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LADY LUCK
1187 JACC April 5, 2016 Volume 67, Issue 13
FIT Clinical Decision Making LADY LUCK Poster Contributions Poster Area, South Hall A1 Sunday, April 03, 2016, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision Making: Non-Invasive Imaging and Valvular Heart Disease Abstract Category: Acute Coronary Syndromes Presentation Number: 1232-283 Authors: Yining Xu, Natalie Bottega, Jewish General Hospital, Montreal, Canada, McGill University Health Centre, Montreal, Canada
Background: Acute hypotension in acute coronary syndrome (ACS) includes a broad differential of potentially fatal mechanical and periprocedural complications. The importance of a systematic diagnostic approach is described.
Case: A 56 y.o. woman presented to emergency with retrosternal chest pain and dyspnea for one week. On arrival her BP=114/62 mmHg, HR= 96 bpm, O2 sat= 94% on 2L O2 and RR = 30/minute. Cardiac exam revealed an elevated JVP and a 2/6 pansystolic murmur at the apex suggestive of MR. Anterior ST depressions were seen on EKG. Troponin was 1180 (normal 0-15), CXR showed cardiomegaly and pulmonary edema and TTE revealed a LVEF = 40%, inferior and inferolateral wall akinesis and posteriorly-directed moderate MR. The patient was admitted with a late presentation Killip 2 NSTEMI with ischemic MR. Dual anti-platelet therapy, heparin IV and diuretics were initiated and an angiogram was planned for the next morning. Suddenly, her systolic BP dropped to 75 mmHg and desaturated to 75% R/A.
Decision Making: Diagnoses considered were infarct extension, papillary muscle rupture and cardiac tamponade. An EKG showed ST depression in V1 to V2 consistent with a posterior STEMI. Angiogram revealed an occluded CX with a severe mid-RCA lesion. The CX was dilated and hemodynamics improved. A TEE was done during the angiogram revealing severe ischemic MR but no papillary muscle rupture was seen. Urgent CABG was requested . While closing femoral access, a large pericardial effusion was accumulating quickly on TEE. Suddenly, her systolic BP dropped to 75 mmHg again and clinical tamponade was diagnosed. Causes considered for tamponade were free wall rupture, iatrogenic coronary artery perforation or aortic dissection. Neither aortic dissection on TEE nor coronary perforation on repeat angiogram were seen. Therefore, free wall rupture was suspected and confirmed intraoperatively where the patient underwent a repair of a lateral LV wall-perforation, three-vessel CABG and a mechanical MVR. She made a full recovery.
Conclusions: There are many causes of acute hypotension due to an ACS such as cardiac tamponade from free wall rupture. A systematic approach is required to diagnose such complications which can be rapidly fatal.
FIT Clinical Decision Making LADY LUCK Poster Contributions Poster Area, South Hall A1 Sunday, April 03, 2016, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision Making: Non-Invasive Imaging and Valvular Heart Disease Abstract Category: Acute Coronary Syndromes Presentation Number: 1232-283 Authors: Yining Xu, Natalie Bottega, Jewish General Hospital, Montreal, Canada, McGill University Health Centre, Montreal, Canada
Background: Acute hypotension in acute coronary syndrome (ACS) includes a broad differential of potentially fatal mechanical and periprocedural complications. The importance of a systematic diagnostic approach is described.
Case: A 56 y.o. woman presented to emergency with retrosternal chest pain and dyspnea for one week. On arrival her BP=114/62 mmHg, HR= 96 bpm, O2 sat= 94% on 2L O2 and RR = 30/minute. Cardiac exam revealed an elevated JVP and a 2/6 pansystolic murmur at the apex suggestive of MR. Anterior ST depressions were seen on EKG. Troponin was 1180 (normal 0-15), CXR showed cardiomegaly and pulmonary edema and TTE revealed a LVEF = 40%, inferior and inferolateral wall akinesis and posteriorly-directed moderate MR. The patient was admitted with a late presentation Killip 2 NSTEMI with ischemic MR. Dual anti-platelet therapy, heparin IV and diuretics were initiated and an angiogram was planned for the next morning. Suddenly, her systolic BP dropped to 75 mmHg and desaturated to 75% R/A.
Decision Making: Diagnoses considered were infarct extension, papillary muscle rupture and cardiac tamponade. An EKG showed ST depression in V1 to V2 consistent with a posterior STEMI. Angiogram revealed an occluded CX with a severe mid-RCA lesion. The CX was dilated and hemodynamics improved. A TEE was done during the angiogram revealing severe ischemic MR but no papillary muscle rupture was seen. Urgent CABG was requested . While closing femoral access, a large pericardial effusion was accumulating quickly on TEE. Suddenly, her systolic BP dropped to 75 mmHg again and clinical tamponade was diagnosed. Causes considered for tamponade were free wall rupture, iatrogenic coronary artery perforation or aortic dissection. Neither aortic dissection on TEE nor coronary perforation on repeat angiogram were seen. Therefore, free wall rupture was suspected and confirmed intraoperatively where the patient underwent a repair of a lateral LV wall-perforation, three-vessel CABG and a mechanical MVR. She made a full recovery.
Conclusions: There are many causes of acute hypotension due to an ACS such as cardiac tamponade from free wall rupture. A systematic approach is required to diagnose such complications which can be rapidly fatal.