1. By Deepak Natarajan

    Tuesday, February 19, 2013

    Operator(s):

    Deepak Natarajan, Nirmalya Mukherjee and Rohit Kumar.

    Affiliation:

    Cardiological Society of India.

    Facility:

    Moolchand MedCity, New Delhi, India

    History:

    A 56 year male who had been smoking for more than 4 decades and had undergone PCI with stenting of his mid left anterior descending (LAD) artery in 2004 presented with severe retrosternal chest pain with perspiration and breathlessness. His 12 lead ECG revealed sinus rhythm with ST elevation from V1-V3 and ST segment depression in L2, L3, and AVF (Figure 1). The patient had persisted with smoking and had been erratic with his medication.

    Angiography:

    1) RCA: Near normal and dominant and providing collaterals to the left circumflex artery (LCX) (figure 2).
    2) LM: 85% ostial stenosis with a 50% stenosis of the proximal LAD. The stent in the LAD was patent. The LCX was totally occluded proximally (figure 3figure 4 ).
    3) The SYNTAX score was calculated at 30 (intermediate risk group).

    Procedure:

    In view of the acute coronary syndrome setting it was decided to do PCI of the left main lesions. A 0.014″ floppy guidewire was negotiated across the LM lesions into the LAD. The LM lesions were pre-dilated with a 2.5x15mm balloon (figure 5) with the balloon protruding slightly into the aorta. A 3.5x15mm Resolute DES was similarly positioned with slight extension into the aorta and deployed at 16atm (figure 6figure 7). Post-dilation was performed with a 4.5X12mm NC balloon at 18atm (figure 8).

    Conclusion:

    Angiogram demonstrated brisk TIMI 3 flow with no residual stenosis (figure 9figure 10). There was also rapid resolution in his 12 lead ECG (figure 11).

    Comments:

    Significant unprotected left main coronary artery stenoses occur in 5-6% of patients undergoing coronary angiography. Meta-analyses have shown similar mortality rates up to one year with CABG and PCI, but repeat revascularization has always been more common with PCI while CVA has always been greater with CABG.

    The 5-year results of the SYNTAX trial has showed comparable mortality and myocardial infarction rates in patients with LM disease undergoing CABG and PCI in the low and intermediate SYNTAX score groups. The results were quite different in patients with 3-vessel disease where CABG was superior in the intermediate and high SYNTAX score groups.

    This patient had an intermediate risk (SYNTAX) score with lesions of his left main ostium and shaft. Left main disease of the ostium and or body are considered a 2a indication by both European and American interventional cardiology societies. But this patient also had multivessel disease and would therefore fall in the 2b indication slot. Managing ostial/shaft left main disease is relatively simpler than distal left main disease, but care must be taken to ensure that the stent protrudes just a little bit proximally into the aorta. In this case a second generation DES was utilized; it may perform the same or better than the paclitaxel DES used in SYNTAX. The ongoing EXCEL trial compares Xience (everolimus eluting) stents with CABG in patients with left main disease.

    In the ACS setting PCI for ULMCA carries an in-hospital mortality rate of almost 20% while death rates have been found to be about 11% in patients with ST-segment elevation myocardial infarction.

    Conflict of Interest:

    None

  2. By Deepak Natarajan

    Monday, November 28, 2011

    Operator(s):

    Deepak Natarajan, Mafooza Rashid, Betshiba Dinaker, Vijeta Maheshwari, Nirmalya Mukherjee.

    Affiliation:

    Cardiological Society of India.

    Facility:

    Department of Interventional Cardiology
    Moolchand MedCity, New Delhi, India

    History:

    A 52 year male who was a chronic smoker was admitted for severe crushing retrosternal chest pain accompanied by nausea and perspiration for the previous 4 hours. He had no previous history of hypertension or diabetes. On examination in the ER he had a heart rate of 62-66 per minute, blood pressure 130/76 mm Hg, a fourth heart sound on auscultation, but no cardiac murmur. His chest was clear. His ECG revealed an acute infero-lateral myocardial infarction (Figure 1).The patient was given 325 mg aspirin, 600 mg clopidogrel and 5000 units heparin.

