a complex stemi case 2018 - a complex.pdfa. fix the rca b. fix the lcx c. fix the lad d. fix ‘em...
TRANSCRIPT
![Page 1: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/1.jpg)
Fahim H. Jafary, M.D., F.A.C.C., F.S.C.A.I.
Diplomate, American Board of Medicine – Cardiovascular Diseases & Interventional Cardiology
Diplomate, Certification Boards of Nuclear Cardiology & Cardiovascular CT
Senior Consultant Department of Cardiology Tan Tock Seng Hospital, Singapore
A complex STEMI case
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Case
• 69 year-old man, former smoker
• Severe pain between shoulder blades after
argument with wife
• On arrival SBP 140 mm Hg, pulses equal, CXR no
mediastinal widening
• EKG showed this …….
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![Page 4: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/4.jpg)
![Page 5: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/5.jpg)
• RCA subtotally
occluded, with
impaired flow
• Acute or chronic?
![Page 6: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/6.jpg)
![Page 7: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/7.jpg)
![Page 8: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/8.jpg)
• LCx subtotally
occluded with impaired
flow
![Page 9: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/9.jpg)
• LAD severely diseased
but TIMI 3 flow.
![Page 10: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/10.jpg)
Hmmmm ….
Still having 8/10 pain
What do I fix ?
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Hmmmm ….
Still having 8/10 pain
What do I fix ?
Options
A. Fix the RCA
B. Fix the LCx
C. Fix the LAD
D. Fix ‘em all
E. Send for CABG ?
![Page 12: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/12.jpg)
My thoughts ….
• He’s having 8/10 pain
• LAD has TIMI 3 flow so
less likely culprit
• Fix RCA then reassess
![Page 13: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/13.jpg)
• Transradial approach
• RCA wired with Fielder
XT-A wire
![Page 14: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/14.jpg)
![Page 15: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/15.jpg)
• Sapphire 1.0 x 10 mm
compliant balloon
crossed with a bit of
difficulty
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• After swapping wires,
dilatation with 1.0 then
2.0 mm balloons
![Page 17: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/17.jpg)
• Orsiro 2.5 x 40 mm
drug-eluting stent
![Page 18: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/18.jpg)
• Orsiro 3.0 x 40 mm
drug-eluting stent
![Page 19: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/19.jpg)
• Anchor wire in aorta to
enable ostial RCA
stenting accurately
• Orsiro 3.5 x 26 mm
stent
• Ostial RCA stent
positioning in spider
view
![Page 20: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/20.jpg)
• Orsiro 3.5 x 26 mm
stent
• Placing ostial RCA
stent in LAO cranial
view
![Page 21: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/21.jpg)
• Stent inflation
![Page 22: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/22.jpg)
• Anchor wire allows the
stent balloon to be
pulled back easily
without guide getting
sucked in
![Page 23: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/23.jpg)
• Post dilated the stent
with 3.0, 3.5 non-
compliant balloons
• Ostial RCA flared with
4.0 mm non-compliant
balloon
![Page 24: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/24.jpg)
• Then patient coughed
and everything came
out !!
![Page 25: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/25.jpg)
• Re-engagement of
RCA with ostial stent
quite easy
![Page 26: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/26.jpg)
• Final
![Page 27: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/27.jpg)
![Page 28: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/28.jpg)
![Page 29: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/29.jpg)
Did we do the right thing ?
• Subjectively, patient chest pain free
• Objectively …..
![Page 30: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/30.jpg)
![Page 31: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/31.jpg)
![Page 32: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/32.jpg)
2 days later ……..
![Page 33: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/33.jpg)
• XB 3.0 guider
![Page 34: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/34.jpg)
• LCx was quite difficult
to wire
• Had to use a Gaia First
wire to cross
![Page 35: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/35.jpg)
• After a bunch of
dilatations and
swapping the Gaia
First wire
![Page 36: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/36.jpg)
• Stented with Orsiro
2.25 x 40 mm stent,
postdilated proximally
with 3.0 mm balloon.
![Page 37: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/37.jpg)
• LAD IVUS
![Page 38: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/38.jpg)
![Page 39: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/39.jpg)
![Page 40: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/40.jpg)
• LAD dilated with a 3.0
balloon
![Page 41: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/41.jpg)
• LAD slow flow
![Page 42: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/42.jpg)
• Orsiro 2.75 x 40 mm
stent
![Page 43: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/43.jpg)
![Page 44: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/44.jpg)
• Orsiro 3.5 x 35 mm
stent
![Page 45: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/45.jpg)
• Final after post
dilatation with 3.0 and
3.5 mm non-compliant
balloons
![Page 46: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/46.jpg)
![Page 47: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/47.jpg)
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Moral of the story
• STEMI cases can be tough when there’s multivessel disease – Identifying culprit lesion can be challenging at times
– Timing of non-culprit intervention can be challenging
• Sometimes you have to just think it through
• Orsiro is a very trackable stent particularly in complex lesions
• Long length availability (40 mm) and thin struts advantageous
• Good outcomes data is very reassuring
![Page 50: A complex STEMI case 2018 - A Complex.pdfA. Fix the RCA B. Fix the LCx C. Fix the LAD D. Fix ‘em all E. Send for CABG ? My thoughts …. •He’s having 8/10 pain •LAD has TIMI](https://reader033.vdocuments.site/reader033/viewer/2022060923/60ae744c81c76d1da602cde2/html5/thumbnails/50.jpg)
Fahim H. Jafary MD, FACC, FSCAI E-mail: [email protected]