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PP-182 [AJC » Cardiac imaging - Echocardiography] Spontaneous RCA Dissection and Massive Intraventricular Thrombus With Normal Ejection Fraction in Behçet Disease
MARCH 23e26, 2017 LAD and the intubated patient was referred to our clinic for further examination and treatment. Upon physical examination, patient was intubated, TA was 80/40 mmHg, heart rate was 130 beats/min, and respiratory rate was 30/min. Left anterolateral thoracotomy incision scar was observed. Q waves in the anterior, high ST and negative T were detected in ECG. Transesophageal echocardiography revealed severe left ventricular hypokinesia and apical akinesia with a left ventricular ejection fraction of 40% and possibility of the LAD fistula and vsd (figure 1). Emergency coronary angiography showed an LAD cut-off at mid part with poor distal run-off and fistula of the LAD to the left ventricle. (figure 2) On post-admission day 7, the patient underwent reoperation, during which he was placed on cardiopulmonary bypass and high-potassium blood cardioplegia was administered. The fistula of the LAD to the left ventricle and VSD was repaired with Prolene 40 and the left interior mammary artery was grafted to the LAD, distal to the site of the suture ligation of the LAD fistula. Patient was transferred to specialty service care unit 3 days after the operation. Minimal residue vsd was detected in the echocardiographic screening on the seventh day, and since no other complications were observed during the follow-up, patient was discharged with full recovery. Conclusion: We suggest that patients with traumatic coronary artery fistulas be considered for elective surgical repair to prevent the development of complications. Operative repair can be accomplished safely with excellent long-term outcome. Keywords: Coronary artery fistula, Penetrating injuries, Surgery.
immune-inflammatory disorder involving vessels of all sizes and often complicated by thrombosis. Cardiac involvement and particularly left ventricular intracardiac thrombus are rarely diagnosed in the course of BD and are often associated with poor prognosis. We present a rare case of spontaneous coronary artery dissection and recurrent intraventricular thrombus with normal ejection fraction in a behçet disease patient. Case: A 43 year-old female patient admitted to our hospital with the complaints of chest pain and palpitation that had began in recent months. The pain was dull, radiating to the neck, not related with exercise. On physical examination, all findings were normal. Electrocardiography showed sinus rhythm with nonspecific ST segment and T wave abnormalities. He underwent coronary angiography and coronary angiography showed spontaneous right coronary artery dissection (Figure-1). Transthoracic echocardiogram (TTE) revealed normal ejection fraction and massive thrombus in left ventricle.(Figure-2). Discussion: Left ventricular (LV) thrombus is a life-threatening complication of severe left ventricular dysfunction. It is a rare complication of hematological diseases like behcet disease in normal ejection fraction patients. Spontaneous coronary artery dissection (SCAD) is a relatively rare and unexplored type of coronary disease. Although atherosclerosis, hormonal changes during pregnancy and connective tissue disorders might represent a sufficiently convincing explanation for some patients with SCAD. Our patient referred to surgery for big
P O S T E R A B S T R A C T S
Figure 1.
Left anterior descending cut-off at mid part with poor distal run-off and fistula of the left anterior descending to the left ventricle LAD, Left anterior descending.
- PP-182 [AJC » Cardiac imaging Echocardiography] Spontaneous RCA Dissection and Massive Intraventricular Thrombus With Normal Ejection Fraction in Behçet Disease. Fatih Mehmet Ucar, Mustafa Adem Yılmaztepe, Gökay Taylan. Trakya Üniversitesi Tıp Fakültesi, Edirne, Turkey. Introduction: Behçet disease (BD) is a systemic vasculitis with a broad range of organ involvement, characterized by a multisystemic,
Figure 2. th
e76 The American Journal of Cardiologyâ MARCH 23e26, 2017 13 INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Poster
MARCH 23e26, 2017 thrombus and dissection of coronary artery. After surgery anticoagulation therapy and systemic anti inflammatory therapy started for patient. Keywords: Spontaneous, Dissection, Intraventricular Thrombus, Behçet Disease
