Prasad Gunaruwan Case Presentation: A case of multiple interventions

Prasad Gunaruwan

Case Presentation: A case of multiple interventions.

History: Mrs MB

• 66, housewife, smoker• Lives with husband at Narrabri (2hrs to

Tamworth, 6hrs to Newcastle)• Recurrent UTI April 2011, US renal tract• Kidneys, ureters, bladder normal but 4.3cm

fusiform AAA• Advice from Vascular Surgeon (Dubbo)

History Continued

• US followup Oct 2011: AAA now 5cm• CT (pre AAA repair): Infra renal AAA with large

amount of mural thrombus, max 4.8x5.7cm• CXR: mild enlarged Cardio-thoracic ratio on a

rotated film• Bloods: EUC/LFT/FBC normal• Spirometry: FEV1/FVC 1.1/1.9L

Intervention 1 & 2

• Endo-luminal AAA stent 12 Dec 2011 • Progress scan : Flow in right external iliac

outside the stent, 14 Dec 2011• Repositioning stent in R iliac 15 Dec 2011• Discharged 17 Dec 2011: • aspirin, atenolol, candesartan, atorvastatin,

prn salbutamol

First Emergency Admission

• 6 weeks post discharge• Presented to Narrabri with shortness of

breath, over a few hours• No chest pain, No fever • In AF • Hb 128, WBC 9.5 (N-8.2), EUC Normal

Troponin 0.55 What is the likely diagnosis?

1. Pneumonia2. AF and left ventricular failure3. Acute coronary syndrome4. Exacerbation of CAL5. Pulmonary embolus

•(pause)

Immediate management

1. Treat pneumonia2. Rate control for AF3. Diuretics for heart failure4. Anti-coagulate for stroke prevention

Progress & Results

• feels better by day 3• Aortic incompetence murmur

• Echocardiogram (in the setting of AF)Mild global LV systolic impairmentModerate aortic regurgitation

What is the cause for the troponin leak?

1. AF with rapid ventricular rate2. Acute coronary syndrome3. Severity of pneumonia 4. RV strain

Causes of a troponin leak

TIMI Risk score for UA/NSTEMI JAMA. 284(7):835-842, August 16, 2000.

5

Radial vs femoral access for angiography• About 70% of JHH caths radial route• No mortality benefit, but less local

complications, easier for the patient • For consent quote: major complication

including MI/stroke/death 1:1000, contrast allergy and nephropathy, bleeding and vascular complications

• In Mrs MB case this route avoids the AAA stent

Intervention 3: Coronary angiography at Tamworth

LV contraction

Moderate aortic regurgitation

What to do now?

• Discussed in angioplasty meeting• For medical treatment• Atorvastatin, digoxin, metoprolol, aspirin and

warfarinised for AF• Referral for cardiothoracic opinion re: aortic

regurgitation

Second Emergency Admission

• Re-present to Narrabri, day 5 post discharge• Severe central heavy chest pain 30 minutes

since onset• Diaphoretic, looking unwell

ECG

National Heart Foundation Algorithm Updated Sept 2011

Source: National Heart Foundation of Australia

Progress• Not thrombolysed• VT/VF arrest resuscitated and transferred to

Tamworth• Cooled, INR 8.5, vitamin K given• Neurological recovery uncertain

Post STEMI day 4

• Conscious, alert, oriented• JVP still raised, controlled AF• Echo confirms RV infarct, LV only mildly

impaired• What now?

- Conservative?- Transfer to JHH for cath?- Cath at Tamworth?

• No radial access available

Intervention 4: Iliac vessels and stent

Coronary anatomy and aortic root 1

Coronary Anatomy and aortic root 2

Stent Displacement

What was displaced?

Post angiography..

• VT, well tolerated• Reverted to AF with RBBB• Stable haemodynamics• What now….?

Lesson for me…

• Never push if resistance…• Extra care in such high risk situations• Support of the boss…beyond measure• Lesson for the boss??? Never let an AT cross

an aortic stent????

Progress since

• Heart failure and AF, well controlled• Admission with fever of unknown origin• Right pleural effusion – ? Heart failure– ? ParapneumonicProtein 23g/L; LDH 150; Cholesterol 0.6Clear fluid, culture negative

Indication for AAA repair

• Absolute diameter – > 5.5cm– Validated by 2 RCTs – UKSAT and ADAM trials that

compared open surgical repair vs surveillance• Rate of growth– > 5mm in 6 months OR >10mm in 1 year

• Complications such as trashing (embolization), fistula formation, etc

Possible complications

• Kinking and obstruction of limbs – in tortuous and calcified anatomy – stent reinforcement

• Endoleaks (continued flow/pressurisation of sac)

• Displacement or migration distally• Miscellaneous – infection, GEE, GEF (fistula),

component separation, fabric tears (leads to repressurisation of sac)

Take home…

• Troponin leak does not mean NSTEMI.• In NSTEMI troponin leak is one of 7 risk

factors.• New STEMI/ACS guidelines with attention to

symptom onset