Download presentation
Presentation is loading. Please wait.
Published byPatrick Lamb Modified over 9 years ago
1
In-Stent Thrombosis or Acute Heart Failure ?
2
History Male, 64yrs Persistent chest pain 22hrs,admitted on 1st Mar. 2011,the symptom did not relieve at admission Old myocardial infarction five years ago, underwent PCI at that time, has not taken any medicine since 3 years ago Hypertension for 10 years T 2 DM for 5 years gout for 3 years
3
Physical Examination T:35.8 ℃, P:74bpm, R:18bpm, Bp:133/77mmHg Slight cyanosis No distention of jugular vein, no rales, no murmur and no S 3 No edema
4
adjunctive Examination ECG (3.1) : sinus rhythm with ST of II 、 III 、 aVF , V7-V9 elevated for 0.1-0.2mV Cardiac marker : CKMB mass >80ng/ml Myo >500ng/ml cTNI >30ng/ml BNP : 414pg/ml
5
ECG at admission
6
Adjunctive test BUN: 6.93mmol/L, Cr: 70 umol/L LDH:1272U/L, CK: 3645U/L, CKMB: 349U/L, cTNI: (+) Na: 134.3mmol/L, K: 4.41 mmol/L WBC:17.62 *10 9 /L, N: 89.3%, Hb:157g/L,PLT :273*10 9 /L BGA: PH:7.49, PaO 2 :77mmHg, PaCO 2 :33mmHg, SaO 2 :96%
7
diagnosis CAHD acute myocardial infarction (inferior wall) old myocardial infardtion (anterior wall) Killip I Hypertension T2DM gout
8
Therapy ASA + Clopidogrel+Tirofiban to enhence anti- platelet and anti-coagulation Statins to stabilize the plaque ACEI to prevent ventricular remodeling Primary CAG+PCI
9
CAG(1) LM d :50%, LAD o :70% in-stent re-stenosis, LAD m :70%, D 1 :70%; LCX:100%
10
CAG(2) Small RCA
11
PCI-1 Wire and thrombus aspiration
12
PCI-2 After thrombus aspiration twice
13
PCI-3 Balloon dilatation 2.0*15mm@8-10atm
14
PCI-4 Stent deployment : 2.75*29mm Partener @ 10atm
15
PCI-5 In-stent postdilatation with Durastar 3.0*10mm@10-20atm
16
PCI-6 Final Results
17
ECG After PCI
18
ECG of the next day after PCI
19
X-Ray ( 2011.3.1) : increase of lungmarkings enlargement of heart shadow UCG : enlargment of left atrial segmental ventricle hepo-kinetics (AMI of Inferior wall ) LVEF:43% Mean Pulmonary Artery pressure:47mmHg X-Ray and UCG
20
UCG at admission Acute myocardial infarctin ( inferior wall ) Segmental hypo-kinetics Left artial enlargement Systolic dysfunction of LV LVEF : 43%
21
Holter Sinus Rhythm Acute myocardial infarction of inferior wall HRV:76ms
22
(2011.3.2): LDH: 1426U/L, CK: 2194U/L CK-MB: 131U/L, cTNI (+) (2011.3.3): LDH: 1194U/L, CK:695U/L CK-MB:40U/L BUN:7.44mmol/L, Cr:86umol/L WBC: 8.84*10 9 /L, N:78.6%, Hb:131g/L Laboratory Test
23
Continue with anti-platelet 、 anti- coagulation 、 lipid-lowering 、 inhibit ventricular remodeling and anti-inflammation therapy No chest pain and no dyspnea Sequential Therapy
24
But 5 days later…… Breast distress and sweating accompanied with dyspnea ECG:ST II 、 III 、 avF , V7-V9 elevated for 0.2mV HR : 102bpm , Bp : 88/59mmHg , SpO 2 :90% , No moist rales Treatment : NTG : 0.5mg sublingually, NTG 5ug/min iv Torasemide : 20mg iv Cedelaind : 0.4mg iv Clopidogrel : 300mg Po st Tirofiban : 17ml iv , 15ml/h
25
ECG of recurrent dyspnea cyanosis, sweating, passive sitting position.HR:101bpm,Bp:95/57mmHg