- PP-183 [AJC » Percutaneous coronary interventions in acute coronary syndromes] Succesful Treatment and Management of LMCA Acute Total Occlusion in a Patient with Acute Myocardial Infarction: The Priority is to Keep the Patient Alive!. _ Nuri Köse1, Tamer Kırat1, Gökhan Ergün2, Ibrahim Altun2, Fatih Akın2. 1Department of Cardiology, Private Yücelen Hospital, Mu gla, Turkey; 2Department of Cardiology, Mugla Sıtkı Koçman University, Mugla, Turkey. Case: A 46 year-old male patient applied to the emergency department with severe chest pain and sweating lasting for one hour. Blood pressure was 60/40 mm Hg with a pulse rate of 80/min. ECG revealed ST elevation in the anterior and inferior derivations. LV was diffuse hypo/ akinetic and LVEF was 20% in the echocardiography. 600 mg clopidogrel and 300 mg chewable ASA was given and 100 IU/ kg heparine was applied intravenously. After insertion of IABP, coronary angiography revealed RCA with some plaque and acute total occlusion of the LMCA bifurcation (Figure 1A). 7 Fr JL4 guiding catheter was inserted to the ostium of the LMCA. After insertion of two guidewires in LAD and Cx arteries, thrombectomy with thrombus aspiration catheter was performed that revealed some thrombus. Critical bifurcation stenosis was stented from the body of LMCA to proximal LAD with a 3.5*30 mm bare metal stent at 14 atm with Cx guidewire jailed. Because of the critical osteal stenosis of Cx, LAD guidewire was withdrawn and advanced to Cx through the distal struts of the stent. Ostium of the Cx was predilated with a 2.0*16 mm balloon and 3.0*15 mm bare metal stent was implanted in Cx with minimal protrusion to the LMCA (T and protrusion (TAP) technique). 4.0*21mm noncompliant balloon from LMCA to LAD and 3.0*15 mm noncompliant balloon from LMCA to Cx were used for kissing balloon dilatation with wide open arteries and TIMI III flows (Figure 1B and 1C). Because of the reimbursement conditions of the patient, bare metal stents were preferred in this patient. Tirofiban infusion was given to
Figure 1.
patient for 24 h with standart medical therapy. Predischarge echocardiography revealed no LV wall motion abnormalities with a LVEF of 60% in the fifth day. Although the patient was asymptomatic, diffuse instent 80% stenosis in the LMCA bifurcation was determined in control coronary angiography which was performed 3 months after (Figure 1D). CABG with LIMA-LAD and saphenous ven from aorta to first diagonal branche, OM1 and OM2 bypass grafts was applied with success. The patient has been aymptomatic for two years follow-up. Conclusion: Intervened LMCA patients should be closely followed up, and especially in the patients with implanted bare metal stents, great care should be taken. Keywords: acute myocardial infarction, cardiogenic shock, left main coronary artery pci, stent restenosis, coronary artery bypass surgery
- PP-184 [AJC » Coronary stents and advances in stent technology] Successful Stent Implantation of LAD Chronic Total Occlusion by Passing of Septal Branch Retrogradely. _ Nuri Köse1, Tamer Kırat1, Gökhan Ergün2, Ibrahim Altun2, Fatih Akın2. 1Department of Cardiology, Private Yücelen Hospital, Mugla, Turkey; 2Department of Cardiology, Mugla Sıtkı Koçman University, Mugla, Turkey. Introduction: Recanalization of coronary chronic total occlusions by retrograde way is a relatively new and exciting method of interventional cardiology. Case: Coronary angiography was performed in a case of 52 year-old man with a diagnosis of inferior myocardial infarction. LAD chronic total occlusion after septal branch and acute total occlusion of RCA were detected. RCA lesion was successfully stented primarily with 4,0* 26 mm bare metal stent with TIMI III flow. After 6 months, RCA stent was found to be open in control coronary angiography and intervention to the LAD chronic total occlusion was decided (Figure 1a). LMCA was intubated with 7 F Extra back-up catheter by the right femoral artery. Because of failure of the antegrade intervention to the LAD chronic total occlusion, retrograde intervention by septal branch was decided. Corsair catheter was positioned to the ostium of well-developed septal branch with a 0,014 floppy wire. SION, SION- BLUE and Fielder XT-R guidewires were used to pass the collateral branches of the septal artery, however, during the intervention, a branch of septal vessel was found to be perforated with minimal contrast extravasation (Figure 1b). Another branch of septal vessel was successfully passed with Fielder XT-R wire which reached to the body of LAD. After failure of Miracle 3 guidewire, Miracle 4,5 guidewire could penetrated the LAD chronic total occlusion retrogradely and reached LMCA. Another guiding catheter (JL4) by left femoral artery was used to intubate LMCA. By using pingpong technique retrograde Miracle 4,5 guidewire could be taken into that catheter. By inflating a 2.0*15 mm PTCA balloon in the guiding catheter to trap the guidewire, retrograde Corsair catheter could be taken into this guiding catheter. RG3 guidewire was used for externalization. 2,0*30 and 2,5 *30 balloons over the externalized guidewire were used to dilate the chronic total occlusion. 2,75 *35 mm ORSIRO (DES) was implanted which was postdilated with a 3.0*15 mm non-compliant balloon with a result of wide open artery and TIMI III flow (Figure 1c). After 6 months, control angiography revealed LAD stent with no stenosis and RCA % 40 instent stenosis (Figure 1d). The patient has been asymptomatic for two years follow-up now. Conclusion: Succesful percutenous recanalisation of coronary chronic total occlusions is correlated with improving LV functions, and increased survival in long term. However, to increase the success rate, this intervention should be applied by experienced operators. Keywords: chronic total occlusion, percutaneous coronary intervention, retrograde
