Paul Teirstein, MD › wp-content › uploads › 2016 › 12 › ... · •Mistakes I have made in...

SCRIPPS CLINIC

Paul Teirstein, MD

Disclosures:

Cordis, Boston, Medtronic, Abbott:

Research Grants

Consultant

Speakers Bureau

SCRIPPS CLINIC

Ahh….the benefit of hindsight

Paul Teirstein, MD

Chief of Cardiology

Director of Interventional Cardiology

Scripps Clinic

La Jolla, California

SCRIPPS CLINIC

A Bold New Era In Cardiovascular

Disease

We need bold new lectures.

•Lectures that go deeper, ie “Ahh….the benefit of hindsight”

•Modern speakers now stress EMOTION over CONTENT

•They tell us how they feel, not what they think!

SCRIPPS CLINIC

“Ahh….the benefit of hindsight”

Ideas for future lectures:

• Phew….that data smells awfully fishy to me

• Expletive deleted! My hospital administrators are killing

• Blah…another one of my papers got rejected

• Wow!...that was a great case

• Yuck!.....got burned by another stent thrombosis

• Ahhh….the benefit of foresight

• Since foresight only becomes apparent in hindsight,

you cant have foresight without hindsight.

SCRIPPS CLINIC

“The farther backward you can look, the farther forward you are

likely to see."

---Winston Churchill

SCRIPPS CLINIC

“Ahh….the benefit of

hindsight”

Mistakes:

• Inadequate response to the COURAGE trial

• Our erroneous referral of too many patients to bypass

surgery

• Mistakes I have made in the cath lab

• Mistakes I have made in my career and my life

“Benefit of hindsight” is really a

chance to talk about mistakes

SCRIPPS CLINIC

COURAGE trial results

should have been more

forcefully refuted

Mistake #1

• Criminal Homicide:

Murder first degree: Premeditation, intent

Murder Second degree: intent, no premeditation

Manslaughter 1st degree (voluntary manslaughter):

• Intent, heat of passion, a reasonable person is provoked to kill

Manslaughter 2nd degree (involuntary manslaughter or negligent homicide):

• No intent, but did not act with the care and caution of a reasonable person (ie kicking brick off bridge that hits someone below)

• Reckless homicide – aware of risk but does not care, ie driving recklessly at 90 MPH

Non-Criminal homicide

• Justifiable homicide – kill to protect yourself, police officer killing in the line of duty,

• Accidental homicide: A lawful act done under a reasonable belief that no harm is possible

Homicide: n. The killing of one person by another

Harmonizing Outcomes with Revascularization and Stents in AMI

≥3400* pts with STEMI with symptom onset ≤12 hours

Emergent angiography, followed by triage to…

Primary PCICABG – Medical Rx–

UFH + GP IIb/IIIa inhibitor

(abciximab or eptifibatide)

Bivalirudin monotherapy

(± provisional GP IIb/IIIa)

Aspirin, thienopyridineR

3000 pts eligible for stent randomizationR

Bare metal stent TAXUS paclitaxel-eluting stent

*To rand 3000 stent pts

Clinical FU at 30 days, 6 months,

1 year, and then yearly through 5 years

1-Year Mortality: Cardiac and Non Cardiac

Number at risk

Bivalirudin alone

Heparin+GPIIb/IIIa

Bivalirudin alone (n=1800)

Heparin + GPIIb/IIIa (n=1802)

1800 1705 1684 1669 1520

1802 1678 1663 1646 1486

Cardiac

Non Cardiac

rtality

Time in Months

0 1 2 3 4 5 6 7 8 9 10 11 12

HR [95%CI] =

0.57 [0.38, 0.84]

P=0.005

Δ = 1.1%

P=0.03

Δ = 1.7%

Mortality = 68 vs 38 pts

Excess deaths = 30

• Intent, heat of passion, ie provoked to kill

• No intent, but did not act with the care and caution of a reasonable person (ie kick brick off bridge)

• Reckless homicide – aware of risk but doesn‟t care,ie driving recklessly at 90 MPH

Hypothetical trial

The HOLIE CHUTE trial

Primary endpoint = Mortality Inexpensive trial

Expected 90% relative risk; 40 pts provides power 0.90, alpha < 0.05

DSMB halts trial early because of excess deaths in treatment group B

Group A Group B

• Intent, heat of passion, ie provoked to kill

• No intent, but did not act with the care and caution of a reasonable person (ie kick brick off bridge)

• Reckless homicide – aware of risk but doesn‟t care,ie driving recklessly at 90 MPH

COURAGE: Clinical Outcomes Utilizing

Revascularization and Aggressive

Guideline-Driven Drug Evaluation

Boden W et al. NEJM 2007;356:1503-16.

