC (contd)

• Catheterization data
• RA mean 18
• RV 45/18
• PA 45/22
• PCW mean 19
• Ao 122/82, LV 122/19
• CO/I 2.8/1.9
• SVR 2285
• Angio 50-55 LMCA, FFR 0.80, Nl LVEF

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SC (contd)

• Failure to wean continued. PCI of LMCA
  undertaken as last ditch effort to assist
  ventilator weaning.
• Pt remains on ventilator. Awaiting tracheostomy
  and transfer to permanent ventilator facility.

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Case 4 LM

• 64 yo aaf with history of CAD, athsma, htn, type
  2 dm, esrd admitted for increased dyspnea.
• PMHx CADnqwmi x 2, lad stent jan 00 required
  ptca for in-stent restenosis june 02 h/o tobacco
  abuse but quit 1993 previous ef 60 remainder
  as above.
• Exam 121/60, 57, 20, af Heart rrr with
  S3 Wheezing bilaterally No peripheral
  edema

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LM (contd)

• Initial data
• EKG
• CXR pulmonary vasc congestion
• BNP gt1300
• Underwent acute dialysis with UF
• Cardiac enzymes followed peak trop 8.34
• Underwent LHC

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LM (contd)

• Cath data LMCA 75 distal lesion LAD
  75 origin, long 60 D1 CCA long 90
  origin RCA 75 ostial, 80-90-
  mid-vessel LV severe inferior hk, mod ant hk.
  EF now 40 with mod to severe MR, significant
  change from 6/02.
• Pt unwilling to consider surgery, so underwent
  PCI of LMCA and proximal LAD and CCA.

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Takagi et al

• Circulation, 6 Aug 2002 Results and Long-Term
  Predictors of Adverse Clinical Events After
  Elective Percutaneous Interventions on
  Unprotected Left Main Coronary Artery.
• Purpose to evaluate outcomes of pci on left main
  disease in elective cases (most previous studies
  intermixed elective and emergent cases).
• 67pts with LM stenosis gt50 that was suitable for
  pci, and either contraindication to CABG or
  patient and referring MD preferred percutaneous
  approach with full knowledge of procedural risks.

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Takagi, et al

• Procedures balloon predilation, rotational
  atherectomy, directional atherectomy, ivus
  according to operator preference. Stent
  implantation encouraged in most lesions.
• Pre and post-procedure ticlid and asa
• Clinical f/u at 1, 3, and 6mos and then at latest
  f/u or telephone interview. Avg length of f/u 31
  mos.
• Angiographic f/u at 6mos or earlier if suggestion
  of ischemia.

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Takagi, et al

• Age 65/-12
• Male 84
• Htn 55
• DM 9
• Cigarettes 46
• Hypercholesterolemia 47
• Unstable angina 40
• Previous MI 34
• Triple vessel dz 45
• LvEF 57 /- 13
• High risk (Parsonnet gt15) 28

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Takagi, et al

• Site of LM lesion ostium 22, mid 18, distal
  bifurcation 60.
• Angiographic success 97, procedural success 91
  (defined as leaving hospital free from death, MI,
  or CABG).
• Stents placed in 64 pts. 39 had balloon
  angioplasty, 16 had dca (13 of those stented), 12
  had rotational atherectomy and stenting. Balloon
  pump in 58, ivus performed in 46, IIb/IIIa
  antagonists in 15. 32 pci of another cor
  segment.
• Mean stenosis decreased from 59 to 4.

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Takagi, et al

• In hospital comlications 2 emergent CABG, 2
  q-wave mi, 3 nqwmi. No deaths.
• Follow-up cardiac events mean follow up 31 mos
  (range 5-94 mos). 11 deaths, 8 cardiac deaths.
  Total event rate including death, MI, any
  revascularization was 34.
• Angiographic f/u in 51pts after 5 /- 2mos 16
  restenoses (31), 13 of these were when the
  distal lmca was initially involved.
• DCA debulking stent not significantly better
  than stenting alone (36 vs 47 restenosis).
  Restenosis in debulked branch only 24.

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Takagi, et al

• Cardiac mortality higher in pts with high
  surgical risk21. In the 72 of pts with low
  surgical risk (Parsonnet score lt15) cardiac
  mortality only 4.2 throughout the f/u.
• Hazard ratio of LVEF lt40 was 8.6. Low ef was
  the covariate of cardiac death.
• Covariate of all cardiac events was reference
  vessel diameter.

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Takagi, et al

• Conclusions
• PCI feasible in variety of LM lesions with high
  immediate success and favorable hospital outcome.
• Follow up affected by relatively high incidence
  of cardiac death, MI, and need for
  reintervention.
• Finding that pts with LM disease and high
  surgical risk or low ef also are high risk for
  pci undermines value of pci as an alternative to
  surgery in these pts.

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Tagaki, et al

• Conclusions
• The fact that 6/8 cardiac deaths occurred in
  first 6mos highlights the dramatic way restenosis
  could manifest in the LM. However, only 2
  cardiac deaths occurred after the first 6mos.
  Thus a solution to the problem of restenosis
  would favorably affect the future use of LM pci.
• Numbers too small to draw conclusions regarding
  atherectomy.
• PCI of LM good long-term results in those with
  low surgical risk and large reference vessel
  diameter.