1. Kansas City, Missouri, USA
CASE PRESENTATION
Barry D. Rutherford, MD
Kansas City, Missouri, USA
CRT 2012

2. 50-Year-Old Male Case Presentation
History:
Oct 2011: Presented to local hospital with dyspnea, chest pain, pulmonary congestion, edema, BNP 600, Creatinine 1.7
Risk Factors:
Hypertension; Diabetes – 20 yrs, Renal Insufficiency;
Heavy cigarette intake – 2 pk/day for 30+ yrs
Exam:
6’1”, 163 lbs, BP 160/90, S3 and S4 gallop, bilateral rales
Meds:
ASA 325 qd, Ibuprofen 200 mg 4X qd, Lisinopril 10 mg qd; Furosemide 40 mg qd; Metformin HCl 500 mg bid
EKG:
NSR, LVH, anterior repolarization abnormality
Cardiac MR
LVEF 30%, Basal-to-mid lateral akinesis and basal-to-mid anterior/anteroseptal akinesis
Viability: Anterolateral/inferolateral subendocardial infarct (<25%)
Anteroseptal/subendocardial infarct (<25%)
All walls are viable.
Cor. Angio:

3. 50-Year-Old Male 11-10-11 CTO of RCA and Functional CTO of LAD

4. 50-Year-Old Male CTO of RCA and Functional CTO of LAD
Treatment Options:
Continued medical therapy
CABG
Percutaneous intervention Method of approach: RCA, LMCA, LAD

5. 50-Year-Old Male CTO of RCA and Functional CTO of LAD
Surgical Opinion:
“graftable acute marginal branch… …unlikely that we would be very gratified with grafts to the LAD or distal RCA. Furthermore, in conjunction with his severe LV dysfunction and fairly diseased vessels, it is unlikely that he would have significant myocardial recovery…”
“…may benefit from high risk stenting to the LMCA to improve flow the LCX marginal branch”
SURGICAL TURNDOWN

6. 50-Year-Old Male 12-13-11 CTO of RCA and Functional CTO of LAD Surgical Turndown LVEF 20%

7. 50-Year-Old Male CTO of RCA and Functional CTO of LAD
Prox LAD
Mid LAD

8. 50-Year-Old Male 1-26-12 CTO of RCA and Functional CTO of LAD Surgical Turndown LVEF 20%

9. 50-Year-Old Male CTO of RCA and Functional CTO of LAD
12/13/11:
Stenting of LMCA and LAD:
3.0x28, 2.75 x 28 and 2.5x20 Promus DES
Procedure time 120 min, Fluoro time 59.9 min, 4 Gy, Contrast load 500 cc’s
Creatinine 12/14/11: 1.9
1/24/12:
Readmitted for PCI to RCA;
Creatinine 2.4; Clinically improved, no LVF
1/26/12:
Creatinine: 1.9 with hydration
Stenting of RCA: x28, 3.0x28, 3.5x28 and 3.5x18 Promus DES
Procedure time 115 min, Fluoro time 42.7 min, 3 Gy, Contrast load 90 cc’s