S A N D R A S U S A N I B A R

MR 12/3/14

CC: chest heaviness and dyspnea

32 yo man

Has had one week of dry cough, 1 day of progressive dyspnea and chest heaviness.

ROS: associated N/V, orthopnea.

PMH

HTN (on no medications in last 6 months)

HPLD

DM

Leukemia s/p BMT age 11 c/b GVHD (skin)

Family History: Grandmother with heart disease and DM

Social History: no use of EtOH, drugs. +tobacco

EKG at presentation

What Now?

Treat for CHF?

Biopsy heart muscle?

Anticoagulate?

Anticoagulate and take to the cath lab?

Send home?

You get some labs and an echo

PMN 74%

Initial Echocardiogram (bedside)

Dilated LV, severe global hypokinesis with inferior and inferolateral akinesis.

Moderate MR with eccentric posteriorly directed jet was noted on Doppler.

Estimated LVEF 10-15%

OK, so now what?

Admit for CHF management?

Take to the cath lab?

Something else?

J U S T I N C A S E T H I S I S A L L F R O M A N A C U T E T H R O M B O T I C M Y O C A R D I A L I N F A R C T I O N .

W H A T D O Y O U E X P E C T T O F I N D ?

You decide to play it safe and take pt for left heart cath

LHC

LM: No significant disease LAD: 100% occluded proximally D1-large caliber with 100% occlusion proximally RCA: 100% distally with large amounts of thrombus. RCA supplies collaterals to the LAD. LCx: mid 50-60% lesion

PCI:

L sided Intraaortic balloon pump was done. Aspiration thrombectomy and 2.75x18mm Integrity BMS was done in distal RCA LAD PCI with 2.5x26 Integrity BMS

EKG 2 days after LHC

Echocardiogram 2 days after revascularization

LV normal size. LVEF 40%

Severe hypokinesis of the apical anterior, apical septal and apical walls.

Moderate hypokinesis of the mid anterior, basal inferior and apical lateral walls.

Moderate MR with regurgitant jet (centrally).

Rest grossly normal

Killip classification- acute myocardial infarction

First published in 1967, this system focuses on physical examination and the development of heart failure to predict risk as described below:

Class I: No evidence of heart failure (mortality 6%)

Class II: Findings of mild to moderate heart failure (S3 gallop, rales < half-way up lung fields or elevated jugular venous pressure (mortality 17%)

Class III: Pulmonary edema (mortality 38%)

Class IV: Cardiogenic shock defined as systolic blood pressure < 90 and signs of hypoperfusion such as oliguria, cyanosis, and sweating. (mortality 67%)

In hospital mortality according to Killipclassification for ACS

Learning points – CAD in young adults

20% cases 80% cases

Learning points - Cardiooncology

Cardiotoxicity from both: Radiation + chemotherapy.

Types

Type I: Irreversible injury (eg. Anthracyclines)

Type II: reversible dysfunction (eg. Herceptin)

Radiation-induced cardiotoxicity potentiates any damage caused by chemotherapy.

Evaluation and Management of Patients With Heart Disease and Cancer: Cardio-Oncology. Herrmann et al. Mayo Clin Proc. 2014;89(9):1287-1306