Presentation Time: 1405-1417
PCI MADE EASY !
DR NAZRUL (1) , DATUK ROSLI MOHD ALI (2)
Mohamed Nazrul Bin Mohamed Nazeeb
University Putra Malaysia
This is a 74 year old female, with underlying Diabetes Mellitus and CABG in 1996. She had multiple admissions in the past one year for angina. Subsequently she was transferred to our center on the 23rd of October 2017 from a peripheral hospital for refractory angina. Unfortunately for this lady, previous MSCT scan done showed all 4 vein grafts to have been occluded. Discussions between the cardiothoracic surgeons and cardiologist concluded that she was not suitable for a second coronary bypass grafting. (Her LIMA was not previously grafted as it was a small vessel).
Echocardiogram done showed an EF of 26% with moderate MR and moderate TR. Previous coronary angiogram showed:
Left Main stem: Distal mild disease
Left anterior descending artery: severe stenosis proximal segment with aneurysm, severe stenosis mid segment.
Left circumflex artery: severe stenosis proximal segment, severe stenosis proximal OM
Right coronary artery: CTO proximal segment, retrograde from Left anterior descending artery
Description of the problem, procedure, technique and equipment’s used
She was planned for PCI to the LM/OM1 (DK crush method) first, followed by PCI to the LM/ LAD. Procedure began with a double puncture to her right and left femoral artery respectively. An EBU 3.0/6Fr guiding catheter was used via the right femoral artery access. The OM1 branch was wired with a SION BLUE, and the circumflex was wired with a RUNTHROUGH floppy. Both vessels were predilated with a semi-compliant 2.0 x 15mm at 16atm, followed by an NC Balloon 2.5 x 15mm at 20 atm. The OM was subsequently stented with an ORSIRO 2.5/18mm at 12 atm, stent balloon was then retracted proximally, and dilated to 20 atm. Proximal stent was then crushed with and NC balloon 2.5 x 15mm at 14 atm. We then noted her to have a perforation of the proximal OM1 branch proceeded with hypotension. We proceeded with long balloon inflation, followed by IV Protamine Sulphate and inotrope infusion. Blood pressure subsequently improved. Urgent bedside Echo done showed no pericardial effusion. Once patient was stabilized, we then post dilated the OM stent with a Tazuna 1.5/15mm and then a Tazuna 2.0 x 15mm. Kissing was then done with an tazuna 2.0 x 15mm in OM1 and Left circumflex at 10 atm. Noted another perforation at circumflex, sealed with long balloon inflation. Left circumflex was then stented ORSIRO 2.25 x 22mm at 14 atm, and post dilated with an NC Quantum 2.75 x 12mm at 16 atm. We then proceeded with stenting of the LM – LAD. We started by wiring down the LAD with a RUNTHROUGH Floppy. LAD lesion was predilated with tazuna 2.0 x 15mm at 20 atm. IVUS was done, to assess the CSA of the LAD, and further predilatation was done with NC Quantum 2.75 x 12mm at 14 atm. Mid LAD was stented with ORSIRO 2.75 X 26MM at 10atm then stent balloon was pull back, and inflated at 14 atm. Proximal LM – LAD was then stented with ORSIRO 3.0 X 30MM at 14 atm, then 20 aatm. Proximal Optimization technique was done for the LM NC TREK 3.5 x 8mm at 16 atm and flare up with ostial LM at 20 atm. Noted pinching of the ostial left cirumflex artery. Lcx was rewired with SION BLUE and proximal lesion was predilated with tazuna 2.0 x 15mm then NC Quantum 2.75 / 12mm at 24 atm. Ostial Lcx with CRE8 (Overlap with proximal LCX) 3.0 / 8mm at 16 atm. Kissing was done between LAD/LCX 3.5 x 8mm and 3.0 x 8mm respectively at 10 atm. Noted lesion distal to mid LAD stent. Proceeded with stenting of distal LAD with ORSIRO 2.25 at 14 atm (Overlap with mid stent) and post dilated with stent balloon at 20atm. Final results good.
We performed two bifurcation stenting between the LAD / LCX and LCX / OM1. We showcased DK Crush technique, proximal optimization technique, and LM stenting using guidance by IVUS. During the case, we also successfully dealt with two perforations via long balloon inflation and infusion with protamine sulphate.
