Case Presentation and Discussion 2 - National Heart Centre ...Lie… · Case Study Acute Cardiac...
Transcript of Case Presentation and Discussion 2 - National Heart Centre ...Lie… · Case Study Acute Cardiac...
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Case StudyAcute Cardiac Care:
Cardiogenic Shock Update
Dr Liew Mei Fong, Dr Nadira Hamid, Dr Aaron Wong, Dr Tan Teing Ee
National Heart Centre Singapore
Case Study
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46 year old chinese male
• Premorbidly well• Non-smoker
Past Medical History1) Ischaemic Heart Disease- Coronary angioplasty with DES to mid RCA (Raffles
Hospital 2004) - Patient stopped aspirin for 5 months post-PTCA on his
own accord as he was concerned about side effects
2) Dyslipidemia
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Presented to NHCS on 13/12/101) Acute onset of chest pain x 1 day
-squeezing pain over central chest, sudden onset at 10pm-no radiation, pain score 7-8/10-similar to previous angina but severity has increased this time-minimal improvement with GTN
-NO SOB, diaphoresis, palpitations-no recent fever/URTI
2) Vomiting-3 episodes-not associated with abdominal pain, diarrhoea
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O/E• Afebrile• BP 96/68, PR 137, SpO2 100% on 3L• Lethargic looking• H: S1S2, irregularly irregular• L: Clear• A: soft,NT. BS+• No differential BP between both upper limbs
Given IV morphine at ED -> Pain score 3-4/10
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ECG on Admission
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What are the differential diagnoses?
1) Acute coronary syndrome
2) Pulmonary Embolism
3) Aortic dissection
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Initial Investigations
TW 14.06, Hb 14.7, Platelet 219Na 132, K 3.8, Cr 89, HCO3 18, Ur 5.5
CXR: No pulmonary congestion. No cardiomegaly
Became hypotensive 83/64 -> started on dopamine
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What would you do next?
1) CCU with IV GTN
2) IV thrombolysis
3) CVL activation
4) CT thorax
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Cardiogenic shock secondary ACS
CVL activated
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Progress• IABP inserted
• Coronary angiography performed
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Coronary Angiogram
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What to do now?
1) Call the CTS
2) Primary PCI
3) Send to CCU
4) Call for help from more senior colleagues
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Progress
• CTS was called in for consideration of emergency CABG
• While awaiting CTS, PCI was attempted
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Primary Coronary Angioplasty
XB 3 6Fr Fielder wire in LAD Kaneka Thrombuster II 6Fr
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Primary Coronary Angioplasty
Post Kaneka Thrombuster II 6FrAsahi Fielder 0.014 Guidewire in LCX, Terumo Tazuna balloon 2.0x15 in distal
LM ‐ ostial LAD
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Primary Coronary Angioplasty
Asahi Fielder Guidewire 0.014 LCx
TIMI 2 flow after balloon angioplasty
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What should we do next?
1. Wait for surgeon
2. Stent the Left Main
3. ECMO
4. More ballooning
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Left Main Stenting
While waiting, TIMI 1 flow to distal vessel
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Left Main Stenting
Biomatrix stent 3.4 x 14mm
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Left Main Stenting
Post Biosensors Biomatrix 3.5X14 (DES) stent LM
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LCx
Asahi Fielder Guidewire 0.014 LCx Boston Scientific 2.5X8 Balloon LCx
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Final Results
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Final Results
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IABP
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Primary Coronary Angioplasty
• PCI/DES (Biomatrix 3.5 x 14mm) to LM 100% lesion
• Distal LM 50% eccentric lesion left untouched.
• POBA to mid to distal LCx
• Residual disease in LCx
• Previous RCA stent patent
• Distal RCA lesion 70%
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What is next?
1. Well done, send to CCU2. Surgeon is here, send to OT urgent3. Suboptimal result, stent the left main and
LAD
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Progress
• Developed APO and respiratory distress after procedure
• Airway team activated as difficult airway due to frothy oral secretions and grade 4 larynx
• Intubated in CVL with glidescope• Stabilized on IABP and inotrope dopamine• Systolic BP >100 mmHg
• ?? Role of prophylactic ECMO
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Repeat ECG Post Procedure
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Progress
• NO ECMO was placed as BP was satisfactory • Patient transferred to CCU• Bedside ECHO: LVEF 15 to 20%, RWMA and
?LV thrombus• 3 hours later in CCU, patient become
hypotensive not responding to maximal inotropicsupport
• ECMO activated and inserted by CTS
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CCU Progress
• Remained on IABP, ECMO and maximuminotropic support following few days
• Weaned off inotropic support first• Remained on IABP and ECMO (as BP tolerated)• Repeat 2D ECHO on 14/12 confirmed presence of
LV apical thrombus•
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Complications
1) LV apical thrombus2) Sepsis (secondary to right middle lobe consolidation),
-> Positive ETT cultures (Kiebsiella and Pseudomonas), -> ID consult -> Commenced on IV Tazocin / Vancomycin /Caspofungin
3) Spontaneous left thigh haematoma4) Regular blood products transfusion (secondary to
consumptive thrombocytopenia and mechanicalhaemolysis)
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2D Echocardiogram
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2D Echocardiogram
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What is next?
1. Explant ECMO and hope for the best
2. LVAD
3. Heart transplant
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Role of LVAD
• Referred to HFS and CTS ‐> for consideration of LVAD as bridge to heart transplant
• Repeat 2D ECHO 7 days post AMI showed improvement of LVEF to 30‐35%.
• Multi‐disciplinary team approach
• ECMO successfully explanted on the 22/12/2010
• Intensive rehabilitation
• Discharged on 04/01/2011
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Repeat 2D Echocardiogram
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What to do with the lesion RCA?
1. PCI to RCA
2. CABG
3. Repeat cath in 3 months and if presence of LMrestenosis, for CABG
4. Medical therapy
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Progress
• Extensive discussion with family and combined departmental cardiac conference regarding long term plans
• Recommend CABG at later date • Was reviewed in outpatient Jan 2011 and doing
well• Due for CABG soon
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Thank You