The American Journal of Cardiologyâ MARCH 23e26, 2017 13th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Poster
e77
P O S T E R A B S T R A C T S
immune-inflammatory disorder involving vessels of all sizes and often complicated by thrombosis. Cardiac involvement and particularly left ventricular intracardiac thrombus are rarely diagnosed in the course of BD and are often associated with poor prognosis. We present a rare case of spontaneous coronary artery dissection and recurrent intraventricular thrombus with normal ejection fraction in a behçet disease patient. Case: A 43 year-old female patient admitted to our hospital with the complaints of chest pain and palpitation that had began in recent months. The pain was dull, radiating to the neck, not related with exercise. On physical examination, all findings were normal. Electrocardiography showed sinus rhythm with nonspecific ST segment and T wave abnormalities. He underwent coronary angiography and coronary angiography showed spontaneous right coronary artery dissection (Figure-1). Transthoracic echocardiogram (TTE) revealed normal ejection fraction and massive thrombus in left ventricle.(Figure-2). Discussion: Left ventricular (LV) thrombus is a life-threatening complication of severe left ventricular dysfunction. It is a rare complication of hematological diseases like behcet disease in normal ejection fraction patients. Spontaneous coronary artery dissection (SCAD) is a relatively rare and unexplored type of coronary disease. Although atherosclerosis, hormonal changes during pregnancy and connective tissue disorders might represent a sufficiently convincing explanation for some patients with SCAD. Our patient referred to surgery for big
P O S T E R A B S T R A C T S
Figure 1.
Left anterior descending cut-off at mid part with poor distal run-off and fistula of the left anterior descending to the left ventricle LAD, Left anterior descending.
- PP-182 [AJC » Cardiac imaging Echocardiography] Spontaneous RCA Dissection and Massive Intraventricular Thrombus With Normal Ejection Fraction in Behçet Disease. Fatih Mehmet Ucar, Mustafa Adem Yılmaztepe, Gökay Taylan. Trakya Üniversitesi Tıp Fakültesi, Edirne, Turkey. Introduction: Behçet disease (BD) is a systemic vasculitis with a broad range of organ involvement, characterized by a multisystemic,
Figure 2. th
e76 The American Journal of Cardiologyâ MARCH 23e26, 2017 13 INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Poster
MARCH 23e26, 2017 thrombus and dissection of coronary artery. After surgery anticoagulation therapy and systemic anti inflammatory therapy started for patient. Keywords: Spontaneous, Dissection, Intraventricular Thrombus, Behçet Disease
- PP-183 [AJC » Percutaneous coronary interventions in acute coronary syndromes] Succesful Treatment and Management of LMCA Acute Total Occlusion in a Patient with Acute Myocardial Infarction: The Priority is to Keep the Patient Alive!. _ Nuri Köse1, Tamer Kırat1, Gökhan Ergün2, Ibrahim Altun2, Fatih Akın2. 1Department of Cardiology, Private Yücelen Hospital, Mu gla, Turkey; 2Department of Cardiology, Mugla Sıtkı Koçman University, Mugla, Turkey. Case: A 46 year-old male patient applied to the emergency department with severe chest pain and sweating lasting for one hour. Blood pressure was 60/40 mm Hg with a pulse rate of 80/min. ECG revealed ST elevation in the anterior and inferior derivations. LV was diffuse hypo/ akinetic and LVEF was 20% in the echocardiography. 600 mg clopidogrel and 300 mg chewable ASA was given and 100 IU/ kg heparine was applied intravenously. After insertion of IABP, coronary angiography revealed RCA with some plaque and acute total occlusion of the LMCA bifurcation (Figure 1A). 7 Fr JL4 guiding catheter was inserted to the ostium of the LMCA. After insertion of two guidewires in LAD and Cx arteries, thrombectomy with thrombus aspiration catheter was performed that revealed some thrombus. Critical bifurcation stenosis was stented from the body of LMCA to proximal LAD with a 3.5*30 mm bare metal stent at 14 atm with Cx guidewire jailed. Because of the critical osteal stenosis of Cx, LAD guidewire was withdrawn and advanced to Cx through the distal struts of the stent. Ostium of the Cx was predilated with a 2.0*16 mm balloon and 3.0*15 mm bare metal stent was implanted in Cx with minimal protrusion to the LMCA (T and protrusion (TAP) technique). 4.0*21mm noncompliant balloon from LMCA to LAD and 3.0*15 mm noncompliant balloon from LMCA to Cx were used for kissing balloon dilatation with wide open arteries and TIMI III flows (Figure 1B and 1C). Because of the reimbursement conditions of the patient, bare metal stents were preferred in this patient. Tirofiban infusion was given to
Figure 1.