Presentation Time: 1418-1430
NOT ALL SHOCKS ARE CREATED EQUAL
Dharmaraj Karthikesan (1), Kang Huan Yean (1), Ahmad Faiz Ezanee (1), Gerard Jason Mathews (1), Liew Kai Soon (1) , Cheng Yi Zhi (1) , Ahmad Shukri Saad (1), Mohd Sabri Yahaya (1) , Salina Basri (1) , Khodijah Mat Isa (1), Shaharudin Hamzah (1) , Lee Siang Chin (1) , Kantha Rao Narasamuloo (1) , Nor Shaffinaz Yusoff Azmi (1) , Liew Chee Tat (1) , Saravanan Krishinan (1)
Hospital Sultanah Bahiyah
Introduction: We describe a case of non-ST-segment elevation myocardial infarction (NSTEMI) in cardiogenic shock with prior undetected pituitary insufficiency.
Objective: The objective of this case is to demonstrate the need for thorough clinical assessment in patients presenting with acute coronary syndrome in cardiogenic shock requiring percutaneous coronary intervention (PCI) where adrenal insufficiency needs to be considered in the presence of shock despite successful coronary intervention.
Description of the case: A 59-year-old man presented with chest pain, bradycardia, and hypotension. He has a long-standing history of symptomatic junctional bradycardia and subclinical hypothyroidism. He refused permanent pacemaker insertion. A diagnosis of NSTEMI in cardiogenic shock was made after assessment with electrocardiogram (ECG) and cardiac biomarkers. Coronary angiography revealed significant mid left anterior descending artery (LAD) stenosis of 95-99% with diffuse disease distally and proximal right coronary artery (RCA) stenosis of 90-95%. Ad hoc percutaneous coronary intervention (PCI) via right radial approach was attempted to the RCA. JR4 catheter was engaged to the RCA and wired distally with BMW wire. Predilated with Sapphire 2.5 x 20 mm and noted small non-flow limiting dissection. Proceeded to stenting with zotarolimus-eluting stent 3.0 x 38 mm and postdilated with Sapphire NC 3.25 X 15 mm (3.40 mm). In view of the presence of cardiogenic shock, PCI to the LAD was also attempted. EBU 3.5 was engaged to the left main coronary artery (LMCA) and LAD wired distally with BMW wire. Predilated with Sapphire 2.5 x 20 mm and stenting with zotarolimus-eluting stent 2.5 x 24 mm was undertaken. Postdilated with Panthera Leo NC 2.5 x 15 mm (2.52 mm). Despite TIMI 3 flow with TMBG 3 obtained, patient remained in shock requiring increasing inotropic support.
Detailed review of previous thyroid function test showed likelihood of secondary hypothyroidism. At this point, we suspected concomitant hypocortisolism secondary to pituitary insufficiency compounding cardiogenic shock. Bedside visual field examination showed bitemporal superior quadrantanopia. Detailed clinical and blood hormone assessment revealed long-standing features of panhypopituitarism. He was started on steroid replacement and demonstrated marked clinical improvement. Magnetic resonance imaging (MRI) of the brain and pituitary fossa confirmed the presence of a pituitary fossa mass compressing on the anterior lobe of the pituitary gland. He has completed 1 year of dual antiplatelets (DAPT) and remains stable on hormone replacement. He is still being evaluated for the need of neurosurgical intervention.
Results: Successful intervention of coronary lesions with timely steroid replacement resulted in recovery of shock.
Presentation Time: 1431-1443
WHY HITTING THE TARGET ISN’T GOOD ENOUGH
Ho Kian Hui (1), Khiew Ning Zan(1), Asri Said (1), Voon Chi Yen(1), Alan Fong Yean Yip (1),Tan Chen Ting (1), Francis Shu Eng Pbeng (1), Khaw Chee Sin (1), Koh Keng Tat (1), Oon Yen Yee (1), Ong Tiong Kiam (1)
Ho Kian Hui
Sarawak Heart Centre
Introduction: Multi-vessel disease found at time of PCI in patient with STEMI is not uncommon. With multivessels disease in STEMI patient with cardiogenic shock, is immediate complete revascularization the way to go?
Objective: To illustrate the Importance of PCI to non-culprit vessels during cardiogenic shock in STEMI.
