My unforgettable emergency case

---The emergency PCI strategy in the all

three vascular obstruction case

宣武医院心脏科许骥 郝恒剑

Sometimes we are forced to face

very troublesome high risk cases. At

this time, the quickly and correct

choice is very important……

Pathogenetic condition

Male, 69y, chest pain for 23 years and persistence for 4

hours.

HT for 40 years; no DM

Condition on admission: severe chest pain;

BP:110/70mmHg ， HR57/min （ sinus

bradycardia ）， normal cardiac sound, a little moist rales

in the both base of lung.

Diagnosis: AMI ( generally anterior wall) ; Hypertension

The patient was sent to catheter room immediately after admission……

After reaching catheter room: HR ascending to 130/min （ sinus tachycardia ） , BP60/40mmHg, severe chest pain, a little dizzy.

Choice 1:1. Stop interventional check and therapy?2. IABP immediately ？3. CAG immediately ？

Dopamine 2mg iv and ivgtt; BP ascending to 65/50mmHg

Emergency CAG immediately……

3 vessels obstructed!

Choice 2

1. Stop operation, notify the family member of the patient.－“ Never died in catheter room”！

2. Emergency CABG

3. Emergency IABP

4. Emergency PCI immediately, recover the blood flow as quickly as we can!

Choice 3

1. Which kind of guiding catheter should be chosed ？

2. Which vessel is the criminal?-LAD

3. If LCX protection is necessary ？

If the flow can not be recovered, other therapy is useless.

－ Open the obstructed vessel immediately！

Decide to open LAD with single wire as quickly as we can:-blood flow recovered 2min later, BP ascended; HR descended……

Guiding ： JL6F-4 wire ： supersoft balloon ： 2.5×20mm Choice 4The wire could not arrived the distal end of LAD----What can we do?The balloon could not arrived the distal end of LAD---What can we do?

Another choice we must face……－ Choice 5

1. Stop operation, CABG in another day?

2. Stenting in LAD?

Choice 6

Stent ： Excel 3.5×18mm （ could not reach point “B” ）1. Balloon dilation once more? （ But the balloon could not reach “B”

too）2. 2 or 3 wires to increase support?3. The distal side of stent be put to point “A”?

stenting

Excel 3.5×18mm 12atm

Time right after stenting

BP ascending to 120/70mmHg ， HR descending to 95/min ， chest pain relieved.To be absolutely secure, IABP implanted.

IABP

Another choice……

Thrombus appearance in the stent after IABP！－ Choice 7 1. Balloon dilation once more? 2. Thrombolysis? 3. Tirofiban?

Final result

After tirofiban injection, thrombosis decreased, end operation and tirofiban ivgtt for 48 hours.

Another episode……

Just when we want to celebrate, cardiac arrest take place just outside the catheter room!

Electrocardio-monitor ： Ventricular fibrillation After 360J defibrillation the patient recovered So, electrocardio-monitor is very important

during transport in emergency PCI.

After operation, tirofiban 12ml/h, heparin 500u/h. 3 hours later, vomit something with blown colour.

------maybe stress ulcer? APTT is 130 s

Choice 8 --------STOP tirofiban ivgtt.?(1) Tirofiban to 6ml/h, heparin to 250u/h

(2) Gastric mucosa protectant

(3) chafing dish before onste Tirofiban to 12ml/h, and no other vomiting.

Final turnover……

Go out of CCU after 1 week

Received CABG after 3 week

Leave hospital after 6 week……

Discuss

1. The doctors assume tremendous risk when facing high risk emergency patient. At this time, the doctors must make a decision quickly: Operation or not? If decide to operation , just do it quickly!

2. Opening the vessel is the most important forever, and “the quicker the better”!

3. We must tolerate the defects during emergency treatment, and we must know what is the end-all.

4. The emergency operation is important, but the monitor after operation is more important.

Thank YouThank You