    Angiography:

    1) LAD: Normal
    2) LCX: 80% stenosis proximally (figure 2).
    3) RCA: 100% mid occlusion (figure 3)

    Procedure:

    The RCA was engaged with a JR 6Fr guiding catheter, and a 0.014″ floppy guidewire was used to cross the occlusion. After pre-dilation with a 2×10 mm balloon and intracoronary administration of 25 mcg/Kg of tirofiban, a 2.75x18mm bare metal stent was deployed at 16 atm with excellent antegrade flow and no residual stenosis (figure 4). The patient, however, continued to be restless and in pain. It was decided therefore to tackle the LCX lesion in the same sitting. The left coronary artery was engaged with a 6 Fr EBU guiding catheter, the same floppy guidewire used for the RCA intervention was positioned in the distal LCX, and the LCX lesion was predilated using a 2x12mm balloon(figure 5). Because the result was not satisfactory, 2.5x10mm balloon was introduced into the guiding catheter over the floppy guidewire. It was suddenly observed that the pressure wave was getting damped, and the systemic pressure was rapidly dropping (figure 6). Angiography demonstrated massive air embolism in both LAD and LCX arteries with no contrast flow beyond the mid segments of both arteries (figure 7). The patient was pulseless with electromechanical dissociation (figure 8). The balloon that was still in the guiding catheter was rapidly removed, and an attempt was made to suck out the air from the left coronary arteries via the guiding catheter. There was absolutely no improvement. Therefore, the guiding catheter was disengaged, and cardiopulmonary resuscitation (CPR) initiated with vigorous external cardiac massage (figure 9figure 10). The patient was given 100% oxygen.The patient by now had received 2 IV atropine injections and was also put on IV dopamine. External cardiac massage was maintained for almost 4 minutes by which time the patient recovered both his heart rate and blood pressure. After ascertaining that the patient was hemodynamically stable (figure 11) and had fully recovered his consciousness, the LCX was stented with a 3x18mm sirolimus eluting stent at 14atm. (figure 12) with TIMI 3 flow and no residual stenosis (figure 13).

    Conclusion:

    The patient was asymptomatic by the time he was moved to the coronary care unit, and his ECG showed almost complete resolution of the elevated ST segments seen prior to the procedure (figure 14). The patient was discharged after 48 hours.

    Comments:

    Coronary air embolism, albeit rare (incidence ranging from 0.2%- 0.8% during percutaneous interventions) can have a heterogenous presentation ranging from mild symptoms to cardiac arrest and death. Air can be introduced inadvertently by inadequate aspiration of the guiding catheters, rupture of balloons, and leakage of air via a defective manifold system. The management of massive air embolism as seen in this case has to be extremely quick with 100% administration of oxygen to drive out the nitrogen from the air bubbles along with supportive measures such as CPR with emphasis on external cardiac massage. Aspiration and also forceful injection of contrast has been recommended. Aspiration did not work in this case, and forceful injections or manipulation of the guidewire were avoided because of the fear of traumatizing the left main, LAD, or LCX arteries. Aspiration with the Export catheter has also been described in a case report. Coronary air embolism during coronary angiography or PCI should be prevented by careful emphasis on good techniques during the procedure. Treatment has to be rapid and should consist of 100% oxygen accompanied by CPR, DC cardioversion, and if needed IABP.

    Conflict of Interest:

    None

  3. By Deepak Natarajan

    Monday, November 22, 2010

    Operator(s):

    Deepak Natarajan

    Affiliation:

    Moolchand MedCity, New Delhi, India

    Facility:

    Department of Interventional Cardiology
    Moolchand MedCity, New Delhi, India

    History:

    A 59 year old non diabetic, non hypertensive male was admitted for crushing chest pain radiating to both arms, accompanied by perspiration for the previous one hour. His EKG revealed extensive anterior myocardial infarction with bifascicular block (Figure 1).

    Angiography:

    1) Left Main: normal
    2) Left Anterior Descending Artery (LAD): 100% occlusion near ostium (Figure 2 and Figure 3)
    3) Left Circumflex Artery (LCX): Mild disease
    4) Right Coronary Artery (RCA): 85% mid vessel stenosis (Figure 4)

    Procedure:

    The left coronary artery ostium was engaged with a 6Fr left EBU guiding catheter and a 0.014″ BMW guidwire that was negotiated across the LAD occlusion. An intracoronary tirofiban bolus of 20mcg/Kg was administered, and repeated manual thrombus extraction was attempted using an Export catheter (Figure 5 and Figure 6). There was, however, little response in antegrade flow despite 6 attempts with the extraction catheter and repeat intracoronary tirofiban bolus of 10mcg/Kg. (Figure 7 and Figure 8). The patient was moved out of the cath lab into the coronary care unit, and intravenous tirofiban was infused at 0.15mcg/Kg/minute for the next 2 hours. The patient was wheeled back to the cath lab, and predilation was performed using 2.5x16mm and a 3x18mm balloons at 12atm (Figure 9and Figure 10). A long residual stenosis was apparent (Figure 11 and Figure 12), but reasonably brisk antegrade flow was achieved. Subsequently a 3.5x23mm everolimus-eluting stent (Xience) was deployed at 20atm (Figure 13). Angiography revealed TIMI 3 flow with minimal residual stenosis (Figure 14). The EKG revealed substantial improvement of the ST segments and disappearance of the bifascicular block (Figure 15).