60 year old gentlemen, smoker with no known medical illness but family history of Ischemic heart disease presented on 25th May 2017 for inferior posterior STEMI with right sided involvement Kilip II. He was thrombolysed successfully but BP remain low after thrombolysis requiring low dose inotrope. Coros was done on 26th May showed triple vessels disease with LMS distal tapering disease, LAD proximal stenosis up to 90% just before D1, LCX high OM 90% stenosis with TIMI 2 flow and RCA occluded at proximal with high thrombus burden. Ad-hoc PCI to RCA was done with intuition coronary wire and mid RCA lesion was pre-dilated with SC balloon Euphora 2.5x12mm up to 14atm. Due to high thrombus burden, aspiration was done with Advance Export catheter. Stenting was deferred in view of still persistent high thrombus burden. TIMI 3 flow achieved and IV tirofiban was given before admit him to ccu for tirofiban infusion. Echo post procedure showed EF 35% with hypokinetic over inferior, posterior, basal septal and lateral wall. His BP remain low and he is still on low dose single inotrope after the PCI. 2 days later his condition deteriorated and he was intubated. ECG showed no dynamic changes but he was arranged for immediate PCI. During COROS, he developed PEA on table and CPR commenced for 15 minutes and defibrillated x 3 for pulseless VT. 6Fr JR 4.0 Guiding catheter and Sion guide wire was wired into the RCA and the mid-RCA lesion was directly stented with 3.5x24mm Promus Premier DES to 14 atm while ongoing CPR. Then the LMS was engaged with 6Fr EBU Guiding Catheter and the same guidewire was introduce to LAD. The lesion in the proximal LAD was pre-dilated with 2.5x15mm NC trek balloon to 14 atm and a 2.5x24mm Promus Premier DES was deployed to 13 atm. The lesion was post-dilated with a 2.75x15mm Sapphire NC balloon to 20 atm. The final angiogram showed a well-deployed stent with TIMI 3 flow in RCA and LAD. IABP was then inserted on the same right femoral puncture for BP support after the PCI as patient was hemodynamically unstable. Echo repeated showed worsening EF to 25%. Post COROS, he was hypotensive requiring 5 inotropes and he developed AKI. He was put on CVVHD and subsequently HD in CCU. He was maintained on IABP from 28th May to 10th June. However, he developed another PEA due to sepsis on 16th June which CPR was commenced for 5 minutes. Due to prolonged intubation from 28th May to 17th June, he developed Ventilated associated pneumonia. However, he was discharged well with good recovery of kidney function not requiring long term dialysis. Repeated Echo in November 2017 showed EF 25% and AICD was inserted in December 2017.
Presentation Time: 1444-1456
Dr Foo Yoke Loong(1), Dr Kamaraj Selvaraj(1), Dr Asri Ranga(1), Dr Abdul Muizz(1), Dr Abdul Kahar(1)
Foo Yoke Loong
University Putra Malaysia
51 year old with hypertension, dyslipidemia, IHD and allergic to T.Asprin. Patient was referred for ischemic dilated cardiomyopathy and ECHO noted EF 27% and CMRI with infarcted LAD. Angiogram showed 2VD with severe stenosis at proximal LAD and RCA.
PCI to RCA was performed and during implantation of stent patient took a deep breath and stent was deployed at proximal RCA jutting out to aorta with Stentys 3.0-3.5x27mm. Post stenting there was TIMI III flow and procedure ended. Due to asprin allergy he was discharged with Ticagrelol and Trifusal.
1 week after discharge patient presented to ED with complaint of chest pain. ECG noted ST elevation at inferior leads. Inferior MI with possible stent thrombosis was diagnosed and angiogram lab was activated. Angiogram showed acute occlusion at ostial RCA with similar findings on left system. JR3.5 guide was used and expected difficulty in wiring the RCA from previous. Possible technique was remote guiding stabilization, remote wiring and re-engage, wiring thru strut and snaring of old stent and re-PCI.
GPIIBIIIA was started and attempted with wiring thru strut with sion blue however heart rocked significantly with every inhalation and guiding was difficult due to previous stent. We noted that the heart doesn’t rock much with patient holding his breath and managed to wire while patient holding deep breath. Proceeded with POBA with 2.0x15 and aspirated white thrombus with export advance. There was residual stenosis distal to stent and further dilatation with 3.0x15mm balloon. We stented distal to the stent with 3.5x16 and post dilated proximal with 4.5x15mm balloon. Post procedure we had TIMI III flow with stable vitals
Rocking during angioplasty is a significant problem as there could be misplacement of stent during implantation. Acute stent thrombosis may be caused by edge dissection, improper implantation of stent, missed the lesion, inadequate coverage of stent or unopposed stent and compliance to medication is a very important. This patient is allergic to asprin and ticagrelol and trifusal was given. In this case stent was jutting out into the aorta making re PCI very difficult and there are technique to cross the stent strut.
