1. In-Stent Thrombosis or Acute Heart Failure ?

2. History Male, 64yrs Persistent chest pain 22hrs,admitted on 1st Mar. 2011,the symptom did not relieve at admission Old myocardial infarction five years ago, underwent PCI at that time, has not taken any medicine since 3 years ago Hypertension for 10 years T 2 DM for 5 years gout for 3 years

3. Physical Examination T:35.8 ℃, P:74bpm, R:18bpm, Bp:133/77mmHg Slight cyanosis No distention of jugular vein, no rales, no murmur and no S 3 No edema

4. adjunctive Examination ECG (3.1) ： sinus rhythm with ST of II 、 III 、 aVF ， V7-V9 elevated for 0.1-0.2mV Cardiac marker ： CKMB mass >80ng/ml Myo >500ng/ml cTNI >30ng/ml BNP ： 414pg/ml

5. ECG at admission

6. Adjunctive test BUN: 6.93mmol/L, Cr: 70 umol/L LDH:1272U/L, CK: 3645U/L, CKMB: 349U/L, cTNI: (+) Na: 134.3mmol/L, K: 4.41 mmol/L WBC:17.62 *10 9 /L, N: 89.3%, Hb:157g/L,PLT :273*10 9 /L BGA: PH:7.49, PaO 2 :77mmHg, PaCO 2 :33mmHg, SaO 2 :96%

7. diagnosis CAHD acute myocardial infarction (inferior wall) old myocardial infardtion (anterior wall) Killip I Hypertension T2DM gout

8. Therapy ASA + Clopidogrel+Tirofiban to enhence anti- platelet and anti-coagulation Statins to stabilize the plaque ACEI to prevent ventricular remodeling Primary CAG+PCI

9. CAG(1) LM d :50%, LAD o :70% in-stent re-stenosis, LAD m :70%, D 1 :70%; LCX:100%

10. CAG(2) Small RCA

11. PCI-1 Wire and thrombus aspiration

12. PCI-2 After thrombus aspiration twice

13. PCI-3 Balloon dilatation 2.0*15mm@8-10atm

14. PCI-4 Stent deployment : 2.75*29mm Partener @ 10atm

15. PCI-5 In-stent postdilatation with Durastar 3.0*10mm@10-20atm

16. PCI-6 Final Results

17. ECG After PCI

18. ECG of the next day after PCI

19. X-Ray ( 2011.3.1) : increase of lungmarkings enlargement of heart shadow UCG ： enlargment of left atrial segmental ventricle hepo-kinetics (AMI of Inferior wall ) LVEF:43% Mean Pulmonary Artery pressure:47mmHg X-Ray and UCG

20. UCG at admission Acute myocardial infarctin （ inferior wall ） Segmental hypo-kinetics Left artial enlargement Systolic dysfunction of LV LVEF ： 43%

21. Holter Sinus Rhythm Acute myocardial infarction of inferior wall HRV:76ms

22. (2011.3.2): LDH: 1426U/L, CK: 2194U/L CK-MB: 131U/L, cTNI (+) (2011.3.3): LDH: 1194U/L, CK:695U/L CK-MB:40U/L BUN:7.44mmol/L, Cr:86umol/L WBC: 8.84*10 9 /L, N:78.6%, Hb:131g/L Laboratory Test

23. Continue with anti-platelet 、 anti- coagulation 、 lipid-lowering 、 inhibit ventricular remodeling and anti-inflammation therapy No chest pain and no dyspnea Sequential Therapy

24. But 5 days later…… Breast distress and sweating accompanied with dyspnea ECG:ST II 、 III 、 avF ， V7-V9 elevated for 0.2mV HR ： 102bpm ， Bp ： 88/59mmHg ， SpO 2 :90% ， No moist rales Treatment ： NTG ： 0.5mg sublingually, NTG 5ug/min iv Torasemide ： 20mg iv Cedelaind ： 0.4mg iv Clopidogrel ： 300mg Po st Tirofiban ： 17ml iv ， 15ml/h