    It was decided to tackle the RCA lesion on a later occasion because the patient was hemodynamically stable and the procedure had been prolonged. Hence, after 6 weeks his left coronary artery system appeared disease free (Figure 16), but the RCA stenosis persisted (Figure 17). The RCA was engaged with a 6 ]Fr JR guiding catheter with side holes. A 0.014″ BMW gjidewire was negotiated through the stenosis; and following predilation with a 2x10mm balloon, a 3×12 sirolimus-eluting stent (Yukon) was deployed at 18atm (Figure 18). There was no residual stenosis and TIMI 3 flow was obtained (Figure 19 and Figure 20).

    Conclusion:

    The patient received continuos IV tirofiban infusion subsequently for 18 hours. The patient was discharged on both occasions on aspirin, clopidogrel, cilostazol, atorvastatin, ramipril, and metoprolol.

    Comments:

    Primary angioplasty is the treatment of choice in the majority of patients. There are, however, instances when the operator is confronted with other affected arteries besides the infarct-related vessel. The majority of interventional cardiologists are currently of the opinion that in the absence of hemodynamic instability, it is prudent to stage the procedure in multivessel disease. The interval can extend from while the patient is still hospitalized to as late as 8 weeks. This patient presented with an extensive anterior myocardial infarction (accompanied by a bifascicular block on his EKG) that necessitated a prolonged procedure involving large quantities of contrast. The index procedure was itself staged because there was little-to-no response to repeated manual thrombus extraction and IC tirofiban. The patient, therefore, was treated after 2 hours of IV tirofiban infusion. A recent New York Sate Registry has reported that patients undergoing staged multivessel intervention within 2 months after STEMI, but not during the index procedure had significantly less mortality.

    Conflict of Interest:

    None

  4. By Deepak Natarajan

    Monday, July 12, 2010

    Operator(s):

    Deepak Natarajan MD, Hakim Udin MD,Nirmalya Mukherjee MD and CK Krishna MD

    Affiliation:

    Moolchand MedCity, New Delhi, India

    Facility:

    Department of Interventional Cardiology
    Moolchand MedCity
    New Delhi, India

    History:

    A 76 year old non-diabetic, non-hypertensive man was admitted in the ER for central chest pain for the previous hour. His 12 lead ECG revealed a sustained monomorphormic ventricular tachycardia at a rate of 150 to 160 per minute of right bundle branch morphology (Figure 1Figure 2). He maintained a systemic blood pressure of 90 mmHg. On reversion to sinus rhythm by 2 bolus injections of 150 mg amiodarone, an acute inferolateral myocardial infarction (ST segment elevation in L 2, L3, AVF, and V5-V6) with marked ST segment depression in V1 to V3 was observed (Figure 3).

    Angiography:

    1) LM normal
    2) LAD 50% mid vessel stenosis (Figure 4)
    3) LCX 100% occluded
    4) RCA multiple 50% stenoses and a long segment 90% PDA stenosis (Figure 5)

    Procedure:

    The left coronary artery was engaged by a 6Fr 3.5 XBU guiding catheter, and a CrossIt 100 guidewire was negotiated across the total occlusion (Figure 6). After manual thrombo suction by a 6Fr Export catheter and intracoronary tirofiban ( 25 mcg/Kg) bolus injection, a tight residual stenosis was seen. A 2.75x12mm sirolimus eluting stent was deployed at 18atm. Brisk antegrade TIMI 3 flow was achieved with no residual stenosis (Figure 7).

    Conclusion:

    There was rapid disappearance of chest pain and near complete resolution of ST segment elevation in the inferolateral leads suggesting good myocardial perfusion (Figure 8). 2D echocardiogram demonstrated inferior wall hypokinesia with global ejection fraction of 50%. The patient was maintained on adequate oxygenation, and his serum potassium and magnesium levels were within normal limits. The patient was discharged 3 days post-admission on oral amiodarone . He did not receive any IV infusion of amiodarone.

    Comments:

    Primary sustained ventricular tachycardia is usually polymorphic and carries worse in hospital prognosis than patients without ventricular tachycardia. However, there is no increased recurrence or sudden death at one year follow up. The patient did not receive an ICD as patients surviving sustained primary VT have similar survival as patients who do not have primary VT. Moreover, this patient had an LV ejection fraction of 50% immediately post-PCI. Prompt revascularization by salvaging substantial myocardium and preventing recurrent ischemia aids in rectifying the electrical instability that accompanies acute MI.

    Conflict of Interest:

    None