In-Stent Thrombosis or Acute Heart Failure

?

History

Male, 64yrs

Persistent chest pain 22hrs ,admitted on 1st Mar. 2011,the symptom did not relieve at admission

Old myocardial infarction five years ago, underwent PCI at that time, has not taken any medicine since 3 years ago

Hypertension for 10 years

T2DM for 5 years

gout for 3 years

Physical Examination T:35.8℃, P:74bpm, R:18bpm ,

Bp:133/77mmHg

Slight cyanosis

No distention of jugular vein, no rales, no murmur and no S3

No edema

adjunctive Examination

ECG (3.1) ： sinus rhythm with ST of

II 、 III 、 aVF ， V7-V9 elevated for 0.1-0.2mV

Cardiac marker： CKMB mass >80ng/ml

Myo >500ng/ml

cTNI >30ng/ml

BNP ： 414pg/ml

ECG at admission

Adjunctive test

BUN: 6.93mmol/L, Cr: 70 umol/L

LDH:1272U/L, CK: 3645U/L, CKMB: 349U/L, cTNI: (+)

Na: 134.3mmol/L, K: 4.41 mmol/L

WBC:17.62 *109/L, N: 89.3%,

Hb:157g/L,PLT :273*109/L

BGA: PH:7.49, PaO2:77mmHg, PaCO2:33mmHg,

SaO2:96%

diagnosis

CAHD

acute myocardial infarction (inferior wall)

old myocardial infardtion (anterior wall)

Killip I

Hypertension

T2DM

gout

Therapy ASA + Clopidogrel+Tirofiban to enhence anti-

platelet and anti-coagulation

Statins to stabilize the plaque

ACEI to prevent ventricular remodeling

Primary CAG+PCI

CAG(1)

LMd:50%, LADo:70% in-stent re-stenosis , LADm:70%, D1:70%; LCX:100%

CAG(2)

Small RCA

PCI-1

Wire and thrombus aspiration

PCI-2

After thrombus

aspiration twice

PCI-3

Balloon dilatation

2.0*15mm@8-10atm

PCI-4

Stent deployment :

2.75*29mm Partener @ 10atm

PCI-5

In-stent postdilatation with Durastar 3.0*10mm@10-20atm

PCI-6

Final Results

ECG After PCI

ECG of the next day after PCI

X-Ray (2011.3.1) : increase of lungmarkings

enlargement of heart shadow

UCG ： enlargment of left atrial

segmental ventricle hepo-kinetics (AMI of Inferior wall )

LVEF:43%

Mean Pulmonary Artery pressure:47mmHg

X-Ray and UCG

UCG at admission

Acute myocardial infarctin （ inferior wall）

Segmental hypo-kinetics

Left artial enlargement

Systolic dysfunction of LV

LVEF ： 43%

Holter Sinus Rhythm

Acute myocardial infarction of inferior wall

HRV:76ms

(2011.3.2): LDH: 1426U/L, CK: 2194U/L

CK-MB: 131U/L, cTNI (+)

(2011.3.3): LDH: 1194U/L, CK:695U/L

CK-MB:40U/L

BUN:7.44mmol/L, Cr:86umol/L

WBC: 8.84*109/L, N:78.6%, Hb:131g/L

Laboratory Test

Continue with anti-platelet 、 anti-

coagulation 、 lipid-lowering 、 inhibit

ventricular remodeling and anti-inflammation

therapy

No chest pain and no dyspnea

Sequential Therapy

But 5 days later…… Breast distress and sweating accompanied with dyspnea

ECG:ST II 、 III 、 avF ， V7-V9 elevated for 0.2mV

HR ： 102bpm ， Bp ： 88/59mmHg ， SpO2:90% ， No moist rales

Treatment ： NTG ： 0.5mg sublingually, NTG 5ug/min iv

Torasemide ： 20mg iv

Cedelaind ： 0.4mg iv

Clopidogrel ： 300mg Po st

Tirofiban ： 17ml iv ， 15ml/h

ECG of recurrent dyspnea

cyanosis, sweating, passive sitting position.HR:101bpm,Bp:95/57mmHg

30 minutes later

Symptom worsening

Transfer to CCU 1hr later

Symptom did not relieve after medical treatment

HR:121bpm,Bp:90/45mmHg ， SpO2:87-90% ， sitting position ， moist rales and S3 can be heard, no edema

