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Prasad Gunaruwan Case Presentation: A case of multiple interventions.

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Presentation on theme: "Prasad Gunaruwan Case Presentation: A case of multiple interventions."— Presentation transcript:

1 Prasad Gunaruwan Case Presentation: A case of multiple interventions.

2 History: Mrs MB 66, housewife, smoker Lives with husband at Narrabri (2hrs to Tamworth, 6hrs to Newcastle) Recurrent UTI April 2011, US renal tract Kidneys, ureters, bladder normal but 4.3cm fusiform AAA Advice from Vascular Surgeon (Dubbo)

3 History Continued US followup Oct 2011: AAA now 5cm CT (pre AAA repair): Infra renal AAA with large amount of mural thrombus, max 4.8x5.7cm CXR: mild enlarged Cardio-thoracic ratio on a rotated film Bloods: EUC/LFT/FBC normal Spirometry: FEV1/FVC 1.1/1.9L

4 Intervention 1 & 2 Endo-luminal AAA stent 12 Dec 2011 Progress scan : Flow in right external iliac outside the stent, 14 Dec 2011 Repositioning stent in R iliac 15 Dec 2011 Discharged 17 Dec 2011: aspirin, atenolol, candesartan, atorvastatin, prn salbutamol

5 First Emergency Admission 6 weeks post discharge Presented to Narrabri with shortness of breath, over a few hours No chest pain, No fever In AF Hb 128, WBC 9.5 (N-8.2), EUC Normal



8 Troponin 0.55 What is the likely diagnosis? 1. Pneumonia 2. AF and left ventricular failure 3. Acute coronary syndrome 4. Exacerbation of CAL 5. Pulmonary embolus (pause)

9 Immediate management 1.Treat pneumonia 2.Rate control for AF 3.Diuretics for heart failure 4.Anti-coagulate for stroke prevention

10 Progress & Results feels better by day 3 Aortic incompetence murmur Echocardiogram (in the setting of AF) Mild global LV systolic impairment Moderate aortic regurgitation

11 What is the cause for the troponin leak? 1.AF with rapid ventricular rate 2.Acute coronary syndrome 3.Severity of pneumonia 4.RV strain

12 Causes of a troponin leak

13 TIMI Risk score for UA/NSTEMI JAMA. 284(7):835-842, August 16, 2000.

14 5

15 Radial vs femoral access for angiography About 70% of JHH caths radial route No mortality benefit, but less local complications, easier for the patient For consent quote: major complication including MI/stroke/death 1:1000, contrast allergy and nephropathy, bleeding and vascular complications In Mrs MB case this route avoids the AAA stent

16 Intervention 3: Coronary angiography at Tamworth

17 LV contraction

18 Moderate aortic regurgitation

19 What to do now? Discussed in angioplasty meeting For medical treatment Atorvastatin, digoxin, metoprolol, aspirin and warfarinised for AF Referral for cardiothoracic opinion re: aortic regurgitation

20 Second Emergency Admission Re-present to Narrabri, day 5 post discharge Severe central heavy chest pain 30 minutes since onset Diaphoretic, looking unwell

21 ECG

22 National Heart Foundation Algorithm Updated Sept 2011

23 Source: National Heart Foundation of Australia

24 Progress Not thrombolysed VT/VF arrest resuscitated and transferred to Tamworth Cooled, INR 8.5, vitamin K given Neurological recovery uncertain

25 Post STEMI day 4 Conscious, alert, oriented JVP still raised, controlled AF Echo confirms RV infarct, LV only mildly impaired What now? - Conservative? - Transfer to JHH for cath? - Cath at Tamworth? No radial access available

26 Intervention 4: Iliac vessels and stent

27 Coronary anatomy and aortic root 1

28 Coronary Anatomy and aortic root 2

29 Stent Displacement

30 What was displaced?

31 Post angiography.. VT, well tolerated Reverted to AF with RBBB Stable haemodynamics What now….?

32 Lesson for me… Never push if resistance… Extra care in such high risk situations Support of the boss…beyond measure Lesson for the boss??? Never let an AT cross an aortic stent????

33 Progress since Heart failure and AF, well controlled Admission with fever of unknown origin Right pleural effusion – ? Heart failure – ? Parapneumonic Protein 23g/L; LDH 150; Cholesterol 0.6 Clear fluid, culture negative

34 Indication for AAA repair Absolute diameter – > 5.5cm – Validated by 2 RCTs – UKSAT and ADAM trials that compared open surgical repair vs surveillance Rate of growth – > 5mm in 6 months OR >10mm in 1 year Complications such as trashing (embolization), fistula formation, etc

35 Possible complications Kinking and obstruction of limbs – in tortuous and calcified anatomy – stent reinforcement Endoleaks (continued flow/pressurisation of sac) Displacement or migration distally Miscellaneous – infection, GEE, GEF (fistula), component separation, fabric tears (leads to repressurisation of sac)

36 Take home… Troponin leak does not mean NSTEMI. In NSTEMI troponin leak is one of 7 risk factors. New STEMI/ACS guidelines with attention to symptom onset

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