26
30 minutes later
27
Symptom worsening
28
Transfer to CCU 1hr later Symptom did not relieve after medical treatment HR:121bpm,Bp:90/45mmHg , SpO 2 :87-90% , sitting position , moist rales and S 3 can be heard, no edema Non-invasive mechanical ventilation IABP Morphine,diuretics, dopamine, dobutamine nitrates
29
Cardiac marker(6 hrs after recurrent symptom) CKMB mass 5.0ng/ml Myo 302 ng/ml cTNI 9.59 ng/ml BNP 1150 pg/ml Cardiac marker(18 hrs after recurrent symptom) LDH 708 U/L CK 114 U/L CK-MB 21U/L Laboratory test(1)
30
Laboratory test(2) BUN 7.3 mmol/L, Cr 96umol/L WBC 9.25×10 9 /L, N 85.6%, PLT 354×10 9 /L, Hb 157g/L BGA: PH 7.44, PaO 2 62mmHg, PaCO 2 29mmHg, SaO 2 90%
31
ECG in CCU
32
UCG in CCU UCG Acute myocardial infarction (inferior wall) Segmental ventricular hypo-kinetics LVEF :42% Systolic dysfunction
33
X-Ray
34
WBC 15.51×10 9 /L, N 94.3%, PLT 336×10 9 /L, Hb 145g/L LDH 586U/L, CK 123U/L, CK-MB 17U/L Na 134.2 mmol/L , K 4.54 mmol/L BUN 13.9 mmol/L, Cr 124umol/L BGA: PH 7.40, PaO 2 : 57mmHg, PaCO 2 : 33mmHg, SaO 2 : 87% PCT : 0.5ng/ml Laboratory test (1 day after recurrent symptom)
35
Clinical outcome The patient’s condition got aggrevated even with anti-imflamation, diuretics, inotropic agents 、 vaso-active agents The symptom exacerbating , SpO2 decreasing to about 80% Invasive mechanical Ventilation 1 day later
36
ECG of the next day
37
X-Ray : inflammation aggravated
38
出入量 Date 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Fluid Infusion 1765 915 765 665 660 355 3374 2342 Drink 1260 1200 2090 2100 1900 1650 200 50 Urine 1400 1850 2450 2375 1825 2825 911 1417 Balance +1625 +265 +405 +390 +735 -820 +2663 +975
39
Laboratory Test of 2011.03.09 WBC : 19×10 9 /L, N : 94% TNI : 1.97ng/ml CK-MB : 18U/L BUN : 21 mmol/L, Cr : 143umol/L BGA: PH : 7.39, PaO 2 : 58.8mmHg PaCO 2 : 32mmHg, BE : -4.9 mmol/L,Lac : 2.5mmol/L BNP : 1080pg/ml
40
X-Ray of the third day
41
Discussion ( 1 ) --- What do you think about this patient ? Recurrent myocardial infarction caused by subacute in-stent thrombus formation ? Acute heart failure Both
42
Discussion ( 2 ) --- What should we do ? Medical therapy? heart failure 、 anti-inflammation 、 anti-ischemia …… CAG again ? If CAG, the incidence of CIN is very high, and the toxicity of contrast must be taken into consideration Revascularization ? If revascularization , IRA only or complete revascularization ?
43
CAG : on the third day of recurrence ( 1 )
44
CAG : on the third day of recurrence ( 2 )
45
CAG : on the third day of recurrence ( 3 )
46
Discussion ( 3 ) The cause of acute heart failure ? No new-onset occlusion of coronary artery No infectious disease before The balance of liquid is almost equal ECG showed ST elevated , but no elevated cardiac marker , is CAG most needed ? How to evaluate ? Is completed revascularization of helpful ?
47
Outcome The patient’s relatives asked to quit all treatment because of financial causes Died of heart failure
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.