COURAGE: Inclusion Criteria

• Pts must have angiographically confirmed single or multivessel CAD (>70%) and objective evidence of ischemia

- LAD: prox or mid

- RCA: prox to PDA

- LCx: prox to PDA/PL

• Pts with classic angina, >80% lesion, without documented objective ischemia

COURAGE: Exclusion Criteria

The very highest CLINICAL risk patients were excluded Unstable angina

CCS class IV angina refractory to medical therapy

Markedly abnormal stress test

• Substantial STD or hypotensive response during Bruce I

Revascularization within the last 6 months

Unprotected LM stenosis (>50%)

Refractory heart failure or cardiogenic shock

Severe LV dysfunction (EF<30%)

19© Cordis Corporation 2007 19

52 year old

business

executive,

diabetic with

class II angina.

Adenosine

perfusion scan

shows lateral

wall ischemia.

55 yo male

with class II

angina and

65 yo male

with two

episodes of

angina;

TMT found

depression

laterally

70 yo male

with Class II

angina,

stress test:

mild anterior

ischemia

and LAD

lesions 60-

70%; By IVUS

they are both

< 4.0 mm;

77 yo male with

class 3 angina,

abnormal nuclear

Where high risk angiographic lesions included in COURAGE?

Local Heart team (surgeon &

interventional cardiologist) assessed

each patient in regards to:Patient’s operative risk (EuroSCORE & Parsonnet

score)

Coronary lesion complexity (newly developed

SYNTAX score)– The goal of the SYNTAX score is to provide a

tool to assist physicians in their revascularization strategies for patients with high risk lesions

Sianos et al, EuroIntervention 2005;1:219-227Valgimigli et al, Am J Cardiol 2007;99:1072-1081Serruys et al, EuroIntervention 2007;3:450-459Coronary tree segments based on the classification proposed by the AHA and modified for the ARTS study Circulation 1975; 51:31-3 & Semin Interv Cardiol 1999; 4:209-19

Leaman score, Circ 1981;63:285-299Lesions classification ACC/AHA , Circ 2001;103:3019-3041Bifurcation classification, CCI 2000;49:274-283CTO classification, J Am Coll Cardiol 1997;30:649-656

Tortuosity

Thrombus

Bifurcation

Total Occlusion

3 Vessel

Left Main

Dominance

Calcification

Number & location of

lesions

SYNTAXscore

COURAGE: Enrollment

35,539 pts screened

3071 pts eligible

32,468 Were excluded

8677 Did not meet inclusion criteria

5155 Had undocumented ischemia

3961 Did not meet protocol for vessels

6554 Were excluded for logistic reasons

18,360 Had one or more exclusions

4513 Had recent (<6 mo) revascularization

4939 Had an inadequate EF

2987 Had a contraindication to PCI

2542 Had a serious coexisting illness

1285 Had concomitant valvular dz

1203 Had class IV angina

1071 Had a failure of medical therapy

947 Had LM>50%

722 Had only restenosis (no new lesions)

528 Had complications after MI

2287 pts consented

PCI (n=1149) Medical (n=1138)

Mean follow-up 4.6 yrs

784 (26%) consent not given by MD or patient

All patients had angiography.

A lot of patients were excluded.

Were the patients who were at high risk for death

and MI excluded?

Hard Endpoints at 4.6 Years%

PCI OMT PCI OMT PCI OMT

Death Spontaneous MI Revascularization

At mean

10 mos

At mean

10.8 mos

P<0.001

NEJM 2007;356:1503-16; AHJ 2006;151:1173-9

Trial design

anticipated

crossovers!

