Cath Conference1 October 2002

Todd Justice

Case #1 BM

53yo wf collapsed at her desk at work. Brought to 53yo wf collapsed at her desk at work. Brought to ed by ems. Upon arrival was in extremis and ed by ems. Upon arrival was in extremis and required immediate intubation for respiratory required immediate intubation for respiratory distress.distress.

History of type 2 dm and smokingHistory of type 2 dm and smoking Exam: BP 40/palp, Pulse 150, intubated, afExam: BP 40/palp, Pulse 150, intubated, af

Chest clear, neck veins distendedChest clear, neck veins distendedHeart tones distant, no murmurHeart tones distant, no murmur Abd Abd benignbenign Ext Ext poorly perfused with absent pulsespoorly perfused with absent pulses

BM (cont’d)

Na 140, K 4.0, Hco3 17, bun 17, cr 1.1, Na 140, K 4.0, Hco3 17, bun 17, cr 1.1, glc 492, AG 21, ca 8.9, mg 2.4, phos 7.9glc 492, AG 21, ca 8.9, mg 2.4, phos 7.9

Wbc 11.6, hct 38.2, plt 307Wbc 11.6, hct 38.2, plt 307 Abg: 7.01/62/21/sat 17%/base def 16.8Abg: 7.01/62/21/sat 17%/base def 16.8 Lactate 14.4Lactate 14.4 Trop 5.98, CK 236, MB 10Trop 5.98, CK 236, MB 10 CXR: nl heart, mediastinum; lung fields clear.CXR: nl heart, mediastinum; lung fields clear. ECGECG Taken emergently to cath lab for rhc, lhc, iabpTaken emergently to cath lab for rhc, lhc, iabp

BM (cont’d)

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

BM (cont’d)

Results (cont’d)Results (cont’d) LMCA: nsdLMCA: nsd LAD: mild diffuse noncritical diseaseLAD: mild diffuse noncritical disease CCA: 30% ostial, occluded distallyCCA: 30% ostial, occluded distally RCA: dominant, mild luminal irreg’s.RCA: dominant, mild luminal irreg’s. IABP placed left femoralIABP placed left femoral PCI on CCA: occlusion was opened with PTCA, PCI on CCA: occlusion was opened with PTCA,

but “no reflow” observed. Small perfusion bed but “no reflow” observed. Small perfusion bed visualized on injection through balloon. visualized on injection through balloon.

BM (cont’d)

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

Echocardiogram and CT chest performed.Echocardiogram and CT chest performed.

BM (cont’d)

Echo results: Hyperdynamic lv, posterolateral Echo results: Hyperdynamic lv, posterolateral akinesis. Small posterior and moderate anterior akinesis. Small posterior and moderate anterior pericardial effusion not echo free. Cannot rule out pericardial effusion not echo free. Cannot rule out clotclot . Collapse of RA during diastole.. Collapse of RA during diastole.

CT chest: Small right pleural effusion with CT chest: Small right pleural effusion with compressive atx. Moderate high density compressive atx. Moderate high density pericardial effusion consistent with pericardial effusion consistent with hemopericardium. Focal bulge of left ventricle. hemopericardium. Focal bulge of left ventricle. No extravasation of contrast noted. No extravasation of contrast noted.

BM (cont’d)

Hospital Course:Hospital Course: LV free wall rupture diagnosed, felt to be LV free wall rupture diagnosed, felt to be

secondary to MI 3-5 days prior.secondary to MI 3-5 days prior. 2 pericardial drains placed.2 pericardial drains placed. Pt went to OR for urgent repair/patch.Pt went to OR for urgent repair/patch. Pt did well post-operatively. Off all vasoactive Pt did well post-operatively. Off all vasoactive

agents by evening of 1agents by evening of 1stst POD. Extubated on POD. Extubated on POD #2 and eating/communicating.POD #2 and eating/communicating.

Case #2: LS

63yo wm s/p 3 vessel CABG 6wks prior to 63yo wm s/p 3 vessel CABG 6wks prior to admission, presented to outside hospital admission, presented to outside hospital complaining of increasing dyspnea on complaining of increasing dyspnea on exertion. Also had cp described as a “pull” exertion. Also had cp described as a “pull” lasting few seconds. lasting few seconds.

