lmca dissection
TRANSCRIPT
![Page 1: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/1.jpg)
Catheter InducedLeftmain Dissection
Dr. Dinh Huynh LinhNNational Heart Centre Singapore
Vietnam National Heart Institute
Dr. Jack Tan Wei ChiehNational Heart Centre SingaporeNational Heart Centre Singapore
![Page 2: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/2.jpg)
• 59 year old gentleman
• Persistent AF, with history of lower limb artery thrombus. On warfarin
• Thorax CT: bronchus stricture + mediastinal lymphadenophathy. Will need lung biopsy
• NSTEMI in November 2012
• MPI: inferior-lateral ischaemia.
• Angiogram: DVD (RCA + LCx)
• PCI in RCA CTO. EF improved, from 24 to 39%
• Elective admission for staged PCI in the LCx
Case presentation
![Page 3: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/3.jpg)
RCA CTO intervention on Nov 2, 2012Genous 3.5 x 33 + MultiLink 3.0 x 38
Post-procedure
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Pre-procedure
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 4: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/4.jpg)
Supposed to be a straightforward 15-minute PCI case
•Type B1 lesion
•Radial approach
•6 French sheath
•EBU 3.75 6F guide
Scheduled PCI to mid-LCx
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 5: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/5.jpg)
Avanta Fluid Injection System
•Volume: 6 mL
•Rate: 5 mL/s
•1000 PSI
![Page 6: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/6.jpg)
First injection
QuickTime™ and aH.264 decompressor
are needed to see this picture. Suspected acute LMCA spiral dissection, extending into LAD and LCx
• Dissection?
• Air embolism?
![Page 7: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/7.jpg)
Catheter induced spiral dissection of LMCA
![Page 8: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/8.jpg)
Clinical course
QuickTime™ and aH.264 decompressor
are needed to see this picture.
• Acute LMCA dissection. TIMI 1 flow in both LAD and LCx
• Retrograde dissection to the coronary sinus
• Pt had chest pain, hypotension, VT, then VF. Multiple defibrillation performed
• Heparin had already been given (5500 IU) after catheter engagement
![Page 9: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/9.jpg)
1. CABG
2. PCI
3. Medical therapy
Q1: What to do next?
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 10: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/10.jpg)
1.No mechanical circulatory support
2.Mechanical circulatory support: IABP
3.Mechanical circulatory support : ECMO
4.Other opinion
Q2: What to do next?
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 11: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/11.jpg)
1.To stent backward or forward?
2.6F or 7F guiding catheter?
PCI: open question?
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 12: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/12.jpg)
1.Hydrophillic guidewire
2.Hydrophobic guidewire
Q4: PCI: which guidewire?
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 13: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/13.jpg)
• The surgical team and ECMO team were activated
• Senior consultant was called for help
• Strategy: Stent the LMCA, LAD, LCx
• RFA puncture
• JL 3.5 6F guide
• Fielder 0.014” to distal LAD
Management
![Page 14: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/14.jpg)
The LMCA’s ostium was covered
QuickTime™ and aH.264 decompressor
are needed to see this picture.
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Genous 3.5 x 33 stent in LMCA
![Page 15: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/15.jpg)
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Restoration of LAD and LCx flow after LMCA stenting and post-dilatation
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 16: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/16.jpg)
QuickTime™ and aH.264 decompressor
are needed to see this picture.
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Stents implantation in LAD and LCx
Proximal LAD stent implantation (Coroflex Blue 3.5 x 19 mm)Coroflex Blue 3.0 x 16 mm in mid LCx
Coroflex Blue 3.0 x 28 mm in ostial LCx (TAP technique)
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 17: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/17.jpg)
Final kissing balloon inflation
QuickTime™ and aH.264 decompressor
are needed to see this picture.
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 18: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/18.jpg)
QuickTime™ and aH.264 decompressor
are needed to see this picture.
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Final results
![Page 19: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/19.jpg)
• Dissection into the left coronary cusp. The right cusp was not involved
• BP 151/64/86, HR 55 bpm, SpO2 97%
• Protamin given to neutralize heparin
• IABP was not inserted due to aortic dissection and stable condition
QuickTime™ and aH.264 decompressor
are needed to see this picture.