SCRIPPS CLINIC

COURAGE Myths

• „COURAGE trial patients were not low risk.‟

Diabetics 34%

Heart failure 5%

Multivessel disease 70%

• No, no, no…….this is high risk

....yada, yada, yada

Peterson and Rumsfeld, NEJM 359;7, 751-752 accompanying

COURAGE QOL manuscript in NEJM

SCRIPPS CLINIC

Courage Myths

• “Although the majority of patients who received optimal medical therapy alone had improved symptoms within 3 months, 21% crossed over and received PCI.” Actually, 32.6% of OMT patients crossed over to PCI

• “Thus, a very reasonable „take-home‟ message from the COURAGE trial is to pursue optimal medical therapy initially and if this is ineffective, turn to PCI” No mention of importance of angiography to risk stratify

1/3 patients will get an extra procedure

Peterson and Rumsfeld, NEJM 359;7, 751-752 accompanying

COURAGE QOL manuscript in NEJM

SCRIPPS CLINIC

Courage Myths

Cost-Effectiveness of Percutatneous Coronary Intervention in Optimally

Treated Stable Coronary Patients

---Weintraub et al Circ Cardiovasc Qual Outcomes. 2008;1:12-30

Item PCI + medical Medical only PCI - Medical

Initial Cost $12,162 $752 $11,410

Lifetime Cost $99,820 $90,370 $9,451

But…the cost of diagnostic angiography was not included in the

medical only arm.

If the cost of the qualifying angiogram where included in the medical

arm, the cost differences would be mitigated.

Thus, the myth of COURAGE is perpetuated , i.e: “Angiography is not

required for patients with stable angina”

SCRIPPS CLINIC

How Has the COURAGE Trial Changed

My Practice?

LESSONS I HAVE LEARNED:

• You don‟t have to stent every little blockage in every

little vessel

• Fix the major, ischemia producing lesions

• Leave the small, distal, sidebranch vessels alone

unless the patient has recalcitraint angina

SCRIPPS CLINIC

Why such controversy? Are there two

different cardiologist phenotypes?

• We all agree medical therapy should be used in

most patients to reduce death and MI

Anti-thrombotics, lipid lowering, beta blockers and ACE

inhibitors

• We disagree about how to control angina. Here,

cardiologists have emotionally charged differences

of opinion:

Aggressive anti-anginal medications versus

revascularization

an oxygen molecule: O2

Revascularization Therapy For Angina:

Open the artery

Stents increase oxygen supply

The Liberated Heart

YOUR HEART VESSELS EXPAND!

YOUR HEART IS

IN 4 POINT

RESTRAINTS!

Beta-blockers, Nitrates,

Decrease Oxygen Demand

The Repressed Heart

Medical Therapy For Angina:

SCRIPPS CLINIC

Think About It! Are you…

• Are you a demand cutting cardiologist who wants

to repress the heart?

• Or

• Are you a supply expanding cardiologist who wants

to liberate the heart?

SCRIPPS CLINIC

THE HEART REPRESSOR?

•THE HEART LIBERATOR?

What‟s Your Phenotype?

SCRIPPS CLINIC

We should be more

aggressively against CABG,

especially when it involves

Mistake #2

770,000810,000

850,000

920,000

980,0001,030,000

1,092,000

1,037,000

305,000 289,000296,000299,500

395,000

485,000

542,000

514,000

200,000

500,000

800,000

1,100,000

PCI Vs CABG: New Vs Old Technology

Sources: Cordis Database, Morgan Stanley

2000 2001 2002 2004 2005 2006 20072003

Angioplasty

Bypass Surgery

POD #1 after multi vessel revascularization:

OLD technologyPOD #1 after multi vessel revascularization:

NEW technology

SCRIPPS CLINIC

What do I dislike about bypass surgery?

• Morbidity of the procedure

• Saphenous vein grafts

• Acceleration of underlying native coronary disease

What do I like about bypass surgery?

