Moderated Complex Case Competition

What’s the matter ith these coronar arteries?What’s the matter with these coronary arteries?

Sang Yeub Lee

Division of Cardiology Department of Internal MedicineDivision of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, South Korea

M/46 chest pain (CCS III) 3 days ago M/46, chest pain (CCS III), 3 days ago

Atherosclerotic risk factor DM/HTN ( / ) Dyslipidemia ( ) Smoking ( )DM/HTN (-/-), Dyslipidemia (-), Smoking (-)

Past medical historyPast medical history Untable angina (+) 6 month ago

But 6 month ago other hospitalBut 6 month ago, other hospital…

Same chest painSame chest pain

But 6 month ago other hospital CAG and PCIBut 6 month ago, other hospital… CAG and PCI

RCA os : tight stenosis

But 6 month ago other hospital CAG and PCIBut 6 month ago, other hospital… CAG and PCI

Predilation with Voyager 3.0X20 mm, Stenting with Biomatrix 3.5X14 mm IVUS: not performed

6 month later chest pain again!6 month later… chest pain again!

At our hospital ER (Dec. 2010)

l hAggravating exertional chest pain

Chest pain on resting and mild exercise for 3 days p g y

Baseline labBaseline lab

ER on Dec. 12, 2010

CBC: 6,500/uL-13.4 g/dL-285 K/uL, / g/ /

CPK: 363 IU/L (< 190 IU/L), CK-MB 5.97 ng/mL (<4.94 ng/mL)

Lipid profile: 149 75 52 77 mg/dL fasting glucose: 78 mg/dLLipid profile: 149-75-52-77 mg/dL, fasting glucose: 78 mg/dL

BUN/Cr: 13.5/0.95 mg/dL

Normal chest X-ray and ECGNormal chest X-ray and ECG

No RWMA and normal LV EF in echoCG

Abnoraml Ankle Brachial Index…

pressure drop in Lt arm. p p

CAG in Dec 2010 (our hospital)CAG in Dec. 2010 (our hospital)

tight stenosis at LM ostiumthe pressure wave was damped

CAG in Dec 2010 (our hospital)CAG in Dec. 2010 (our hospital)

tight stenosis at RCA ostium and proximal edge of previous stenting sitetight stenosis at RCA ostium and proximal edge of previous stenting site

RCA ostium might be missed in previous stent implantation.

When I and my colleague saw cine image,y g g ,We went silent…

What’s the matter with these coronary arteries?

Summary of problemsSummary of problems

Problem listIsolated bilateral coronary ostial stenosis(RCA, LMCA sequential stenosis)N k bl th l i i k f tNo remarkable atherosclerosis risk factors

RCA stenting and ostial restenosisRestenosis ? or missed RCA ostial stent coverageg

Both arm BP difference

Consumptive diagnosis Usual atherosclerotic coronary artery diseaseAortitisAortitis

Rhuematologic vasculitisTakayasu’s arteritisInfectious arteritis

Clinical Diagnosis, NSTEMI!g ,Tight stenosis in LM ostium!

We decided to perform PCI to LM.

IVUS – isolated bilateral ostial stenosis IVUS – isolated bilateral ostial stenosis

IVUS after Post balloon dilation : large plaque or tissue burden, CSA stenosis 73%

Left main ostial stentingLeft main ostial stenting

JL4, 7 Fr sidehole GC, Predilation with Maverick 2.5X15 mm

Left main ostial stentingLeft main ostial stenting

Stenting with PRO-KINETICS 4.5X15 mmPostdilation with Quantum 4.5X8 mm

Left main ostial stentingLeft main ostial stenting

Left main ostial stentingLeft main ostial stenting

RCA ostium - POBA only and 2 stage PCI -scheduled

POBA with Maverick 2.5X15 mm

After PCI Additional LaboratoriesAfter PCI, Additional Laboratories

l d bBlood Labhs-CRP: 0.16 mg/dL (< 0.3)ESR: 21 (0~9 mm/hr)ESR: 21 (0~9 mm/hr)c-ANCA: 44 AAU (150~180), p-ANCA: 44 AAU (150~180)FANA: negativeVDRL: reactive (X128), TPA:30.18 positiveFTA-ABS IgM: positive, FTA-ABS IgG: positive

CSF L bCSF LabProtein: 65.3 mg/dL (15~45), Glucose: 61 mg/dL (50~75)WBC: 120 VDRL: reactive (X8)WBC: 120, VDRL: reactive (X8)

Lab test reveal Lab test reveal…

Tertiary syphilis

Coronary and Aorta CT-angiographyCoronary and Aorta CT-angiography

Coronary and Aorta CT-angiographyCoronary and Aorta CT-angiography

TreatmentTreatment

NSTEMI PCI for biostial lesion

Tertiary syphilis Massive antibiotics

We really wondered

whether the patient would recover

from ostial stenosis of aortic branch

After MASSIVE ANTIBIOTIC THERAPY

W h k d th F ll CT i hWe checked the Follow up CT angiography

Follow up CT angiography 4month laterFollow up CT angiography, 4month later

Dec. 2010 April 2011

Follow up CT angiography 4month laterFollow up CT angiography, 4month later

Dec. 2010 April 2011

Follow up CT angiography 4month laterFollow up CT angiography, 4month later

Dec. 2010 April 2011

Follow up 4month laterFollow up, 4month later

• But No chest pain, No other symptom

Isolated Bilateral Coronary ArteryOstial Stenosis

• atherosclerotic

• Congenitalg

• Radiation exposure

Periaortitis• Periaortitis

– Inflammatory aneurysms

– Tuberculosis

– Syphilis

– non-specific aortitis

– Takayasu's disease

– Kawasaki's disease

Cardiovascular manifestation of SyphilisCardiovascular manifestation of Syphilis

• Cardiovascular abnormalities are well-known manifestations of tertiary

syphilis infections which although not frequent, are still causes of

morbidity and mortality.

• The cardiovascular manifestations of syphilis compromise asymptomatic

aortitis, aortic regurgitation, coronary ostial stenosis, aortic

aneurysm, and gummatousmyocarditis

• Coronary ostial stenosis can be seen in approximately 26% of the

patients with syphilitic aortitis

• Treatment of IOS in syphilitic aortitiss : CABG, PCI, medical Tx not

confirmed