Non-invasive mechanical ventilation

IABP

Morphine,diuretics, dopamine , dobutamine nitrates

Cardiac marker(6 hrs after recurrent symptom) CKMB mass 5.0ng/ml Myo 302 ng/ml cTNI 9.59 ng/ml BNP 1150 pg/ml

Cardiac marker(18 hrs after recurrent symptom) LDH 708 U/L CK 114 U/L CK-MB 21U/L

Laboratory test(1)

Laboratory test(2) BUN 7.3 mmol/L, Cr 96umol/L

WBC 9.25×109/L, N 85.6%, PLT 354×109 /L, Hb 157g/L

BGA: PH 7.44, PaO2 62mmHg, PaCO2 29mmHg, SaO2 90%

ECG in CCU

UCG in CCU

UCG Acute myocardial infarction (inferior wall)

Segmental ventricular hypo-kinetics

LVEF :42%

Systolic dysfunction

X-Ray

WBC 15.51×109/L, N 94.3%, PLT 336×109 /L, Hb 145g/L

LDH 586U/L, CK 123U/L, CK-MB 17U/L

Na 134.2 mmol/L ， K 4.54 mmol/L

BUN 13.9 mmol/L, Cr 124umol/L

BGA: PH 7.40, PaO2 ： 57mmHg, PaCO2 ： 33mmHg, SaO2 ：87%

PCT ： 0.5ng/ml

Laboratory test (1 day after recurrent symptom)

Clinical outcome The patient’s condition got aggrevated even

with anti-imflamation , diuretics, inotropic agents 、 vaso-active agents

The symptom exacerbating ， SpO2 decreasing to about 80%

Invasive mechanical Ventilation 1 day later

ECG of the next day

X-Ray ：inflammation aggravated

出入量

Date 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

Fluid Infusion 1765 915 765 665 660 355 3374 2342

Drink 1260 1200 2090 2100 1900 1650 200 50

Urine 1400 1850 2450 2375 1825 2825 911 1417

Balance +1625 +265 +405 +390 +735 -820 +2663 +975

Laboratory Test of 2011.03.09

WBC ： 19×109/L, N ： 94%

TNI ： 1.97ng/ml CK-MB ： 18U/L

BUN ： 21 mmol/L, Cr ： 143umol/L

BGA: PH ： 7.39, PaO2 ： 58.8mmHg

PaCO2 ： 32mmHg, BE ： -4.9 mmol/L ,Lac ： 2.5mmol/L

BNP ： 1080pg/ml

X-Ray of the third day

Discussion （ 1 ） --- What do you think about this patient？

Recurrent myocardial infarction caused by subacute in-stent thrombus formation ？

Acute heart failure

Both

Discussion （ 2 ） --- What should we do？

Medical therapy? heart failure 、 anti-inflammation 、 anti-ischemia ……

CAG again？

If CAG, the incidence of CIN is very high, and the toxicity of contrast must be taken into consideration

Revascularization ？

If revascularization ， IRA only or complete revascularization？

CAG ： on the third day of recurrence（ 1 ）

CAG ： on the third day of recurrence （ 3 ）

Discussion （ 3 ） The cause of acute heart failure？

No new-onset occlusion of coronary artery

No infectious disease before

The balance of liquid is almost equal

ECG showed ST elevated ， but no elevated cardiac marker ， is CAG most needed ？ How to evaluate？

Is completed revascularization of helpful？

Outcome

The patient’s relatives asked to quit all treatment because of financial causes

Died of heart failure