In-Stent Thrombosis or Acute Heart Failure ?

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

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

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

ECG at admission

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%

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

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

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

CAG(2) Small RCA

PCI-1 Wire and thrombus aspiration

PCI-2 After thrombus aspiration twice

PCI-3 Balloon dilatation

PCI-4 Stent deployment : 2.75*29mm 10atm

PCI-5 In-stent postdilatation with Durastar

PCI-6 Final Results

ECG After PCI

ECG of the next day after PCI

X-Ray ( ) : 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

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

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

( ): LDH: 1426U/L, CK: 2194U/L CK-MB: 131U/L, cTNI (+) ( ): 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

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

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

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

30 minutes later

Symptom worsening

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

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)

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%

ECG in CCU

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

X-Ray

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 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)

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

ECG of the next day

X-Ray ： inflammation aggravated

出入量 Date Fluid Infusion Drink Urine Balance

Laboratory Test of 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

X-Ray of the third day

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

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 ？

CAG ： on the third day of recurrence （ 1 ）

CAG ： on the third day of recurrence （ 2 ）

CAG ： on the third day of recurrence （ 3 ）

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 ？

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