high take off rca 이진희97 4.ppt [호환 모드] › pdf › pdf › 1888_high take off...
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High Take Off of Right Coronary ArteryHigh Take Off of Right Coronary ArteryHigh Take Off of Right Coronary Artery with Dynamic Compression by Large Artery
High Take Off of Right Coronary Artery with Dynamic Compression by Large Artery
Daegu Catholic University Medical CenterDaegu Catholic University Medical Center
Presenter : Jin Bae LeeOperator : Kee Sik Kim, Jin Bae Lee
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Patient profilePatient profile
Consult from pediatricianConsult from pediatricianConsult from pediatrician
• 18-year-old male
Consult from pediatrician
• 18-year-old male
• Recurrent syncope after chest pain(#5)
• PHx – Osteogenesis imperfecta type I
• Recurrent syncope after chest pain(#5)
• PHx – Osteogenesis imperfecta type IPHx Osteogenesis imperfecta type IPHx Osteogenesis imperfecta type I
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• Electrocardiography : Normal• cardiac markers• Electrocardiography : Normal• cardiac markers• cardiac markers – CK-MB : 2.1 ng/ml
T I 0 1 / l
• cardiac markers – CK-MB : 2.1 ng/ml
T I 0 1 / l– cTn-I : 0.1 ng/ml
• Echocardiography – cTn-I : 0.1 ng/ml
• Echocardiography – no regional wall motion abnormality – LVEF : 68%– no regional wall motion abnormality – LVEF : 68%
• Holter ECG: NSR• Holter ECG: NSR
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Neurologic examination: NormalNeurologic examination: Normal• Neurologic examination: Normal• Electroencephalography : Normal• Neurologic examination: Normal• Electroencephalography : Normal• Brain CT: Unremarkable• Brain MRI: Unremarkable• Brain CT: Unremarkable• Brain MRI: Unremarkable• Brain MRI: Unremarkable• Brain MRI: Unremarkable
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CT angiographyCT angiography
CT angiography showed high take off RCACT angiography showed high take off RCA
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CT angiographyCT angiography
PA
PAPAPAAo Ao Ao Ao
CT angiography showed high take off RCA which is compressed by pulmonary artery and aortaCT angiography showed high take off RCA which is compressed by pulmonary artery and aorta
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What is next stepWhat is next step
•Exercise stress test?•Exercise stress test?
-History of recurrent fracture
-Risk of syncope during exercise
-History of recurrent fracture
-Risk of syncope during exerciseRisk of syncope during exerciseRisk of syncope during exercise
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Left coronary angiographyLeft coronary angiography
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Right coronary angiographyRight coronary angiography
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Dobutamine stress FFRDobutamine stress FFR
20µg/kg/min chest pain tightness and palpitation, BP 175/10020µg/kg/min chest pain tightness and palpitation, BP 175/100
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Dobutamine stress FFRDobutamine stress FFR
40µg/kg/min Severe chest pain, Patient said can not tolerate, BP drop40µg/kg/min Severe chest pain, Patient said can not tolerate, BP drop
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Dobutamine stress FFRDobutamine stress FFR
Chest tightness, BP 175/100Chest tightness, BP 175/100 Severe chest pain, BP 98/49Severe chest pain, BP 98/49
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Dynamic Compression after Dobutamine Stress Dynamic Compression after Dobutamine Stress y py p
A B CA B C
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What is your treatment plan?What is your treatment plan?
1. Observation because FFR > 0.81. Observation because FFR > 0.82. CABG because dynamic FFR drop
and chest pain2. CABG because dynamic FFR drop
and chest painpp
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We decided to perform CABGWe decided to perform CABGWe decided to perform CABGfor prevent syncope, chest pain and We decided to perform CABGfor prevent syncope, chest pain and possible sudden death.possible sudden death.
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CABG procedureCABG procedure
RIMA to RCA anastomosisRIMA to RCA anastomosis
Ligation of proximal RCA Ligation of proximal RCA
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CT angiograpy after CABGCT angiograpy after CABG
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Patient is asymtoatic after CABGPatient is asymtoatic after CABGPatient is asymtoatic after CABGPatient is asymtoatic after CABG
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High take off of RCAHigh take off of RCA
•In the majority of patients, the RCA courses•In the majority of patients, the RCA courses
between the aortic root and the pulmonary arterybetween the aortic root and the pulmonary artery
•Ischemia : acute take-off from the aorta and compression between the aorta and the•Ischemia : acute take-off from the aorta and compression between the aorta and thecompression between the aorta and the pulmonary artery.compression between the aorta and the pulmonary artery.
•MI and sudden death : > 30%•MI and sudden death : > 30%
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Discussion pointDiscussion point• Can we apply FFR for evaluation of ischemia on dynamic compression like high• Can we apply FFR for evaluation of ischemia on dynamic compression like highischemia on dynamic compression like high take off RCA and myocardial bridge?ischemia on dynamic compression like high take off RCA and myocardial bridge?
• What is cut off value of FFR on dynamic • What is cut off value of FFR on dynamic compression?compression?
• Does FFR value above 0.8 or 0.75 mean l i i ifi t?
• Does FFR value above 0.8 or 0.75 mean l i i ifi t?always insignificant?always insignificant?
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Fixed stenosis vs Dynamic compressionFixed stenosis vs Dynamic compression
Fixed stenosis
Dynamic compression