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 20: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/20.jpg)
Proximal ascending aorta intramural hematoma, from the LMCA, extending till the sinotubular junction
Thorax CT Angiography
LMCA
![Page 21: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/21.jpg)
• Patient was clinically stable. No chest pain
• ECHO: no pericardial effusion, no LV thrombus
• No EKG changes
• No postprocedural cardiac enzyme elevation
• Patient was discharged well 4 days later, on aspirin 100 mg and clopidogrel 75 mg
Post-procedural course
![Page 22: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/22.jpg)
12.2012 1.2013
CTA 1 month laterComplete healing of the ascending aorta
![Page 23: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/23.jpg)
• Follow-up CT: The intramural hematoma in the posterior wall of the proximal ascending aorta shows complete resolution
• Lung cancer was excluded
• Restart warfarin
• Life long aspirin. 2 months of clopidogrel
• Pt recovered uneventfully. No recurrence of angina
Clinical follow-up
![Page 24: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/24.jpg)
• Catheter induced LMCA dissection:
• 0.008 to 0.02% of diagnostic catheterizations
• 0.06 to 0.07% of PCI
• Ostial LMCA dissection is rarer than RCA dissection
• Risk factors: LMCA disease, Amplatz usage, acute MI, catheter manipulation, hard contrast injection
• Urgent revascularization is mandated
• Retrograde dissection involving the coronary cusp or extending up the aortic wall < 40 mm: conservative treatment
Literature review
Boyle AJ et al. Catheter-induced coronary artery dissection: risk factors, prevention and management. J Invasive Cardiol. 2006 Oct;18(10):500-3
![Page 25: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/25.jpg)
• Guiding catheter can be dangerous, especially if not co-axially engaged
• Vigorous contrast injection can be dangerous
• PCI is a life-saving approach for acute LMCA dissection
• Complete seal-off of the entry site, as well as the LMCA’s origin, is important to prevent the further extension of the dissection
• Limited dissection to the aorta can be treated conservatively, without any surgical intervention
• Always call for help
What I have learnt
![Page 26: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/26.jpg)
Thank you!
![Page 27: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/27.jpg)
Catheter InducedLeftmain Dissection
Dr. Dinh Huynh LinhNNational Heart Centre Singapore
Vietnam National Heart Institute
Dr. Jack Tan Wei ChiehDr. Jack Tan Wei ChiehNational Heart Centre SingaporeNational Heart Centre Singapore
![Page 28: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/28.jpg)
• 59 year old male
• Persistent AF, on warfarin. History of lower limb artery thrombus, treated with thrombolysis
• Mediastinal and hilar lymphadenophathy
• NSTEMI in November 2012
• MPI: inferior-lateral ischaemia. EF=24%.
• Angiogram: double vessel disease
• PCI in RCA CTO
• Elective admission for checking prior stents in RCA and PCI in the LCx
Case presentation
![Page 29: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/29.jpg)
The LMCA was stented (Genous 3.5 x 33 mm at 16 atm)Post-dilate the LMCA with Hiryu 3.5 x 15 mm NC balloon
QuickTime™ and aH.264 decompressor
are needed to see this picture.
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 30: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/30.jpg)
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Proximal LAD stent implantation (Coroflex Blue 3.5 x 19 mm)
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 31: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/31.jpg)
RCA CTO intervention on Nov 2, 2012Genous 3.5 x 33 + MultiLink 3.0 x 38
Post-procedure
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Pre-procedure
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 32: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/32.jpg)
Angiogram on Dec 11, 2012
December 11November 2
QuickTime™ and aH.264 decompressor
are needed to see this picture.
![Page 33: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/33.jpg)
• 59 year old gentleman.
• Persistent AF, on warfarin
• Thorax CT: suspected lung maglinancy. Will need lung biopsy
• NSTEMI in November 2012 with inferior-lateral ischemia on MPI
• Angiogram: DVD (RCA + LCx)
• PCI in RCA. EF improved from 24% to 39%
• Elective admission for staged PCI in the LCx
![Page 34: Lmca dissection](https://reader037.vdocument.in/reader037/viewer/2022103113/554b439ab4c9054b5e8b4b76/html5/thumbnails/34.jpg)
IVUS