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TCTAP C-228 Intraluminal Narrowing in Acute Coronary Syndrome - The Value of Intracoronary Imaging to Aid Diagnosis
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
Case Summary. Using OCT enabled visualisation of the stented vessel in detail. The distal stent edge dissection was left alone as the flow was good, dissection 6mm. Mild part of stent had thrombus and calcium and was post dilated. The proximal underexpended stent was also post dilated. We did not perform a repeat OCT after the post dilatation as patient had hypotension and was on inotrope. Could not repeat FFR as wire was spoit. Patient recovered well and was discharged well the next day. He remains pain free. TCTAP C-228 Intraluminal Narrowing in Acute Coronary Syndrome - The Value of Intracoronary Imaging to Aid Diagnosis Sohail Q. Khan1 1 University Hospitals Birmingham, United Kingdom [CLINICAL INFORMATION] Patient initials or identifier number. TR Relevant clinical history and physical exam. A female in her 40s presented as an emergency with a history of central retrosternal discomfort with associated shortness of breath. She gave a history of a left sided dull ache 2 days previously. She had ongoing chest pain despite use of analgesics. The only risk factor was current smoking and there was no other relevant past medical history. Examination findings: normal blood pressure and a resting heart rate of 64 bpm, she had a good palpable radial pulse with normal heart sounds. Relevant test results prior to catheterization. The 12 lead ECG showed preserved R waves throughout with T wave inversion in the lateral leads I and aVL. High sensitive troponin T was significantly elevated at 305ng/L. Echocardiogram showed apical hypokinesia with preserved function at the basal segment. There were no valvular abnormalities noted. Relevant catheterization findings. Given her history and unstable symptoms she was listed directly for coronary angiography. The procedure was performed from the radial approach and showed a smooth unobstructed LAD, there was TIMI 1 flow in a large diagonal branch with evidence of disruption in the proximal vessel. The circumflex was non-dominant vessel and free of disease, the right coronary artery was dominant with no atheroma. Left ventricular angiography showed impaired LV function with apical ballooning.
S379
[INTERVENTIONAL MANAGEMENT] Procedural step. The patient had on-going chest pain and a decision was made to proceed to PCI via the radial artery. A 6F Voda 3.5 guide catheter was used and a runthrough wire was passed to the diagonal. The vessel was prepared with a 2.0 x 15mm balloon which improved flow to TIMI 2. The LAD was protected with a BMW elite wire and the diagonal was stented with a 2.25 x12Promus drug-eluting stent sparing the ostium. TIMI 3 flow was achieved in the diagonal and the chest pain improved. However at this point compromise of the LAD lumen was noted at the level of the diagonal branch. The appearances did not change despite use of nitrates. As the patient was stable OFDI was performed and showed the presence of an intramural haematoma (IMH) with vasa vasorum but no evidence of a proximal dissection flap. No coronary atheroma or fibrous thickening was noted on the OFDI. The minimal luminal area in the LAD distal to the diagonal was 6.1mm2, at the level of restriction it was 3.3mm2. The proximal LAD was large with an area of 12.1 mm2. As the chest pain had settled I elected not to proceed to LAD PCI at this stage. The patient remained stable and was successfully discharged on day 4. She was re-admitted electively at 6 months for further OFDI of the LAD and diagonal. This showed resolution of the IMH and good healing and strut coverage in the diagonal stent which was well apposed with a minimal stent area of 2.43mm2.She was advised to continue on medical therapy.
S380
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
TCTAP C-229 Acute Coronary Syndrome Due to LAD Myocardial Bridging Treated with Self-expandable Balloon Releasable DES (Stentys X-position): Coronary Computed Tomography Angiography, FFR and IVUS Guided Procedure Farhat Fouladvand1 Holy Family Hospital (Ospedale Sacra Famiglia), Italy
1
[CLINICAL INFORMATION] Patient initials or identifier number. RR 15-295/15-433 Relevant clinical history and physical exam. We present a case of fisically active young gentlemen (BD 4.6.61) without any risk factors and not known heart or other disease, which was admitted with typical chest pain and ECG signs of ischemia in anterior leads, but without alteration of the LV segmenta kinesis (Fig.1).
Relevant test results prior to catheterization. Next day CT scan demonstrates 30 mm intramuscular mid LAD segment with thickness of the muscular bridge about 2 mm with some reduction in the mid LAD diameter (Fig.2.). At this point the patient was scheduled for coronary angiography through right radial artery to complete the diagnostic work-up.
Case Summary. Spontaneous IMH is a rare cause of myocardial infarction causing medial disruption and luminal compromise. OFDI has superior spatial resolution to IVUS and allows for better tissue characterisation. IMH are associated with connective tissue abnormalities, pregnancy and fibromuscular dysplasia. In the presence of chest pain and ECG abnormalities it is not unreasonable to intervene on the vessel however as we have shown a conservative strategy for the LAD resulted in reabsorption of the haematoma at around 6 months. Intravascular imaging was useful in confirming the diagnosis and also subsequently showing healing of the vessel. The patient remains well on follow-up.
