One patient, two years, three choices, four PCI ZHAO Peng Cardiology ， the Affiliated Hospital of...

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 !