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Case Presentation: A case of multiple interventions.

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

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Case Presentation: A case of multiple interventions.

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

  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

  6. 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)

  7. Immediate management • Treat pneumonia • Rate control for AF • Diuretics for heart failure • Anti-coagulate for stroke prevention

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

  9. What is the cause for the troponin leak? • AF with rapid ventricular rate • Acute coronary syndrome • Severity of pneumonia • RV strain

  10. Causes of a troponin leak

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

  12. 5

  13. 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

  14. Intervention 3: Coronary angiography at Tamworth

  15. LV contraction

  16. Moderate aortic regurgitation

  17. 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

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

  19. ECG

  20. National Heart Foundation Algorithm Updated Sept 2011

  21. Source: National Heart Foundation of Australia

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

  23. 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

  24. Intervention 4: Iliac vessels and stent

  25. Coronary anatomy and aortic root 1

  26. Coronary Anatomy and aortic root 2

  27. Stent Displacement

  28. What was displaced?

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

  30. 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????

  31. 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

  32. 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

  33. 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)

  34. 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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