Case Summary. Using OCT enabled visualisation of the stented vessel in detail. The distal stent edge dissection was left alone as the flow was good, dissection 6mm. Mild part of stent had thrombus and calcium and was post dilated. The proximal underexpended stent was also post dilated. We did not perform a repeat OCT after the post dilatation as patient had hypotension and was on inotrope. Could not repeat FFR as wire was spoit. Patient recovered well and was discharged well the next day. He remains pain free. TCTAP C-228 Intraluminal Narrowing in Acute Coronary Syndrome - The Value of Intracoronary Imaging to Aid Diagnosis Sohail Q. Khan1 1 University Hospitals Birmingham, United Kingdom [CLINICAL INFORMATION] Patient initials or identifier number. TR Relevant clinical history and physical exam. A female in her 40s presented as an emergency with a history of central retrosternal discomfort with associated shortness of breath. She gave a history of a left sided dull ache 2 days previously. She had ongoing chest pain despite use of analgesics. The only risk factor was current smoking and there was no other relevant past medical history. Examination findings: normal blood pressure and a resting heart rate of 64 bpm, she had a good palpable radial pulse with normal heart sounds. Relevant test results prior to catheterization. The 12 lead ECG showed preserved R waves throughout with T wave inversion in the lateral leads I and aVL. High sensitive troponin T was significantly elevated at 305ng/L. Echocardiogram showed apical hypokinesia with preserved function at the basal segment. There were no valvular abnormalities noted. Relevant catheterization findings. Given her history and unstable symptoms she was listed directly for coronary angiography. The procedure was performed from the radial approach and showed a smooth unobstructed LAD, there was TIMI 1 flow in a large diagonal branch with evidence of disruption in the proximal vessel. The circumflex was non-dominant vessel and free of disease, the right coronary artery was dominant with no atheroma. Left ventricular angiography showed impaired LV function with apical ballooning.
S379
[INTERVENTIONAL MANAGEMENT] Procedural step. The patient had on-going chest pain and a decision was made to proceed to PCI via the radial artery. A 6F Voda 3.5 guide catheter was used and a runthrough wire was passed to the diagonal. The vessel was prepared with a 2.0 x 15mm balloon which improved flow to TIMI 2. The LAD was protected with a BMW elite wire and the diagonal was stented with a 2.25 x12Promus drug-eluting stent sparing the ostium. TIMI 3 flow was achieved in the diagonal and the chest pain improved. However at this point compromise of the LAD lumen was noted at the level of the diagonal branch. The appearances did not change despite use of nitrates. As the patient was stable OFDI was performed and showed the presence of an intramural haematoma (IMH) with vasa vasorum but no evidence of a proximal dissection flap. No coronary atheroma or fibrous thickening was noted on the OFDI. The minimal luminal area in the LAD distal to the diagonal was 6.1mm2, at the level of restriction it was 3.3mm2. The proximal LAD was large with an area of 12.1 mm2. As the chest pain had settled I elected not to proceed to LAD PCI at this stage. The patient remained stable and was successfully discharged on day 4. She was re-admitted electively at 6 months for further OFDI of the LAD and diagonal. This showed resolution of the IMH and good healing and strut coverage in the diagonal stent which was well apposed with a minimal stent area of 2.43mm2.She was advised to continue on medical therapy.
S380
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
TCTAP C-229 Acute Coronary Syndrome Due to LAD Myocardial Bridging Treated with Self-expandable Balloon Releasable DES (Stentys X-position): Coronary Computed Tomography Angiography, FFR and IVUS Guided Procedure Farhat Fouladvand1 Holy Family Hospital (Ospedale Sacra Famiglia), Italy
1
[CLINICAL INFORMATION] Patient initials or identifier number. RR 15-295/15-433 Relevant clinical history and physical exam. We present a case of fisically active young gentlemen (BD 4.6.61) without any risk factors and not known heart or other disease, which was admitted with typical chest pain and ECG signs of ischemia in anterior leads, but without alteration of the LV segmenta kinesis (Fig.1).
Relevant test results prior to catheterization. Next day CT scan demonstrates 30 mm intramuscular mid LAD segment with thickness of the muscular bridge about 2 mm with some reduction in the mid LAD diameter (Fig.2.). At this point the patient was scheduled for coronary angiography through right radial artery to complete the diagnostic work-up.
Case Summary. Spontaneous IMH is a rare cause of myocardial infarction causing medial disruption and luminal compromise. OFDI has superior spatial resolution to IVUS and allows for better tissue characterisation. IMH are associated with connective tissue abnormalities, pregnancy and fibromuscular dysplasia. In the presence of chest pain and ECG abnormalities it is not unreasonable to intervene on the vessel however as we have shown a conservative strategy for the LAD resulted in reabsorption of the haematoma at around 6 months. Intravascular imaging was useful in confirming the diagnosis and also subsequently showing healing of the vessel. The patient remains well on follow-up.