Presentation Time: 1457-1509
FROM ZERO TO HERO
Mohd Firdaus Bin Hadi(1), Ahmad Syadi Bin Mahmood Zuhdi (1), Imran Zainal Abidin (1), Wan Azman Bin Wan Ahmad
Mohd Firdaus Bin Hadi
University Malaya Medical Malaysia
Clinical History and examination
This is a case of 61 years old gentleman with no known comorbidities, was referred to our center with severe chest pain. He describes it as heaviness at the center of the chest with pain score 10 over 10. It occurs while he was in a table tennis game. He also experiences vomiting, sweating and dyspnea. He presented to the casualty where the ECG shown features of atrial flutter. He was immediately treated as NSTEMI with aspirin and clopidogrel and further admitted to the ward. Troponin T and CKMB elevated.
In the ward he continues to experience multiple episodes of chest pain and repeated ECG shows features of Wallen syndrome. He was then referred to our center for further management. However, a repeated ECG at our center showed an ST Segment elevation at V1 – V4, with deep Q waves and T inversion over I, aVL. A repeated cardiac marker shows a significant raised of Troponin I to more than 50 ng/mL and CKMB Mass 330 ng/mL. This new finding suggests a missed event of myocardial infarction, which urges the need for an urgent PCI.
Relevant Blood test and investigation
Troponin I > 50 ng/mL and CKMB Mass 330 ng/mL, Lipid profile shows total cholesterol (TC) 5.3, Triglycerides (TG) 0.9, HDL 3.0 and LDL 3.8. Renal profiles, Urea 2.8, Creatinine 103, eGFR 67, Sodium 138 and Potassium 3.9. Liver function test; ALP: 50, GGT: 52, ALT 70, AST 502. HbA1c 5.6 %. Hb 15.3, WCC 13.6, Platelet 195.
ECG ST Segment elevation at V1 – V4, with deep Q waves and T inversion over I, aVL.Description of the problem, procedure, technique and equipment’s used
A radial approach by the 6F Terumo radial sheath was used, and engagement to view the coronary vessel was applied with the 5F TIG. The diagnostic coronary of the left coronary was initially thought to be difficult, and multiple manipulation and approach was applied, and still unable to find the left coronary. Due to that we direct in visualizing the diagnostic of right coronary artery. The right coronary artery was found to be ecstatic and huge with no significant obstruction or stenosis. Following that, reattempting to approach view of left coronary was made by multiple guide catheter and finally we used the pigtail catheter with contrast infusion to try fully visualizing left coronary. Then, we noted there was a small stumps’ which is probably a totally block left side of the coronary. An XB 6F guide catheter sheath was used to approach the left coronary. A guidewire Fielder XT, manage tract the channel flow of the coronary artery, and balloon 2.0 x 15 used to dilate the vessel. Finally, we manage to open and visualize the left coronary artery. IVUS was applied, multiple degree of stenosis with lesion characteristic of plaque and calcified disease over the LAD and LMS. Following that assessment, a stent 3.5 x 38 applied which initially unable to fit in. Further dilatation with NC balloon 3.0 x15 was used. Finally the stent was placed covering the ostial left main until the LAD with pressure inflation of 10 atm. Again, IVUS was applied to ensure the optimal vessel angioplasty applied. A proximal optimization technique over the proximal stent near the left main was done via NC balloon 4.0 x 12. Finally, IVUS reassessment of stent placement shows good result.
In this case we describe a case, despite the total occlusion of the left main coronary artery, understanding and proper strategy are the key to success in the case.
Presentation Time: 1510-1522
OOPS, IT’S SNAP!
Dr Hartini Mohd Yusof (1), Datuk Dr Abd Kahar Bin Abd Ghapar (1), Dr Kamaraj A/L Selvaraj (1)
Hartini Mohd Yusof
OOPS, IT’S SNAP!
