1. 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

2. 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

3. 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

4. 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

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

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

7. 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

8. MY WORST CASE

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

10. 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

11. 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

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)

13. 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

14. THANK YOU

15. 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