• Left internal mammary

The Interventionalist‟s View of Bypass Surgery

Impact of increased sheer

stress on native disease

progression

Percent of Native Arteries with Progression

Progression (> 20% decrease in MLD) of atherosclerosis in native vessels was

accelerated by vein grafts and occurred in over 50% of native vessels within 2 years

of surgery

<50% stenosis <50% stenosis >50% stenosisNon Grafted Grafted Grafted

Less than 1 year

1 to 2 years

Greater than 2 years

----- Cosgrove et al. Cleveland Clinic; J Thorac and Cardiovasc Surg 82:520-530, 1981

IMA SVG

Effect of Coronary Artery Bypass Grafting on Native

Coronary Artery Stenosis----Hamada, Y. et al. Journal of Cardiovascular Surgery 2001; 42: 159-164

p = 0.016

35% of native coronaries bypassed with a vein graft

progressed to total occlusion by 5 month angiography

SCRIPPS CLINIC

Risk Factors for

Acceleration of Coronary Disease

• Smoking

• Hypertension

• LDL cholesterol

• Obesity

• Sedentery life style

• Bypass surgery

especially saphenous vein graft implantation

The most frequently implanted

surgical graft in the U.S. is still a

saphenous vein…

and after a few years, it‟s not a pretty

SCRIPPS CLINIC

2006 Isolated CABG Data:

Society of Thoracic Surgeons STS

• 156,128 patients with isolated CABG

LIMA = 88.2%

Bilateral IMA = 4.4%

Radial artery = 7.7%

---- 2006 STS database

Bilateral IMA = 27.6%

---- SYNTAX

By 5 years, vein graft patency was less than 40%. It was even worse for radial

artery conduits and not much better for RIMAs!

----Khot UN et al. Cleveland Clinic, Circulation. 2004;109:2086-91.

Cumulative patency (<70% stenosis) by type of graft

A contemporary study (2002-2003), 73%

received statins, 90% received aspirin!

1,820 (81%) patients underwent 12 month angiography

By 12 months ¼ of SVG‟s are occluded; 40% of

patients had at least one occluded SVG

At 1 year ITA failure was less frequent than SVG failure 8% Vs 29%

Saphenous vein graft failure

+ Native disease acceleration

= A very difficult day for the

Interventional cardiologist!

Vein graft failure profoundly increased death, MI

and revascularization

Example: The Graft Dependent Patient

• The graft dependent patient was not graft dependent before surgery.

• He is graft dependent because of surgery

SCRIPPS CLINIC

Three Great Myths of Cardiac Surgery

• Myth # 1: “Cardiologists do not obtain informed consent

from patients prior to multivessel PCI.”

No surgical consultation obtained

Risk of restenosis not disclosed

• How many cardiac surgeons do you know who inform

patients that their saphenous vein graft only have about a

50% chance of patency within 5 years?

• How many cardiac surgeons do you know who inform

patients that their underlying native vessel disease will

accelerate due to SVG bypass, making their overall

coronary diseased burden much worse when the SVG

occludes?

AWESOME 454 5

MASS-II* 408 1

SOS 988 2

ARTS 1,205 1

ERACI-II* 450 2.5

BARI* 1,829 10

EAST 392 8

CABRI 1,054 4

GABI 359 1

ERACI* 127 3

RITA* 1,011 6.5

Total 8,258

PCI vs CABGMortality

CABG better

PCIbetter Hazard*/risk ratios

.1 1 10

Pt F-U Odds ratio(no.) (yr) 95% Cl

Holmes DR Jr., Berger PB: Complex Intervention. Textbook of Interventional Cardiology, 4th

Edition, Topol EJ, editor. 2003:201-22.

One-year Rates of Repeat Revascularization in 4

CABG vs. Stent Assisted PCI Trials

Mercado et al, J thoracic Cardiovasc Surg, 2005

3.5 3.22.2

4.3 4.8

MACCE D/MI/CVA Death MI CVA Repeat

Revasc

CABG (N=897) TAXUS (N=903)

P=0.0015*

P=0.98

P=0.11

P=0.003

Serruys, Mohr ESC 2008

P=0.37

P<0.001

*Primary Endpoint

One Year Clinical OutcomesSYNTAX

SCRIPPS CLINIC

• Myth # 2: Target vessel revascularization rates are much

higher following PCI compared to CABG

SCRIPPS CLINIC

Repeat Revascularization Following CABG:

Interpreting Clinical Trial Results

• Several years post CABG, both the native vessel and SVG often progress to a total occlusion or diffuse disease resulting in limited options for PCI.