patient for 24 h with standart medical therapy. Predischarge echocardiography revealed no LV wall motion abnormalities with a LVEF of 60% in the fifth day. Although the patient was asymptomatic, diffuse instent 80% stenosis in the LMCA bifurcation was determined in control coronary angiography which was performed 3 months after (Figure 1D). CABG with LIMA-LAD and saphenous ven from aorta to first diagonal branche, OM1 and OM2 bypass grafts was applied with success. The patient has been aymptomatic for two years follow-up. Conclusion: Intervened LMCA patients should be closely followed up, and especially in the patients with implanted bare metal stents, great care should be taken. Keywords: acute myocardial infarction, cardiogenic shock, left main coronary artery pci, stent restenosis, coronary artery bypass surgery
- PP-184 [AJC » Coronary stents and advances in stent technology] Successful Stent Implantation of LAD Chronic Total Occlusion by Passing of Septal Branch Retrogradely. _ Nuri Köse1, Tamer Kırat1, Gökhan Ergün2, Ibrahim Altun2, Fatih Akın2. 1Department of Cardiology, Private Yücelen Hospital, Mugla, Turkey; 2Department of Cardiology, Mugla Sıtkı Koçman University, Mugla, Turkey. Introduction: Recanalization of coronary chronic total occlusions by retrograde way is a relatively new and exciting method of interventional cardiology. Case: Coronary angiography was performed in a case of 52 year-old man with a diagnosis of inferior myocardial infarction. LAD chronic total occlusion after septal branch and acute total occlusion of RCA were detected. RCA lesion was successfully stented primarily with 4,0* 26 mm bare metal stent with TIMI III flow. After 6 months, RCA stent was found to be open in control coronary angiography and intervention to the LAD chronic total occlusion was decided (Figure 1a). LMCA was intubated with 7 F Extra back-up catheter by the right femoral artery. Because of failure of the antegrade intervention to the LAD chronic total occlusion, retrograde intervention by septal branch was decided. Corsair catheter was positioned to the ostium of well-developed septal branch with a 0,014 floppy wire. SION, SION- BLUE and Fielder XT-R guidewires were used to pass the collateral branches of the septal artery, however, during the intervention, a branch of septal vessel was found to be perforated with minimal contrast extravasation (Figure 1b). Another branch of septal vessel was successfully passed with Fielder XT-R wire which reached to the body of LAD. After failure of Miracle 3 guidewire, Miracle 4,5 guidewire could penetrated the LAD chronic total occlusion retrogradely and reached LMCA. Another guiding catheter (JL4) by left femoral artery was used to intubate LMCA. By using pingpong technique retrograde Miracle 4,5 guidewire could be taken into that catheter. By inflating a 2.0*15 mm PTCA balloon in the guiding catheter to trap the guidewire, retrograde Corsair catheter could be taken into this guiding catheter. RG3 guidewire was used for externalization. 2,0*30 and 2,5 *30 balloons over the externalized guidewire were used to dilate the chronic total occlusion. 2,75 *35 mm ORSIRO (DES) was implanted which was postdilated with a 3.0*15 mm non-compliant balloon with a result of wide open artery and TIMI III flow (Figure 1c). After 6 months, control angiography revealed LAD stent with no stenosis and RCA % 40 instent stenosis (Figure 1d). The patient has been asymptomatic for two years follow-up now. Conclusion: Succesful percutenous recanalisation of coronary chronic total occlusions is correlated with improving LV functions, and increased survival in long term. However, to increase the success rate, this intervention should be applied by experienced operators. Keywords: chronic total occlusion, percutaneous coronary intervention, retrograde
The American Journal of Cardiologyâ MARCH 23e26, 2017 13th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Poster
e77
P O S T E R A B S T R A C T S