1. Crashed in a minute in ACS with Extensive AWMI
Dr AM Thirugnanam, MD, FSCAI, PhD.
Director of Interventional Cardiology
Ipcard Cardiac Care Center, Hyderabad, India.
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

2. Patient’s History 56 years old lady, Had HTN for 10 years
Non Diabetes, Known DLP
Had Septicemia and Multiple Organ dysfunction 6 years back and recovered well
She was on regular NSAID abuse for her frequent vague body pain and lower back pain.
Completely sedentary
Met the patient after 6 years with crescendo angina for 2 days without thrombolysis

3. Physical Examination and Lab values
BP-80/110mmHg, HR-120/min, O2-93% with room air, Pulse- medium volume and regular.
Lungs-bilateral crepitation, Normal S1,S2 sounds.
ECG-ST elevation is >7mm in all chest leads with complete RBBB
LVEF-35%, Severe Hypokinesia in LAD territory with dilated and moderate MR
CtnI-2850ng/dl, CK-NAC-1790IU, CKMB-955IU
Other values are normal

4. Pre-cath investigations and medications
5/8/2018 7:27 AM
Pre-cath investigations and medications
Bolus Abciximab 10ml, and Loading dose of Ecosporin 325, Atorvastatin-80mg, Clopidogrel-600mg were given.
Noradrenalin infusion
Bolus and continuous infusion of Bivalirudin
Femoral venous line for TPI standby
RFA line for Supporting devices kept open
CAG done by radial route
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

5. LAD proximal-99%, RCA-Proximal 90% tandem lesions

6. Immediately after guiding with in a minute
Pressure dropped to 00/000
Put stent and no response
?????????? Reason in Myocardial Apoptosis in extensive AWMI and delayed reperfusion

7. Complete shock to patient and Doctor

8. Myocardial Apoptosis
We don’t have any commercially available bio marker to detect apoptosis level
Timing of Apoptosis in human happens in between hours.
Markers like TUNEL +DNA laddering, Annexin V,
Bcl, Bax, sFAS, P53, JAK/STAT and SAPK, but they are not practically helping in emergency situation in predicting outcome of the procedure.
TUNEL- Teminal deoxynucleotide Transferace Mediated dUTP nick end labelling, sFas- an inhibitor of apoptosis, sFas ligand- an inducer of Apoptosis, JAK-Janus kinase, STAT- Signal transducer and activator of transcription, SAPK- stress activated protein kinase

9. Critical ACS with STEMI
Mostly we confuse with slow flow and micro embolism in apoptosis induced mitochondrial energy loss
Apoptotic myocardial cell death can not be managed at any condition
No device and measures will have any benefit

10. Myocardial Apoptosis is a real nightmare to doctors
Markers must
Take home message