the nightmare in cath lab: early identification and emergent correct treatment
DESCRIPTION
The Nightmare in Cath Lab: Early Identification and Emergent Correct Treatment. Yuejin Yang MD, PhD, FACC, FESC Cardiovascular Institute and Fu-Wai Hopital, CAMS & PUMC. The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013. - PowerPoint PPT PresentationTRANSCRIPT
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The Nightmare in Cath Lab: The Nightmare in Cath Lab: Early Identification and Emergent CEarly Identification and Emergent C
orrect Treatment orrect Treatment
Yuejin Yang MD, PhD, FACC, FESCYuejin Yang MD, PhD, FACC, FESC
Cardiovascular Institute and Fu-WaiCardiovascular Institute and Fu-Wai
Hopital, CAMS & PUMCHopital, CAMS & PUMC
The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013
The 11th Nanjing Course on Cardiac Revascularization & ACS, in conjunction with CAP-CCBC, Nanjing, Sept. 13, 2013
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Numbers of PCI in Each Year @ Fu Wai
415 618 9211386 1605
19672555
32823821
47785148
6599
8050
10649
3 3 13 186 374706
12472018
2659
38404326
5623
7229
9673
0
2000
4000
6000
8000
10000
12000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Total PCI Radial
2011: PCI case No: 10649, Radial 90.8%2011: PCI case No: 10649, Radial 90.8% (( 9673/10649)9673/10649)
TRI from <1% in 1998 to >90% in 2011 with the very low mortality rate of just 0.05% in elective PCI
TRI from <1% in 1998 to >90% in 2011 with the very low mortality rate of just 0.05% in elective PCI
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The Impact of PCI on CHD
Effective in:– Interventional revascularization
– Cure the patients with CHD
Safety problems:– Severe complications
Hurt the patients
Even leading to death of the patients
If identification late and treatment
improperly or correctively
– Or nightmare in the Cath Lab
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Nightmares in Cath Lab ?
Severe PCI complications
Resulting in severe consequences
Even leading to:
– death
– MI
– Emergency CABG
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Category of PCI ComplicationsCoronary
Puncture site
Others
Stent related (BMS, DES)
TRI related
Medication related:– Antiplatelet and anticoagulation– Contrast media
Hypersensitivity (anaphylactic shock)
AKI
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Coronary Complications
Coronary injury leading to:
Severe dissection
Acute closure
Rupture
Perforation
Thrombosis
Thrombotic embolism
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Access Site Complications
Bleeding
Big hematoma
Post-peritoneal hematoma
A-V fistula
Vessel injury (dissection)
Thrombosis
Thrombo-embolism
Infection
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Other Complications
ComorbiditiesSystemic thrombo-embolismsMicrovascular embolisms
( thrombosis and air)StrokeBrain hemorrhageGI bleedingBleeding on other organsVagal reflex and hypotensionHemodynamic instability
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Stent Related Complications
Stent thrombosisAcute (<24 hrs)
Subacute (1-30 ds)
Late (1-12 ms)
Very late (>1 yr)
Definite
Probable
Possible
Stent dislodge
Stent dystroy
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TRI Related Complications
Radial artery closureVessel injury by wire and hematoma along with the route
Forearm hematoma and osteo-compartment syndromeNeck hematomaMediastinum hemotomaChest hemotoma or pleural bleedingStroke
Aortic dissection
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Medication Related Complications
Dual antiplatelet and antithrombin therapyBleeding ( brain, GI, fundus, gum, et al)
Hemotoma
HIT due to heparin
Plateletcyclopedia due to 2b/3a inhibitor at al
WBC decrease
Hypersensitivity
Contrast media CKD
Allergy even allergic shock
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Clinical Nightmares in Cath Lab
CV collapse
Big coronary (including sidebranch) acute closure
Coronary rupture
Severe no-reflow phenomenon
Cardiac tapenade
Severe allergic shock
Stent thrombosis
Brain hemorrhage
stroke
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Case 1: CV Collapse after CAA in Pts with STEMI (IPW)
Mr. Zhang Zhengang, M 66 yrs, 810865
STEMI (IPW) for 4 hrs, 2012-6-13
CV collapse after LCA A
Bp continually declined before RCA A
Continuous CPR, IABP, Intubation preparation
IABP pulled out during CPR
Left femoral approach to RCA A
TIMI flow II with 95% stenosis
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Case 1: CV Collapse after CAA in Pts with STEMI (IPW)
TIMI flow back to III after 1st aspiration
Residual stenosis 90%
After 2nd aspiration, residual stenosis 80%
No PTCA, No Stent
CCU stay for 10 days
CABG suggested, but 1-2 Mons later needed
Pts discharged on his own demand
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Baseline LCA A
LAD & LCX CTO Poor local collateral circulation
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CPR and RCA A
Bp declined before RCAA LFA RCAA under CPR
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Final Results• After 2nd aspiration,
TIMI flow III• RCA to LAD collateral
circulation• Residual stenosis 80%• IABP via LFA • Pts calmed,
hemodynamics stable• Sent to CCU
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Case 2: Severe Complication – LM dissection leading to acute closure
Mr. Song Chen Wu, M 40 yrs, 841948
2013-2-26
XB-LAD Guiding
LM dissected and acute closure
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Baseline CAA
Guiding engaged uncoaxially LM & LAD dissected severely
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LAD closure
LAD acute closure & IABP support, Wiring
Guiding changed to Judkins L3.5
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Rescue Successful
Wiring successful & ballooning TIMI flow III
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Stenting
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Final Results
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Case 3 RCA Rupture after Post-stent Kissing
Mr. Wang Yu min, M 54 yrs, 819648
2012-9-19
Admitted due to ACS
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Baseline CAA
LAD 80%, Dia 80%, distal LCX 80%
Distal RCA & Bifurcation 90%
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PTCA and Stenting
After PTCA After Stenting ( 2.75 × 24mm )
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Kissing Ballooning
1st Kissing OK 2nd Kissing with high pressure of 12atm
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RCA Rupture
RCA Rupture Balloon occlusion, pericardial centesis, cardiac surgeon consulted
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Covered Stent
Covered stent Almost sealed
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Final Results ?