25. ECG of recurrent dyspnea cyanosis, sweating, passive sitting position.HR:101bpm,Bp:95/57mmHg

26. 30 minutes later

27. Symptom worsening

28. Transfer to CCU 1hr later  Symptom did not relieve after medical treatment  HR:121bpm,Bp:90/45mmHg ， SpO 2 :87-90% ， sitting position ， moist rales and S 3 can be heard, no edema  Non-invasive mechanical ventilation  IABP  Morphine,diuretics, dopamine, dobutamine nitrates

29. Cardiac marker(6 hrs after recurrent symptom)  CKMB mass 5.0ng/ml  Myo 302 ng/ml  cTNI 9.59 ng/ml  BNP 1150 pg/ml Cardiac marker(18 hrs after recurrent symptom)  LDH 708 U/L  CK 114 U/L  CK-MB 21U/L Laboratory test(1)

30. Laboratory test(2) BUN 7.3 mmol/L, Cr 96umol/L WBC 9.25×10 9 /L, N 85.6%, PLT 354×10 9 /L, Hb 157g/L BGA: PH 7.44, PaO 2 62mmHg, PaCO 2 29mmHg, SaO 2 90%

31. ECG in CCU

32. UCG in CCU UCG  Acute myocardial infarction (inferior wall)  Segmental ventricular hypo-kinetics  LVEF :42%  Systolic dysfunction

33. X-Ray

34. WBC 15.51×10 9 /L, N 94.3%, PLT 336×10 9 /L, Hb 145g/L LDH 586U/L, CK 123U/L, CK-MB 17U/L Na 134.2 mmol/L ， K 4.54 mmol/L BUN 13.9 mmol/L, Cr 124umol/L BGA: PH 7.40, PaO 2 ： 57mmHg, PaCO 2 ： 33mmHg, SaO 2 ： 87% PCT ： 0.5ng/ml Laboratory test (1 day after recurrent symptom)

35. Clinical outcome The patient’s condition got aggrevated even with anti-imflamation, diuretics, inotropic agents 、 vaso-active agents The symptom exacerbating ， SpO2 decreasing to about 80% Invasive mechanical Ventilation 1 day later

36. ECG of the next day

37. X-Ray ： inflammation aggravated

38. 出入量 Date 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 Fluid Infusion 1765 915 765 665 660 355 3374 2342 Drink 1260 1200 2090 2100 1900 1650 200 50 Urine 1400 1850 2450 2375 1825 2825 911 1417 Balance +1625 +265 +405 +390 +735 -820 +2663 +975

39. Laboratory Test of 2011.03.09 WBC ： 19×10 9 /L, N ： 94% TNI ： 1.97ng/ml CK-MB ： 18U/L BUN ： 21 mmol/L, Cr ： 143umol/L BGA: PH ： 7.39, PaO 2 ： 58.8mmHg PaCO 2 ： 32mmHg, BE ： -4.9 mmol/L,Lac ： 2.5mmol/L BNP ： 1080pg/ml

40. X-Ray of the third day

41. Discussion （ 1 ） --- What do you think about this patient ？ Recurrent myocardial infarction caused by subacute in-stent thrombus formation ？ Acute heart failure Both

42. Discussion （ 2 ） --- What should we do ？ Medical therapy? heart failure 、 anti-inflammation 、 anti-ischemia …… CAG again ？ If CAG, the incidence of CIN is very high, and the toxicity of contrast must be taken into consideration Revascularization ？ If revascularization ， IRA only or complete revascularization ？

43. CAG ： on the third day of recurrence （ 1 ）

44. CAG ： on the third day of recurrence （ 2 ）

45. CAG ： on the third day of recurrence （ 3 ）

46. Discussion （ 3 ） The cause of acute heart failure ？  No new-onset occlusion of coronary artery  No infectious disease before  The balance of liquid is almost equal ECG showed ST elevated ， but no elevated cardiac marker ， is CAG most needed ？ How to evaluate ？ Is completed revascularization of helpful ？

47. Outcome The patient’s relatives asked to quit all treatment because of financial causes Died of heart failure