Post op course had been complicated by rt Post op course had been complicated by rt pleural effusion occuring 3 weeks post op pleural effusion occuring 3 weeks post op for which he had needed thoracostomy tube.for which he had needed thoracostomy tube.

LS (cont’d)

PMHx: NQWMI, CABG, h/o AF, type 2 dm, PMHx: NQWMI, CABG, h/o AF, type 2 dm, cerebrovasc disease, gerd with esophageal stricture, cerebrovasc disease, gerd with esophageal stricture, HTN.HTN.

Meds: Avandia, ASA, Lopressor, Dilt, Lipitor, Meds: Avandia, ASA, Lopressor, Dilt, Lipitor, amiodarone, insulin, isdnamiodarone, insulin, isdn

Habits: chews tobaccoHabits: chews tobacco Exam: Exam: bp 143/54, p88, 90% on 4L O2bp 143/54, p88, 90% on 4L O2

jvp 8cm…to angle of jaw with hjrjvp 8cm…to angle of jaw with hjrheart rrr no mrgheart rrr no mrgdecreased bs at basesdecreased bs at bases 1+ 1+ pitting edema of lower ext b/l pitting edema of lower ext b/l

LS (cont’d)

EKGEKG Cardiac enzymes negativeCardiac enzymes negative Catheterization Data (after 3L diuresis):Catheterization Data (after 3L diuresis):

RA mean 7RA mean 7 RV 38/12RV 38/12 PA 38/11 (23)PA 38/11 (23) PCW mean 15PCW mean 15 Ao 108/48Ao 108/48 LV 106/24LV 106/24

LS (cont’d)

Cath data (cont’d):Cath data (cont’d): LIMA-LAD: occludedLIMA-LAD: occluded SVG-ramus: occluded proximallySVG-ramus: occluded proximally SVG-CCA: occluded proximallySVG-CCA: occluded proximally LMCA: 60-70% distalLMCA: 60-70% distal LAD: severe diffuse disease up to 70% mid vesselLAD: severe diffuse disease up to 70% mid vessel CCA: 30% prox, 100% after OM3 CCA: 30% prox, 100% after OM3 RCA 70% ostial, diffuse up to 50% prox/midRCA 70% ostial, diffuse up to 50% prox/mid LV: AK of basal inf wall, EF 50%, no MRLV: AK of basal inf wall, EF 50%, no MR

LS (cont’d)

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

Case #3: SC

48yo WF with longstanding tobacco abuse and 48yo WF with longstanding tobacco abuse and COPD requiring home O2, presented to OSH with COPD requiring home O2, presented to OSH with hypercapnic respiratory failure with severe acidosis hypercapnic respiratory failure with severe acidosis and hypotension. No chest pain. No history of and hypotension. No chest pain. No history of CAD.CAD.

Transferred to UK MICU service intubated and on Transferred to UK MICU service intubated and on DA gtt.DA gtt.

Exam:Exam: 121/63, 131, 10/10, AF121/63, 131, 10/10, AF WheezingWheezingRegular Regular

tachycardia, no mrgtachycardia, no mrg No edemaNo edema

SC (cont’d)

Initial studies/Hospital course: Initial studies/Hospital course: ABG: 7.09/175/197; serum HCO3 58ABG: 7.09/175/197; serum HCO3 58 EKG sinus tach with nonspecific ST/T EKG sinus tach with nonspecific ST/T

abnormalitiesabnormalities Troponin peaked at 0.05Troponin peaked at 0.05 Could not be weaned from ventilator. Could not be weaned from ventilator. Had bilateral ptx due to barotraumaHad bilateral ptx due to barotrauma Developed MRSA pneumoniaDeveloped MRSA pneumonia

SC (cont’d)

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

SC (cont’d)

Failure to wean continued. PCI of LMCA Failure to wean continued. PCI of LMCA undertaken as last ditch effort to assist undertaken as last ditch effort to assist ventilator weaning.ventilator weaning.

Pt remains on ventilator. Awaiting Pt remains on ventilator. Awaiting tracheostomy and transfer to permanent tracheostomy and transfer to permanent ventilator facility.ventilator facility.

