“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

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.

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.

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. ( , )

PCI for proximal LAD & D1 lesion

After Ballooning

Stenting at D1g g

2.5 x 30 mm Endeavour Resolute Intergrity RX stent at D1.

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.

PCI for proximal LAD & D1 lesionPCI for proximal LAD & D1 lesion

Final Angiogram – LAO cranialFinal Angiogram – AP cranial g gg g

Recent EKGEKG

Severe chest pain was recurred 4 hours after PCI.

F/U EKGEKG aVR

ST segment elevation in diffuse anterior wall

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.

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.

Thrombus aspiration at D1, pLAD

Aspiration at pLAD lesionThrombus aspiration at D1, pLAD Aspiration at pLAD lesion

7F Export aspiration cathetercatheter

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.

Final Angiogram – AP cranial Final Angiogram – LAO cranial

TIMI 3 flow in all coronary vascular beds.

Remnant thrombi were planned to be treated medically.

Recent EKGEKG

F/U EKGEKG aVR

Resolution of ST segment elevation in anterior wall leads.

Transthoracic EchocardiographyParasternal long axis view Parasternal short axis view

Apical 4-chamber view Apical 2-chamber viewLAD territory wall hypokinesia

Recent EKGEKG aVR

As the Glycoprotein IIb/IIIa receptor antagonist IV infusion was ended, patient complained of rest dyspnea.

F/U EKG

aVREKG

new developed ST segment elevation in diffuse anterior wall leads.

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.

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

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

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.

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

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.

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.

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

“CompleteRevascularizationinAMI!Complete Revascularization...

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