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STEMI, NSTEMI and Cardiac Arrest Case presentation
Sam Dawkins, MD PhD Cedars-Sinai Heart Institute, Los Angeles, CA Controversies and Advances in the Treatment of Cardiovascular Disease Los Angeles, CA
Background
• 72 year old male
• Sudden onset shortness of breath with chest tightness
• Hypertension and hyperlipidemia
• No other significant past medical history
Background
• 72 year old male
• Sudden onset shortness of breath with chest tightness
• Hypertension and hyperlipidemia
• No other significant past medical history
• Ambulance transfer direct to cath lab
• On arrival
SaO2 88% on 15L
HR 105 sinus rhythm BP 110/55
Background
• 72 year old male
• Sudden onset shortness of breath with chest tightness
• Hypertension and hyperlipidemia
• No other significant past medical history
• Ambulance transfer direct to cath lab
• On arrival
SaO2 88% on 15L
HR 105 sinus rhythm BP 110/55
What is the strategy?
• PCI? Which vessel? Multivessel?
• Support – Impella, balloon pump?
• Anesthesia?
10
Procedure
• General anesthesia
• Intra-aortic balloon pump sited
• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent
• Guide wire to circumflex for guide stability
• Unable to cross proximal LAD lesion
11
Procedure
• General anesthesia
• Intra-aortic balloon pump sited
• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent
• Unable to cross proximal LAD lesion
• Eventually wired LAD with Fielder XT and Corsair backup
12
Procedure
• General anesthesia
• Intra-aortic balloon pump sited
• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent
• Unable to cross proximal LAD lesion
• Eventually wired LAD with Fielder XT and Corsair backup
• Intravascular ultrasound to confirm true lumen
13
Procedure
• General anesthesia
• Intra-aortic balloon pump sited
• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent
• Unable to cross proximal LAD lesion
• Eventually wired LAD with Fielder XT and Corsair backup
• Intravascular ultrasound to confirm true lumen
• Balloon dilatation of proximal LAD
14
Procedure
• General anesthesia
• Intra-aortic balloon pump sited
• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent
• Unable to cross proximal LAD lesion
• Eventually wired LAD with Fielder XT and Corsair backup
• Intravascular ultrasound to confirm true lumen
• Balloon dilatation of proximal LAD
15
Procedure
• General anesthesia
• Intra-aortic balloon pump sited
• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent
• Unable to cross proximal LAD lesion
• Eventually wired LAD with Fielder XT and Corsair backup
• Intravascular ultrasound to confirm true lumen
• Balloon dilatation of proximal LAD
• Drug eluting stent to proximal LAD
16
Procedure
• General anesthesia
• Intra-aortic balloon pump sited
• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent
• Unable to cross proximal LAD lesion
• Eventually wired LAD with Fielder XT and Corsair backup
• Intravascular ultrasound to confirm true lumen
• Balloon dilatation of proximal LAD
• Drug eluting stent to proximal LAD
21
Clinical Course
• Transferred to ICU
• TTE
Severe left ventricular impairment (EF 20%)
Anterior akinesis, hypokinesis elsewhere
No significant valvular pathology
• Balloon pump removed after 24 hours
• Failed attempt to extubate after 48 hours
• Falling blood pressure with pulmonary edema, requiring pressor support
22
Clinical Course
• Transferred to ICU
• TTE
Severe left ventricular impairment (EF 20%)
Anterior akinesis, hypokinesis elsewhere
No significant valvular pathology
• Balloon pump removed after 24 hours
• Failed attempt to extubate after 48 hours
• Falling blood pressure with pulmonary edema, requiring pressor support
• Extubated day 9
• Discharged day 29