Case #4 LM

64 yo aaf with history of CAD, athsma, htn, type 2 64 yo aaf with history of CAD, athsma, htn, type 2 dm, esrd admitted for increased dyspnea. dm, esrd admitted for increased dyspnea.

PMHx: CAD…nqwmi x 2, lad stent jan 00 PMHx: CAD…nqwmi x 2, lad stent jan 00 required ptca for in-stent restenosis june 02; h/o required ptca for in-stent restenosis june 02; h/o tobacco abuse but quit 1993; previous ef 60%; tobacco abuse but quit 1993; previous ef 60%; remainder as above.remainder as above.

Exam: Exam: 121/60, 57, 20, af121/60, 57, 20, afHeart rrr with S3Heart rrr with S3Wheezing bilaterallyWheezing bilaterallyNo peripheral edemaNo peripheral edema

LM (cont’d)

Initial data:Initial data: EKGEKG CXR: pulmonary vasc congestionCXR: pulmonary vasc congestion BNP >1300BNP >1300

Underwent acute dialysis with UFUnderwent acute dialysis with UF Cardiac enzymes followed: peak trop 8.34Cardiac enzymes followed: peak trop 8.34 Underwent LHCUnderwent LHC

LM (cont’d)

Cath data:Cath data:LMCA: 75% distal lesionLMCA: 75% distal lesion

LAD: 75% origin, long 60% D1LAD: 75% origin, long 60% D1CCA: long 90% originCCA: long 90% originRCA: 75% ostial, 80-90-% RCA: 75% ostial, 80-90-%

mid-vesselmid-vessel LV: severe inferior hk, mod ant LV: severe inferior hk, mod ant hk. EFhk. EF now 40% with mod to severe now 40% with mod to severe MR,MR, significant change from 6/02.significant change from 6/02.

Pt unwilling to consider surgery, so underwent Pt unwilling to consider surgery, so underwent PCI of LMCA and proximal LAD and CCA. PCI of LMCA and proximal LAD and CCA.

Takagi et al

Circulation, 6 Aug 2002: “Results and Long-Term Circulation, 6 Aug 2002: “Results and Long-Term Predictors of Adverse Clinical Events After Elective Predictors of Adverse Clinical Events After Elective Percutaneous Interventions on Unprotected Left Main Percutaneous Interventions on Unprotected Left Main Coronary Artery.”Coronary Artery.”

Purpose: to evaluate outcomes of pci on left main Purpose: to evaluate outcomes of pci on left main disease in elective cases (most previous studies disease in elective cases (most previous studies intermixed elective and emergent cases).intermixed elective and emergent cases).

67pts with LM stenosis >50% that was suitable for 67pts with LM stenosis >50% that was suitable for pci, and either contraindication to CABG or patient pci, and either contraindication to CABG or patient and referring MD preferred percutaneous approach and referring MD preferred percutaneous approach with full knowledge of procedural risks. with full knowledge of procedural risks.

Takagi, et al

Procedures: balloon predilation, rotational Procedures: balloon predilation, rotational atherectomy, directional atherectomy, ivus atherectomy, directional atherectomy, ivus according to operator preference. Stent according to operator preference. Stent implantation encouraged in most lesions.implantation encouraged in most lesions.

Pre and post-procedure ticlid and asaPre and post-procedure ticlid and asa Clinical f/u at 1, 3, and 6mos and then at latest f/u Clinical f/u at 1, 3, and 6mos and then at latest f/u

or telephone interview. Avg length of f/u 31 mos. or telephone interview. Avg length of f/u 31 mos. Angiographic f/u at 6mos or earlier if suggestion Angiographic f/u at 6mos or earlier if suggestion

of ischemia. of ischemia.

Takagi, et al

Age 65+/-12Age 65+/-12 Male 84%Male 84% Htn 55%Htn 55% DM 9%DM 9% Cigarettes 46%Cigarettes 46% Hypercholesterolemia 47%Hypercholesterolemia 47% Unstable angina 40%Unstable angina 40% Previous MI 34%Previous MI 34% Triple vessel dz 45%Triple vessel dz 45% LvEF 57% +/- 13%LvEF 57% +/- 13% High risk (Parsonnet >15) 28%High risk (Parsonnet >15) 28%

Takagi, et al

Site of LM lesion: ostium 22%, mid 18%, distal Site of LM lesion: ostium 22%, mid 18%, distal bifurcation 60%.bifurcation 60%.

