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One patient, two years, One patient, two years, three choices , four PCIthree choices , four PCI
ZHAO Peng
Cardiology, the Affiliated Hospital of Medical College of CPAPF, Tianjin, China
Case presentation
• Male , 61 years old• Chest pain for 4 hours• ECG : ST segment elevation on V1-V5 lea
d• Smoking 、 hypertension 、 hyperlipidem
ia• No diabetes mellitus• Diagnosis: Acute myocardial infarction
Coronary angiography
Treatment strategy
• Open the culprit vessel as early as possible
• Use coil wire to avoid into the false lumen
• Crush the thrombus by balloon dilation• Implant stent to restore the blood suppl
y
Balloon : 2.5*14mm
Pressure : 8atm
After nitro. bolus , TIMI-3 flow
Stent 1: Cypher 3.0*18mmPressure:12atm
Stent 2: Cypher 3.0*23mmPressure:16atm
The final film
Patient condition
• The symptom of angina disappeared• Vital sign were stable• Echocardiograph showed LVEF 42%
11 months later• Intermittent chest pain for 5 days• ECG on symptom: ST segment elevation
on avR lead• No drug terminate• Stop smoking• Blood pressure, glucose and lipoids wer
e satisfactory• So, WHY?
Recheck Coronary Angiography
LM ostial-proximal lesion
LCX ostial lesion
No lesion in RCA
Unstable plaque in LM and LCX
IVUS check
What’s the next?
• CABG? PCI?• Our determination : PCI No calcification lesion, easily transport devices DES , seldom restenosis Checked by IVUS , perfect stent- adherent
LCX, Balloon dilation, 3.0*15mm , 12atm
Stent location
Stent : Endeavor 4.0*24mmPressure:16atm
Kissing balloon
LM 4.0*24mm 16atm
LAD 3.0*13mm 16atm
Stent implanted, checked by IVUS, perfect stent-adherent
Patient condition• The symptom of angina disappeared again
after PCI• UCG: LVEF45%• Take more drug , adding cilostazol • No symptom for 1 year, recheck coronary a
ngiography
Coronary angiography
What we can do?
• Clinical observation ?• CABG ?• PCI ?• After the communication with the patien
t’s kin, the final choice was PCI
LAD ostial lesion
Cutting Balloon 3.5*6mm
8atm
LAD ostial lesion
LCX ostial lesion
LCX ostial lesion
Cutting balloon 3.5*6mm
8atm
Cypher 3.5*23mm
Located to LM ostium
18atm
Kissing balloon
LAD 3.5*15mm 12atm
LCX 3.5*15mm 12atm
LM, the stent’s corollas overlapped
The final film
7 days later• Chest pain exploded, cold sweat and shock• ECG: ST segment elevation on avR lead and depression on V1-V6 lead• Troponin T was elevated• treatment : IV tirofiban coronary angiography
The bulk of thrombus filled LM, proximal LAD and LCX, the blood of LAD was TIMI-2 grade
What we can do?
• We had no choice besides PCI• IABP• Thrombus suction • anticoagulants• Vasoactive agent
Sucking thrombus
TIMI-3 flow
The final film
Present condition
• Persistent IABP for 4 days• Twice acute heart failure • 7 days in CCU• UCG: LVEF 25%• Underwent CABG after 4 weeks
Thanks !