• Given the high threshold for repeat bypass surgery (particularly in the presence of a patent LIMA graft), many post CABG patients are not offered repeat revascularization; not because they wouldn‟t benefit from re-intervention, but because the risks are prohibitive and the likelihood of success is low.

• Thus, much of the relative increase in repeat revascularization following PCI observed in clinical trials is because the post PCI patient, in contradistinction to the post CABG patient, remains a good candidate for further revascularization.

SCRIPPS CLINIC

What‟s missing from the PCI vs

CABG trial data discussion?

• Why does the debate seem to always focus on mortality

and repeat revascularization?

• Shouldn‟t we include morbidity endpoints?

Any above complication 53% 1%

53% of CABG patients had a morbid complication compared to only 1%

of DES patients

PREVENT 4

JAMA 2005

CABG + CABG +

Risk of Procedural Stroke

PCI Vs CABG = 0.6% vs 1.2%, p = 0.002

3.5 3.22.2

4.3 4.8

Revasc

P=0.0015*

P=0.98

P=0.11

P=0.003

P=0.37

P<0.001

*Primary Endpoint

SCRIPPS CLINIC

• Myth # 3: Given differences in morbidity, bypass

surgery can even be compared to PCI.

If my PCI patient has a pseudo aneurysm requiring

surgical repair of the femoral artery, it is considered a

major complication that I have to defend at M&M and QA

committee. The untoward event is a small surgical

incision in the groin.

All CABG patients have a major surgical incision in the

chest. Therefore 100% of all CABG patients, by this

definition, suffer a major complication as a result of

their care plan.

0 1 2 3

3 VD with Disease of the Proximal LAD Artery

Hannan EL: NEJM, 2005

CP1190491-7

Stenting

A thought experiment!

Number needed to treat = 20 pts

Start with 20 pts

3 yrs post CABG = 18 pts left

3 yrs post stenting = 17 pts left

Original Article

Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease

Edward L. Hannan, et al N Engl J Med, Volume 358(4):331-341 Jan 24, 2008

Mortality (after adjustment) 7.3% for DES Vs. 6.0% for CABG

This 1.3% absolute difference (p=0.03) yields a NNT of 77

If we need to do 77 bypasses to save one life, I believe the

mortality benefit is clinically meaningless!

This point was completely missed by the lay press

SCRIPPS CLINIC

The TVR Trade-off:

Good data – Bad interpretation

• The clinician‟s perspective

Most of my patients tell me they would rather go through 3, 4 or

even 5 PCI procedures rather than go through one bypass surgery

• Yet some are using SYNTAX data to say exactly the

opposite

3.5 3.22.2

4.3 4.8

Revasc

P=0.0015*

P=0.98

P=0.11

P=0.003

P=0.37

P<0.001

*Primary Endpoint

Number of CABGs needed to

prevent one re-PCI = 13

At the cost of almost 4 times as

many strokes

Number needed to prevent analysis

All-Death CVA (Stroke)

Myocardial Infarction Revascularization

Stent (N=357)

CABG (N=348)

Adverse Events to 12 Months Left Main Subset

P=0.009*P=0.88*

P=0.97* P=0.02*

4.2%2.7%

4.3%6.7%

At the cost of 9 times as many

strokes

This means 18 of every 19

CABGs were unnecessary!

Number Needed to Prevent

54 yo business man

with angina,

dyspnea on exertion

and ischemic

dilatation on nuclear

After long

discussion, patient

requests stents

Three stents to RCA two weeks later

69 yo male with class III angina, antero-

lateral ischemia on cardiolyte scan, new

decrease in EF on stress echo. Angio finds

CTO of RCA with bridging collaterals and

high grade distal LM and ostial LAD.

Patient requests stents.

Single DES “cross-

over” circumflex with

final kissing balloon

inflation.

Will stage RCA chronic

occlusion.

