“CompleteRevascularizationinAMI!Complete Revascularization...
Transcript of “CompleteRevascularizationinAMI!Complete Revascularization...
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“Complete Revascularization in AMI !”Complete Revascularization in AMI ! The fantastic and fatal Temptation ! ; The Complete Revascularization had better notComplete Revascularization had better not
be Performed in Some AMI Patients?.
CHOE SEONGILHanyang University Kuri Hospital,
KOREAKOREA
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Male/57, Rest chest pain
A 57 year-old male visited at ER due to rest chest pain for 1 hour.
Chest APCardiovascular risk factor: None ; traffic accident (+)Alcohol: NoneVital Sign: 36 3℃– 20 – 75 BPM– 162/106 mmHgVital Sign: 36.3℃– 20 – 75 BPM– 162/106 mmHgPhysical Exam: Regular heart beat without murmur
EKGI aVR V1 V4
Cardiac biomarker
Angiography ; 2 hours after Aspirin & Clopidogrel administeration.
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Coronary angiogramCoronary angiogramLeft coronary artery Right coronary artery
At first heparin were IV injected. acute total occlusion at first diagonal branch with TIMI 0 flow and significant stenosis at
proximal LAD with TIMI 3 flow.
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PCI for proximal LAD & D1 lesionPCI for proximal LAD & D1 lesionAfter engagement &wiring Balloon dilatation
engaged with a 7 Fr Cordis XB 3.5 guiding catheter. ATW and Route coronary guidewire were passed
through LAD and D1, respectively. Apollo 2.0 x 20 mm balloon
(14 atm, Goodman)through LAD and D1, respectively. ( , )
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PCI for proximal LAD & D1 lesion
After Ballooning
PCI for proximal LAD & D1 lesion
Stenting at D1g g
2.5 x 30 mm Endeavour Resolute Intergrity RX stent at D1.
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PCI for proximal LAD & D1 lesionStenting at pLAD
PCI for proximal LAD & D1 lesionHigh 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.
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PCI for proximal LAD & D1 lesionPCI for proximal LAD & D1 lesion
Final Angiogram – LAO cranialFinal Angiogram – AP cranial g gg g
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IV1
Recent EKGEKG
aVR
V4
I V1
Severe chest pain was recurred 4 hours after PCI.
F/U EKGEKG aVR
V4
ST segment elevation in diffuse anterior wall
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Repeated Coronary AngiogramRepeated Coronary Angiogram
Left coronary a.-RAO caudal Left coronary a.-RAO cranialy y
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.
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PCI for proximal LAD & D1 lesionPCI for proximal LAD & D1 lesion
Balloon dilatation at pLADBalloon dilatation at pLAD
Balloon dilatation at D1
Post-Ballooning
engaged with a 7 Fr Cordis XB g g3.5 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 Apollo 2.0 x 20 mm balloon. 20 mm balloon.
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PCI for proximal LAD & D1 lesion
Thrombus aspiration at D1, pLAD
PCI for proximal LAD & D1 lesion
Aspiration at pLAD lesionThrombus aspiration at D1, pLAD Aspiration at pLAD lesion
7F Export aspiration cathetercatheter
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PCI for proximal LAD & D1 lesionPCI for proximal LAD & D1 lesion
High pressure Balloon dilatationKissing Balloon
Dilatation at bifurcationHigh pressure Balloon dilatation Dilatation at bifurcation
High pressure balloon dilatation at pLAD. Kissing balloon dilatation at bifurcation with g p p(Apollo, 3.0 x 10 mm, 18 atm, Goodman)
gApollo 3.0 X 10 mm and 2.0 X 20 mm balloon.
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PCI for proximal LAD & D1 lesion
Final Angiogram – AP cranial Final Angiogram – LAO cranial
PCI for proximal LAD & D1 lesion
TIMI 3 flow in all coronary vascular beds.
Remnant thrombi were planned to be treated medically.
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I V1
Recent EKGEKG
aVRV4
IV1
F/U EKGEKG aVR
V4
Resolution of ST segment elevation in anterior wall leads.
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Transthoracic EchocardiographyParasternal long axis view Parasternal short axis view
Apical 4-chamber view Apical 2-chamber viewLAD territory wall hypokinesia
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I V1
Recent EKGEKG aVR
V4
I V1
As the Glycoprotein IIb/IIIa receptor antagonist IV infusion was ended, patient complained of rest dyspnea.
I V1
F/U EKG
aVREKG
V4
new developed ST segment elevation in diffuse anterior wall leads.
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Follow up coronary angiogramo o up co o a y a g og a
Left coronary artery Right coronary artery
N i ifi t i t l hNo significant interval change.
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Follow up TTE immediately after CAGParasternal long axis view Parasternal short axis view
Apical 4-chamber view Apical 2-chamber viewapicoseptal and apicolateral wall akinesia
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I aVR V1 V4T.P.R chart
Systolic BP; 90mmHgFU CAG
Cardiogenic shock & ARFchart Cardiogenic shock & ARF
DopamineDopamine
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
A i di li i Ab N i A i X LMWH N iAnti-cardiolipine Ab Negative Anti-Xa LMWH Negative
CYP2C9 genotyping Wild type Heparin PF4 Ab Not check
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After 3 days of discharge
EKG atDischarge
aVRI V4V1
I aVR V1 V4
Revisit for chest discomfort
EKG atRevisit
Pathologic Q waves with 2 mm ST segment elevation in V2-V4 leads.
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Follow up coronary angiogramo o up co o a y a g og 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
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Follow up TTE at 4 months laterParasternal long axis view Parasternal short axis view
Apical 4-chamber view Apical 2-chamber viewLAD territory wall hypokinesia with slightly wall thinning.
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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.
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TCTAP
Conclusion1. Although the complete revascularization is
h l i l i hthe ultimate goal in the PCI,the pursuit of ideal perfection can sometimes lead to the serious tragic results due to the unexpected challengesthe 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.
3 If iblIn AMI patients,
3. If possible, the complete revascularization had better not be performed in some AMI.
April, 26, 2012