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40 Minutes Later
Massive clot showed in pericardium & stent leakage at distal vessel
Obvious contract media stay in pericardial cavity
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Re-sealed
Another covered stent, JR guiding very deep seating to seal the leakage
Covered stent deployed & leakage sealed with the price of PDA acute closure
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Final Results
No sign of pericardial effusion
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Pericardial Cine Check
No sign of pericardial effusion
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Case 4: LAD&Dia two stent complicated with ST
Mr. Ni Xiang ren, M 45, 819127
2012-8-22
Admitted due to ACS
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Baseline CAA
LAD 90%, big Dia 90%, LCX 90% Distal RCA 100% with collateral circulation from LAD
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Two Stent Strategy
Rewiring & Reballooning Kissing ballooning
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Final Results
OK OK
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3 Hrs Later, Chest Pain with ST Elevation
Stent total occlusion due to AST Ballooning
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Final Results
TIMI Flow OK, LCX 100% Flow sluggish without emptying, CV Collapse happened, CPR
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Case 5: Acute Closure of Big RCA
Mr. Shang Feng yi, M 56 yrs, 838552
2013-1-13
Big RCA very tortuous
Acute closure due to wire injury
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Baseline CAA
LAD & LCX OK Big RCA very tortuous with tight lesion
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RCA Closure and Rescue
RCA acute closure due to BMW injury
IABPPilot 50 wiring & ballooning
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Stenting
Big RCA opened Stenting
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Final Results
OK, No distal dissection RCA TIMI flow III
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Case 6: RCA Stenting Complicating with Side Branches Acute Closure
Mrs. Cao Wen hua, F 64 yrs, 782315
2012-1-10
CABG for 5 yrs
LAD & LCX 100%
RCA In-stent stenosis & occlusion with big side branches
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Baseline CAA
LAD & LCX 100% RCA In-Stent 100% involving two PDA branches
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RCA PCI
Ballooning without side branches wire protection
Two big branches acute closure
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RCA PCI
Hemodynamic unstableIABP & Temporary Pacemaker
Two side branches TIMI flow I+
One weeks later, Pts died of SCD
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Case 7: High risk pts without hemodynamic support
Mrs. Zhang Xiu zhen, F 80 yrs, 713486
2010-2-8
Primary PCI for STEMI
High risk Pts without hemodynamic support
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Baseline CAA
LAD 100% RCA 70%
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Ballooning
Pre-stent ballooning After ballooning, TIMI flow I& CV collapse happened
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IABP & Reballooning
IABP & Reballooning TIMI flow remained I
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Take Home Messages
Always keep in mind:
– There are some possibilities of complication
when we do every PCI cases
– Early identification and emergent correct
management can avoid the nightmare in the
Cath. Lab.
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WelcomeWelcome Attend China Heart Conference (IHF2014)Attend China Heart Conference (IHF2014) ::
6th6th international TR Coronary Therapeutics (T international TR Coronary Therapeutics (TRCT)RCT)
Chaired byChaired byYue-Jin Yang MD. PhD. FACCYue-Jin Yang MD. PhD. FACC
Co-Chaired byCo-Chaired byDr. SaitoDr. Saito
Dr. kiemeneijiDr. kiemeneijiCNCC, CNCC, 2014/08/08-11, Beijing, China2014/08/08-11, Beijing, China
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Thank You for Your Thank You for Your Attention !Attention !