MY WORST CASE OF THE YEAR SCAI FALL FELLOWS COURSE LAS VEGAS, NEVADA DECEMBER 5-8, 2012 MY WORST CASE OF THE YEAR Howard A. Cohen, MD, FACC, FSCAI Professor of Medicine Director Temple Interventional Heart & Vascular Institute Director Cardiac Cardiac Intervention and Catheterization Laboratories Temple University Health System

THE WORST CASE OF MY CAREER SCAI FALL FELLOWS COURSE LAS VEGAS, NEVADA DECEMBER 5-8, 2012 THE WORST CASE OF MY CAREER Howard A. Cohen, MD, FACC, FSCAI Professor of Medicine Director Temple Interventional Heart & Vascular Institute Director Cardiac Cardiac Intervention and Catheterization Laboratories Temple University Health System

MY WORST CASE History 89 yo female, dementia (oriented x1) Recurrent CHF, cannot lie flat Known severe AS Referred for cath and possible aortic PTAV Consent obtained from the son

MY WORST CASE Physical Examination Frail, elderly patient lying on a wedge on the cath lab table Dyspneic at rest with head elevated NVD, carotid bruits with slow upstroke Cardiac exam consistent with severe AS and MR Not a surgical candidate

MY WORST CASE Echo Severe TR, pulmonary HTN Severe AS, MS/MR Left atrial enlargement LVH, normal EF

MY WORST CASE Questions Why am I doing this case? Should I do this case?

MY WORST CASE Hemodynamics: Patient cathed on a wedge at 45° RA 17 mm Hg, PA 80/30 PCW 28 (v 50) Pa sat = 32%, Estimated Fick CO = 1.16 L/min AVG = 60mmHg (mean) AVA = 0.16 cm² MVG =18 mmHg (mean) MVA≥ 0.24 cm2

MY WORST CASE

MY WORST CASE Hemodynamics repeated post LV angiography Patient began to cough SEVERE MASSIVE HEMOPTYSIS! Patient expired within 60 seconds

Pulmonary Artery Rupture Incidence Retrospective study 32,000 RHC with balloon tip catheter 0.0031% Mortality of 70% Kearney et al. Chest 1995;108:134952

Pulmonary Artery Rupture Risk Factors Advanced age Pulmonary hypertension with sclerotic and fragile vessels High pressure gradient across pulmonary vascular bed Post-menopausal female Barash et al . J Thorac and Cardiovasc Surgery 1981;82:5-12

Pulmonary Artery Rupture Treatment Emergency selective intubation of the uninjured lung Emergency surgery in presence of hemothorax Balloon tamponade Embolization (coils, gelatine sponge particles, liquid occlusive tissue adhesive agents – isobutyle-2-cyanoacyclate)

TAKE HOME MESSAGE We can’t save everyone – some patients will die due to their heart disease. Be a doctor not a technician! Let good judgment rule. “Good judgment comes from experience and experience comes from poor judgment.” “I know the patient is sick, but that doesn’t mean that I have to do a sterile autopsy!” Frank C. Spencer, MD

THANK YOU

MY WORST CASE OF THE YEAR Principles and Perspectives in Interventional Cardiology State of the Art 2008 Maui Prince Resort July 21-25, 2008 MY WORST CASE OF THE YEAR Howard A. Cohen, MD, FACC, FSCAI Director Division of Cardiovascular Intervention Lenox Hill Heart & Vascular Institute