2007.P

Safety at 12 Months (Death/CVA/MI)Left Main Subset

ITT population

8.17.4 7.7

LM all LM only LM+1VD LM+2VD LM+3VD(n=705) (n=91) (n=138) (n=218) (n=258)

P>0.99 P=0.29 P=0.72 P=0.57 P=0.11

TAXUS® Express® Stent

Presented by Dr. Serruys; TCT 2008

The safety and effectiveness of the TAXUS® Express® Stent System have not been established in the following patient populations: lesions located in the unprotected left main coronary artery

or patients with multi-vessel disease.

2007.P

Revascularizations* at 12 MonthsLeft Main Subset

ITT population

15.3 14.8

7.76.5 6.4 6.0

LM all LM only LM+1VD LM+2VD LM+3VD(n=705) (n=91) (n=138) (n=218) (n=258)

P=0.02 P=1.0 P=0.68 P=0.08 P=0.02

*Any revascularization (PCI or CABG)

TAXUS® Express® Stent

Presented by Dr. Serruys; TCT 2008The safety and effectiveness of the TAXUS® Express® Stent System have not been established in the following patient populations: lesions located in the unprotected left main coronary artery

or patients with multi-vessel disease.

Number Needed to Prevent

LM + 3VD Patients

SCRIPPS CLINIC

Who would I send CABG Surgery?

Several restenoses, large territory at risk

Diabetics with diffuse disease, particularly if small vessels but usually these are poor targets for CABG

Total occlusions with large and important territory at risk, not amenable to PCI or failed PCI

Excessive proximal tortuosity, particularly if calcified with good distal targets

You Can Call Me Now…

• Bypass surgery is very hard to go through more than

– Your saphenous vein grafts will likely close down

– Your native vessels will likely shrivel up

– Your subsequent PCI will likely be more difficult

• But, PCI can be repeated as often as you like

– And you can always have a bypass

– Sometime in the future

– Or, maybe never

…Or You Can Call Me Later

But Remember:

Bypass the Bypass!

SCRIPPS CLINIC

Mistakes I have made in the

cath lab

Mistake #3

Top Ten Things Not to Say

in the Cath Lab

6) Can I get a nurse in here who knows what she's

doing.

7) I just can't understand this anatomy.

It’s really weird. Where's the LAD?

8) This room is horrible...I can’t see anything I’m

doing! Can you see anything?

9) Stop that!...your killing my patient.

10) Wow! I've never done that before... lets give it a

Top Ten Things Not to Say

in the Cath Lab

1) Ugh! This is the worst case I've ever had in my

entire life!

2) You smell really nice. What are you wearing?

3) I’ve got to get out of here, lets hurry up!

4) Huh? Where’d the stent go. Can anyone find the

stent?

5) No, I have no idea what vessel that is! Our job is

to fix vessels, not name them.

The Cardiovascular

Research Foundation

Lenox Hill Heart and Vascular

Institute of New York

The Cardiovascular

Research Foundation

The Cardiovascular

Research Foundation

The Cardiovascular

Research Foundation

The Cardiovascular

Research Foundation

The Cardiovascular

Research Foundation

The Cardiovascular

Research Foundation

The Cardiovascular

Research Foundation

The Cardiovascular

Research Foundation

The Cardiovascular

Research Foundation

"A smart person learns from his own mistakes,

a brilliant person learns from the mistakes of

others"

--- Bill Collins (Mike's father)

4-4701 911

Beep…Beep…Beep…Beep…Beep…Be

1171 800 Fix A StentSCRIPPS CLINIC

“Success is going from failure to

failure with no loss of

enthusiasm”

--Winston Churchill

Stranger Then Fiction

69 yo female, fell in bathtub and hit her head.

Went to ER, CT was obtained and something

“unusual” observed.

Due to stent procedure 8 years previously at

another hospital, patient referred to cardiology

for evaluation

Cine images of chest obtained

Lesson

Learned:

Always do a

“wire out”

80 yo female, no

grafts, s/p double

barrel DES with

LAD in-stent

restensosis and

angina

Mid LAD Cypher ISR

Simple re-stent with

Taxus for Cypher

A humbling

experience

Re-stent with TAXUS

2.5 mm followed by

non-compliant 2.5

mm balloon @ 20 atm

Some “plaque shift”

into proximal LAD.

