Case Presentation CRT Sumith Aleti

History 66yo morbidly obese (BMI: 45), past smoker & no known medical history on a trip from Pennsylvania Syncope in her car while at gas station Immediate CPR by a bystander who is a paramedic Received 4 shocks, amiodarone 300mg, Epinephrine x2, intubated and transferred to a near by ED Labs: Na: 143; K:2.7; Cl: 100; HCO3: 19; BUN: 14; Creat:1.2, Troponin T 0.031 Hgb: 17; WBC: 11; Plt: 279

Initial Hospital Course Transferred to our hospital PEA arrest on arrival and regained pulse with Epi and CPR. EKG: long QT and nonspecific ST/T changes. CT chest: complete collapse of the left LL and partial collapse of the left UL along with possible pneumonia right LL and multiple rib fractures, no pulmonary embolism Bronchoscopy performed for lung collpase. Peak troponin T 1.6; CKMB 48.8 Bedside ECHO: limited by body habitus but grossly normal.

ECG

Coronary Angiogram Performed next day Right radial access 6Fr 13cm sheath Tight distal LM stenosis Occluded mid LCx Collaterals to LAD and OM from right LVgram (RAO and LAO): normal wall motion with LVEF 60%

Decision to intervene CT surgery urgently consulted. Patient was felt to a poor candidate for surgery due to: Respiratory issues Fractured Ribs Collapsed lung Pneumonia Morbid obesity Proceeded with unprotected LM PCI

Preparation for PCI Femoral access for unprotected LM, possible balloon pump. Difficulties in obtaining access due to morbid obesity Unable to advanced 7Fr sheath 4Fr sheath was placed Femoral angiogram was obtained. Exchanged for 7Fr 23cm

Access Problems Noticed right groin hematoma and increasing in size Angiogram performed

Access site bleeding Closed with 8Fr angioseal No active bleed was evident Right iliac angiogram performed via right radial access via a balloon catheter to confirm hemostasis

Management of Bleed 8 x 20mm RIVAL balloon 135cm catheter Asahi prowater 0.014 wire Balloon tamponade proximal to bleeding site 4 inflations 5 min each 4 atm max pressure Post tamponade result

LM stenting Given patient’s clinical presentation, proceed with LM stenting using: Rt radial route EBU 3.75 guide Asahi Prowater 0.014 wires into LAD and OM1 IVUS pre and post PCI

IVUS Diffusely diseased proximal LAD MLD of LM: 0.3mm LM vessel diameter: 4.8mm LM stented into LAD and another stent in proximal LAD

LM Stenting Predilated with 3.0 x 12mm Apex 4.5 x 20mm x 140cm VERIFLEX BMS Post dilated with 4.5 x 08mm NC TREK RX

LAD Stenting Proximal LAD stented with 4.0x15mm Integrity BMS Post dilated with 4.0x8mm NC Quantum Apex. Post PCI IVUS showed well expanded and apposed LM and LAD stents

Further hospital course Duplex right lower extremity Thrombosed pseudoaneursym of right distal EIA 2.7cm x 3.9cm 1 cm wide neck Follow up duplex stable Failure to wean off ventilator BAL grew Cryptococcus and patient was treated for it. Tracheostomy and PEG tube performed Transferred to nursing home for long term care