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Percutaneous Coronary Intervention f L ft M i A t M di l I f tifor Left Main Acute Myocardial Infarction;
Stay calm, and things will go well.
Teppei Sugaya
Cardiovascular CenterHokkaido Social Insurance Hospital
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
Case: Male in his 70’s
• Clinical history: yThe patient presented with severe chest pain
and dyspnea for 1 hour.
• Coronary risk factor: Current smoking HypertensionCurrent smoking, Hypertension
• Blood pressure at emergency room : p g y100/70 mmHg
• Breath sound : Clear
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
ECG: Sinus rhythm, HR 70, ST segment elevation in aVr T wave progression in V1 2ST-segment elevation in aVr, T-wave progression in V1-2ST-segment depression in Ⅱ, Ⅲ, and aVF, V3-6
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
Approach siteApproach site
For CAG and PCI Possible Left Main ACS
Rt Femoral arteryLt F l t7 Fr sheath
for Guiding catheterLt Femoral artery
5 Fr sheath
In order to exchange to cannula for PCPS immediately if required
Rt Femoral vein7 Fr sheathfor temporary pace maker Lt Femoral vein
immediately if required.
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
for temporary pace maker Lt Femoral vein5 Fr sheath
Baseline Coronary Angiography (LCA)
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
Blood pressure 80 / 40 mmHg
Left main ACSLeft main ACS• The incidence of acute LMCA occlusion is 0.9% in
ti t ith STEMI d i i i l tpatients with STEMI undergoing primary angioplasty.
D it f f i PCI ti t ith AMIJACC cardiovasc intv 2011 Jun;4(6):618-26.
• Despite performance of primary PCI, patients with AMI due to LMCA occlusion were associated with >50% in-hospital mortalityhospital mortality.
Point.Catheter cardiovasc intv 2012 Jan 10.
Point.
Don’t hesitate to start PCPS(percutaneousDon t hesitate to start PCPS(percutaneous cardiopulmonary support) in acute left main ACS if not contraindicated.Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
ACS if not contraindicated.
Approach sitepp
For primary angioplasty For PCPS
Rt Femoral arteryRt Femoral artery7 Fr sheath
for Guinding catheter
Rt Femoral artery16 Fr Cannulafor PCPS
Rt Femoral vein7 Fr sheathfor Temporally pace maker
Rt Femoral vein21 Fr Cannulafor PCPS
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
for Temporally pace maker
Baseline Coronary Angiography (RCA)with PCPS
Intratracheal intubation with sedation.
BP: 100 / 70 mmHg
PCPS flPCPS flow: 2.0-2.6 L/min1900-2100 RPM
ECG: sinus rhythm, HR 70
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
AspirationAspiration
G/C: 7Fr Judkins Left G/W: Sion blue
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
G/C: 7Fr Judkins Left G/W: Sion blue
After aspirationAfter aspiration
Suspicious of true bifurcation lesion; MEDINA classification (1 1 1)
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
Suspicious of true bifurcation lesion; MEDINA classification (1,1,1)
LCX wiring micro catheter(Finecross) + Fielder FCmicro catheter(Finecross) + Fielder FC
Crossing of guide wire was very difficult due to stenosis of
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
LCX ostium and extremely angulated bifurcation.
Multifunctional catheterMultifunctional catheterCrusade
Superior GW movementA “Double layer lumen” allows superior GW movement.
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
LCX wiring with Crusade + Fielder FCg
We reacted calmly this difficult situation because of
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
ypatient’s stable condition with PCPS.
Comparison of wire movement
Without Crusade With Crusade
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
Kissing balloon
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
LAD: 2.5x15 mm LCX: 2.5x15 mm
After kissing balloonAfter kissing balloon
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
IVUS
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
Modified T (mini crush) stenting
LCX: 3.5x23mm EES Crush balloon: 3.0x20mm
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance HospitalLAD: 3.5x23mm EES
Wire recross to LCXWire recross to LCX
Thereafter wire recross into LCX was attempt with Fielder FC alone.
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
IVUS to LADLCX
distal
Wire
proximal
The wire re-crossed into
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
the proximal strut.
Gap
The two stents are actually in a crossed position.(One above the other)
PointRecrossing the wire to the distal strut is favorable in crush stenting.
Proximal strutProximal strut
Distal strut
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance HospitalCollapse of the strut into side branch
LCX wiring with Crusadeg
Crusade can also prevent the wire from crossing out of the gproximal edge of stent if struts are malaposed.
The wire was successfully recrossed to the distal strut with Crusade, and we reacted
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
calmly this complication task because of the patient’s stable condition with PCPS
IVUS to LADIVUS to LADdistal
LCX
WireWire
proximal
The wire situated on the distal side
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
the distal side
Final Kissing Balloon TechniqueFinal Kissing Balloon Technique
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
LAD: 3.5x20 mm LCX: 3.0x20 mm
IVUS
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
Final AngiographyFinal Angiography
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
LVGLVG
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
After PCIFor IABPFor IABPand Central vein catheter
For PCPS
Rt Femoral artery
Central vein catheter
Rt Femoral arteryRt Femoral artery y16 Fr Cannulafor PCPS
Rt Femoral artery7 Fr sheathfor Guinding catheter
Rt Femoral artery8 Fr sheathfor IABP
Rt Femoral veinfor central vein catheter
Rt Femoral vein21 Fr Cannulafor PCPS
Rt Femoral vein7 Fr sheathfor temporary pace maker
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
Clinical courseClinical course• Peak CK 9800 U/L• 1 POD weaning from PCPS• 1 POD weaning from PCPS• 4 POD weaning from IABP• 6 POD weaning from ventilator• 6 POD weaning from ventilator• 8 POD reintubation due to pulmonary edema
9 POD pericardial drainage• 9 POD pericardial drainage• 14 POD left thoracic drainage
18 POD i ht th i d i• 18 POD right thoracic drainage• 19 POD weaning from ventilator
21 POD it CCU• 21 POD exit CCU• 37 POD CAG : no restenosis of stents
ODivision of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
• 42 POD discharge home
3-month follow up CAG3 month follow up CAG
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
12-month follow up CAG12 month follow up CAG
Division of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
SummarySummary• We experienced and successfully treated a
case of left main AMI with complicated bifurcation lesion.
• We reacted calmly in this tough case duringWe reacted calmly in this tough case during PCI procedure because of the patient’s stable condition with PCPS.condition with PCPS.
C d i f l th t f t l• Crusade is a very useful catheter for extremely angulated bifurcation and recrossing after crush t tiDivision of Cardiology,Cardiovascular Center,Hokkaido Social Insurance Hospital
stenting.
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