After “discussion”

decision to deploy

second stent

….hmmmm

Position second

2.5 mm stent

Deploy second

stent at 18 atm

!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Tamponade with

stent delivery

balloon at 4 atm.

But….patient is

receiving AngioMax

Patient tolorates

inflation well, insert

Need to wait 45 min

for AngioMax to

wear off

How to pass the

Question 30

Which one of the following statements is true regarding echocardiography with

dobutamine administration in comparison with exercise echocardiography?

End of text

(A) Sensitivity and specificity are lower

(B) Oxygen demand is greater

(C) The incidence of procedural complications is lower

(D) It provides superior assessment of myocardial viability

(E) It is less desirable for assessment of risk prior to noncardiac surgery

Much improved.

Lets wait another 15

minutes.

Re-inflate balloon

for another 15

minutes

How should we

pass the time?

Question 31

In patients over age 60, which of the following characterizes cardiovascular risk for those

who have elevated systolic blood pressure, in comparison with those who have elevated

diastolic blood pressure?

End of text

(A) Lower

(B) Equivalent

(C) Higher

Question 36

A 60-year-old man is admitted to the hospital for treatment of atrial fibrillation,

associated with dyspnea and orthopnea, of two weeks' duration. He has had a heart

murmur for many years. Physical examination reveals pulse rate of 108 per minute

with irregularly irregular rhythm. Vital signs are otherwise normal. Cardiac examination

reveals a grade 3/6 holosystolic murmur at the apex and an S3 followed by a short

low-frequency murmur at the apex.

Electrocardiogram reveals atrial fibrillation. Chest radiograph shows moderate cardiac

enlargement and prominent vascular markings.

Therapy with digoxin, atenolol, furosemide, and potassium chloride results in marked

improvement of the patient's symptoms and slowing of the ventricular rate to 76 beats

per minute at rest. Doppler echocardiogram reveals nearly normal left ventricular

function, severe mitral regurgitation without evidence of mitral stenosis, and left atrial

dimension of 5.5 cm. Estimated left ventricular ejection fraction is 55%.

End of text

Which of the following is most appropriate at this time?

(A) Start warfarin therapy, and schedule semiannual evaluations including Doppler

echocardiography

(B) Start warfarin therapy, and perform direct-current cardioversion in three to four

weeks; then schedule semiannual evaluations including Doppler echocardiography

(C) Start heparin therapy, and schedule coronary angiography and mitral valve surgery

(D) Start heparin and warfarin therapy, and order transesophageal echocardiography; if

no clot is present, perform direct-current cardioversion; then schedule semiannual

evaluations including Doppler echocardiography

(E) Start warfarin and angiotensin-converting enzyme inhibitor therapy, and schedule

semiannual evaluations including Doppler echocardiography

After another 15

minutes of balloon

tamponade, (total

inflation time 1

hour) perforation

is a bit worse.

Remove IABP,

exchange for

second guide

catheter.

Deflate balloon for a

few seconds to allow

passage of second

guidewire

Then, reinflate

balloon!

Bring Jo-stent

through proximal

double barrel

stents down LAD

right up to inflated

balloon

Position 3.0 x 12 mm

Jo-stent across

perforation

Deploy Jo-stent @ 16

Final result

Echo: minimal

pericardial effusion

ReoPro bolus plus

infusion

Discharge next

morning: no CPK

rise, no pericardial

effusion.

Emergency Angiogram for a 83 y.o Man Admitted

with Episodic Angina and Hypotension

The left main

coronary artery

has a 99%

stenosis, and is

intermittently

obstructing!

Patient requests

stents

Sudden Cardiac Arrest Due to Complete

Closure of Left Main Artery – CPR!

Emergency Balloon Inflation in Left Main Artery

A Little More Flow but CPR Continues

More Balloon Inflations

Better Flow but CPR Continues!

Now the Flow is Increasing and Cardiac

Contraction is Improving

More Balloon Inflations

Position Stent in Left Main Artery

Deploy Stent in Left Main Artery

Final Result – Normal Flow!