Authors: DR HARTINI MOHD YUSOF1, DATUK DR ABD KAHAR BIN ABD GHAPAR1, DR KAMARAJ A/L SELVARAJ1, DR NOR HALWANI HABIZAL1
1 Cardiology Department, Hospital Serdang, Selangor, Malaysia
Entrapment and fracture of coronary wire is rare. The incidence is approximately 0.1% to 0.2%. The management of patients with retained coronary wires are difficult. Over the years, they are many case studies on fractured coronary wire fragment retrieval, namely from conservative treatment, percutaneous retrieval and surgical removal. In some case studies, small fractured components were left within a chronically occluded coronary artery without sequelae. Some cases required immediate surgical removal, eventually combined with bypass grafting may be indicated if percutaneous retrieval is unsuccessful or difficult.
In this case, we would like to highlight a case of percutaneous retrieval of retained coronary wire following Rotational atherectomy.
We described a case of retained coronary wire. Our patient is a 60 years old Indian lady with cardiovascular risk factor of End stage renal disease, Diabetes Mellitus, Hypertension and Ischemic heart disease. She was referred from other hospital to our center for NSTE-ACS.
Coronary angiogram done via right femoral artery approach and showed calcified severe distal Left Main (LM) disease with calcified osteal Left Anterior Descending (LAD) artery lesion to proximal LAD lesion ranging from 60% to 95% disease and calcified osteal Left Circumflex artery(LCx) lesion of 99% disease. The Right Coronary Artery showed calcified moderate disease of mid RCA.
After discussion with respective consultant, we proceeded with percutaneous coronary intervention to LM/LAD (osteal LAD to mLAD) via provisional stenting approach. We used guiding catheter EBU 3.5 6F via right femoral approach. Asahi Rinato coronary wires were advanced into both LAD and LCx. We decided to protect the LCx because of very tight osteal lesion. This was followed by finecross microcatheter insertion into LAD and Rotawire insertion. Rotational atherectomy was done for LM/LAD lesion. We then predilate the lesion with Non Compliance (NC) Euphora balloon size 2.5x 15mm at 26 atm. Stent deployed with Resolute Integrity size 3.0x38 mm at 14 atm. We postdilated the stent with NC Euphora 3.0 mm x 15 mm at 26 atm.
Self-apposing stent, Stentys (X position S) 3.5/4.5 x 27 mm at 14 atm was deployed to LM lesion and posdilated with NC Euphora 4.0 x 15 mm at 24 atm. The final cineangiogram showed impingement of osteal LCx with flow was compromised.
Later, upon removal of Rinato wire from LCx, it was accidentally snapped. We tried to retrieve the fractured wire with Amplatz GOOSE NECK microsnare kit for few times but failed. The procedure was abandoned in view of long procedure hours, huge amount of contrast had been used and the patient was hemodynamically stable. We decided to reattempt fractured coronary wire retrieval later.
Unfortunately, 3 days later, patient developed NSTE-ACS and the ECG changes showed ST depression in lateral leads. Urgent relook coronary angiogram was done and showed no coronary blood flow in LCx and patent LM/LAD stents. Retained coronary wire retrieval reattempted. We used guiding catheter EBU 3.0 7F via 7F femoral sheath. We wired LAD with Asahi Sion Blue. We had difficulty to wire the LCx and multiple wires were used namely Rinato, Fielder XT-R and finally succeeded with Asahi Sion Black. The Amplatz GOOSE NECK microsnare kit then delivered into LCx via Terumo Progreat microcatheter. Eventually, the retained coronary wire was successfully retrieved. We then predilated the LCx osteal lesion with multiple balloons which were Tazuna 1.5 x 15 mm at 16 atm, Tazuna 2.5 x 15 mm at 14atm and predilated the LM with Accuforce 4.0 x 15 mm. the LM/ LCx lesion was stented with Orsiro 2.75 x 18mm. Finally, kissing balloon done for both LM/LAD and LM/LCx lesions with Accuforce 4.0 x 15 mm and Tazuna 2.5 x 15 mm. We also did POBA (Plain old balloon angioplasty) to osteal LM with Accuforce 4.0 x 15mm.
TIMI flow III was established in both LM/LAD and LCx. There were no ECG changes thereafter. However, the patient developed Hospital Acquired Pneumonia and she had few days hospital stay. She was then discharged well.