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