3 Months Later: Asymptomatic

1701 800 Fix A StentSCRIPPS CLINIC

“Good judgement comes

from experience . . .

and experience comes from

bad judgement”

Lillehei

SCRIPPS CLINIC

Mistakes I have made in my

career and in my life

Mistake #4

SCRIPPS CLINIC

Top 10 mistakes I have made in my career

and in my life

10) I did not invent the coronary stent

9) My first automobile was a Renault...sorry

8) I took singing lessons in medical school…pointless!

7) I recently drilled a small hole in the trunk of my

Mercedes…right into the fuel tank…it‟s a long

story…I‟ll tell you at the break

6) Sending emails when upset

5) Sending emails when intoxicated

4) Thinking I could think of 10 mistakes, when all I

could come up with is 8 mistakes

1)…Not marrying my wife about 10 years sooner

Paul Teirstein, MD › wp-content › uploads › 2016 › 12 › ... · •Mistakes I have made in...

Documents

lcx composite manual german - Swiss-Cave-Diving

WBLCX(Wireless Broadband Leaky Coaxial Cable) …WBLCX(Wireless Broadband Leaky Coaxial Cable) 無線LAN用ケーブル型アンテナ AP LCX-5D 10m) LAN PC LAN PoE AP PC AP LCX 不感地

Measurement & Spectroscopy - OXXIUS · Measurement & Spectroscopy One ... less than 200 mW Ì ≤ 15 W for LCX-532 & LCX-1064, 500 mW Ì ≤ 15 ... Control mode Automatic power control

LINEAR SLIDE CYLINDER LCX SERIES Position locking type and

LCX Composite Manual - dcfpnavymil.org Protection/SCBA/SCBA Tip 04/lcx...5.5 Pressure Testing 6. Cylinder Damage Criteria ... Ultra thin-walled aluminium liner ... at a designated

Lowrance GM, LMS ja LCX kasutusjuhend

Mccarthy michael budget 2015 news 3961

S Kenen Lcx v-ck Co Con€¦ · bcc Qcx cya See \ S Kenen Lcx v-ck Co Con . Created Date: 9/25/2018 7:36:32 PM

Apresentação evento lcx tecnologia com sofisticação em f5

dasa - progestao.ana.gov.brprogestao.ana.gov.br/portal/progestao/progestao-1/acompanhamento... · Tclelooe: 3961 4949' 3961 4951 . ANA AGENCIA NACIONAL DE AGUAS PROGESTAO ... Perfuracão

Our Ref: 3961 - tmr.qld.gov.au/media/Projects/B/Bruce Highway... · 3961-131217-0.1 Draft Kieran Aland Kaine Pritchard Paul Wood ... no part of this report, ... 5 1.0 INTRODUCTION

Notice gyspot inverter BP-LCX ESP v1.10

Is 3961 p 2 current rating for heavy duty pvc cable

OCT$guided$Rotabla0on$ $in$bifurcao n$lesions$lad cpr （lcx bif) lad cpr （d1 bif) d1 lad lad lcx

LCX · 2016-11-22 · Installation, use and maintenance manual COOLING-ONLY, HEAT PUMP AND FREE-COOLING VERSIONS USER MANUAL. LCX RG66010687_rev.00 2 For further information or communication,

Abstract 1. Introduction - URSI · A typical LCX-based intruder detection system is composed of a pair of LCX cables and an impulse response measuring equipment. The wideband RF (Radio

SPPAARREE PARRTTSS ACCAATTALLOOGGUUEE TELMMAA AA … · Item Description Quantity Telma part number 1 Stator assembly : Retarder LCx 1x1 122 ( w ith connecting block) Retarder LCx

RED THREAD IIA, DUALOY 3000/LCX, 3000/L FUEL … Pipe Brochure_All Pipes_1000795.9C... · red thread™ iia, dualoy™3000/lcx, 3000/l fuel handling piping systems

Advanced Features for LBX, LCX, LSX, LPX - Oxxius€¦ · Advanced Features for LBX, LCX, LSX, LPX L1C & L1C+ MPA Motorized Power Attenuator - 0 to 100% range - Maintains beam quality

China im Bild der deutschsprachigen Literatur ... - ULB Bonnhss.ulb.uni-bonn.de/2015/3961/3961.pdf · Danksagung Für die vorliegendeArbeit habe ich an erster Stelle Prof. Dr.Wolfgang