Angiographic success 97%, procedural success 91% Angiographic success 97%, procedural success 91% (defined as leaving hospital free from death, MI, or (defined as leaving hospital free from death, MI, or CABG).CABG).

Stents placed in 64 pts. 39 had balloon angioplasty, 16 Stents placed in 64 pts. 39 had balloon angioplasty, 16 had dca (13 of those stented), 12 had rotational had dca (13 of those stented), 12 had rotational atherectomy and stenting. Balloon pump in 58%, ivus atherectomy and stenting. Balloon pump in 58%, ivus performed in 46%, IIb/IIIa antagonists in 15%. 32% pci performed in 46%, IIb/IIIa antagonists in 15%. 32% pci of another cor segment.of another cor segment.

Mean stenosis decreased from 59 to 4%.Mean stenosis decreased from 59 to 4%.

Takagi, et al

In hospital comlications: 2 emergent CABG, 2 q-wave In hospital comlications: 2 emergent CABG, 2 q-wave mi, 3 nqwmi. No deaths.mi, 3 nqwmi. No deaths.

Follow-up cardiac events: mean follow up 31 mos (range Follow-up cardiac events: mean follow up 31 mos (range 5-94 mos). 11 deaths, 8 cardiac deaths. Total event rate 5-94 mos). 11 deaths, 8 cardiac deaths. Total event rate including death, MI, any revascularization was 34%.including death, MI, any revascularization was 34%.

Angiographic f/u in 51pts after 5 +/- 2mos: 16 restenoses Angiographic f/u in 51pts after 5 +/- 2mos: 16 restenoses (31%), 13 of these were when the distal lmca was (31%), 13 of these were when the distal lmca was initially involved.initially involved.

DCA debulking + stent not significantly better than DCA debulking + stent not significantly better than stenting alone (36 vs 47% restenosis). Restenosis in stenting alone (36 vs 47% restenosis). Restenosis in debulked branch only 24%.debulked branch only 24%.

Takagi, et al

Cardiac mortality higher in pts with high surgical Cardiac mortality higher in pts with high surgical risk—21%. In the 72% of pts with low surgical risk—21%. In the 72% of pts with low surgical risk (Parsonnet score <15) cardiac mortality only risk (Parsonnet score <15) cardiac mortality only 4.2% throughout the f/u.4.2% throughout the f/u.

Hazard ratio of LVEF <40% was 8.6. Low ef was Hazard ratio of LVEF <40% was 8.6. Low ef was the covariate of cardiac death. the covariate of cardiac death.

Covariate of all cardiac events was reference Covariate of all cardiac events was reference vessel diameter.vessel diameter.

Takagi, et al

Conclusions:Conclusions: PCI feasible in variety of LM lesions with high PCI feasible in variety of LM lesions with high

immediate success and favorable hospital immediate success and favorable hospital outcome.outcome.

Follow up affected by relatively high incidence Follow up affected by relatively high incidence of cardiac death, MI, and need for reintervention. of cardiac death, MI, and need for reintervention.

Finding that pts with LM disease and high Finding that pts with LM disease and high surgical risk or low ef also are high risk for pci surgical risk or low ef also are high risk for pci undermines value of pci as an alternative to undermines value of pci as an alternative to surgery in these pts.surgery in these pts.

Tagaki, et al

Conclusions:Conclusions: The fact that 6/8 cardiac deaths occurred in first 6mos The fact that 6/8 cardiac deaths occurred in first 6mos

highlights the dramatic way restenosis could manifest highlights the dramatic way restenosis could manifest in the LM. However, only 2 cardiac deaths occurred in the LM. However, only 2 cardiac deaths occurred after the first 6mos. Thus a solution to the problem of after the first 6mos. Thus a solution to the problem of restenosis would favorably affect the future use of restenosis would favorably affect the future use of LM pci.LM pci.

Numbers too small to draw conclusions regarding Numbers too small to draw conclusions regarding atherectomy. atherectomy.

PCI of LM good long-term results in those with low PCI of LM good long-term results in those with low surgical risk and large reference vessel diameter.surgical risk and large reference vessel diameter.