Anamnesis Cardiologic history - TOBI · Ostial LM stenosis RCA restenosis CABG LIMA>LAD; RIMA >RCA...

Anamnesis

2004 NSTEMI CX stenosis DES on CX

2012 Acute Pulmonary

Oedema

Severe Aortic Valve Stenosis

Aortic Valve Bioprosthesis

2013 Unstable Angina

Ostial RCA stenosis

Ostial RCA DES

2014 Acute Pulmonary

Oedema

Ostial LM stenosis RCA restenosis

CABG LIMA>LAD; RIMA

>RCA

Severe Mitral valve

regurgitation

Mitral Valve Bioprosthesis

2015 Acute Heart Failure

Hospitalization Coronarography

• BD 29.7.1939

Female

• HTN, DM, Dyslipidaemia

Risk factors

• Long history

Cardiologic

• Heart failure

Last admission

Cardiologic history

• Ostial stenosis

• FFR LAD 0,70

• FFR CX 0,72

LM

• Ostial instent occlusion

RCA

• Distal anastomosis stenosis

LIMA-LAD


RIMA-RCA

• Right femoral 6F

Coronary angiography

Diagnostic angiography: Tight stenosis of LM and ostial instent occlusion of RCA of native coronaries and distal anastomosis stenosis of by-pass LIMA>LAD; RIMA>RCA

Fig.1.a

Fig.1.b

Fig.1.c

Fig.1.d

• Ostial stenosis

• FFR LAD 0,70

• FFR CX 0,72

LM

• Ostial instent occlusion

RCA


LIMA-LAD


RIMA-RCA

• Right femoral 6F

Coronary angiography

Diagnostic angiography: Tight stenosis of LM and ostial instent occlusion of RCA of native coronaries and distal anastomosis stenosis of by-pass LIMA>LAD; RIMA>RCA

Fig.1.b Fig.2.a Fig.2.b

Implantation of bifurcation dedicated self-expandable DES – AXXESS on LM after adequate predilatations

•Acrostak GRIP 3,0x12 at 16 Atm

POBA LM-LAD


POBA LM-CX

•Axxess 3,5 x 11

Bifurcation DES LM

• LM-LAD 3,5x11

• LM-CX 3,5x11

Axxess kissing balloon

• LM 4,0 x 8

Axxess post dilatation

•Angiographic

• IVUS

• FFR

Good final result

• Same day

•7F right femoral

Procedure on LM

Fig.3.a. Axxess navigation Fig.3.b. Axxess initial opening

Fig.3.c. Axxess point of no return Fig.3.d. Axxess final opening

Implantation of bifurcation dedicated self-expandable DES – AXXESS on LM • Same day

•7F right femoral

Procedure on LM

Fig.4.b. Axxess post-dilatation Fig.4.a. Kissing balloon Axxess

Fig.5.a. Final result – LAO_CAUD Fig.5.b. Final result – RAO_CAUD


POBA LM-LAD


POBA LM-CX

•Axxess 3,5 x 11

Bifurcation DES LM

• LM-LAD 3,5x11

• LM-CX 3,5x11


• LM 4,0 x 8


•Angiographic

• IVUS

• FFR

Good final result


•7F right femoral

Procedure on LM


POBA LM-LAD


POBA LM-CX

•Axxess 3,5 x 11

Bifurcation DES LM

• LM-LAD 3,5x11

• LM-CX 3,5x11


• LM 4,0 x 8


•Angiographic

• IVUS

• FFR

Good final result

Fig.6.a FFR LM-LAD with Acist RXi

Fig.6.b. FFR LM-CX with Acist RXi


•7F right femoral

Procedure on LM


POBA LM-LAD


POBA LM-CX

•Axxess 3,5 x 11

Bifurcation DES LM

• LM-LAD 3,5x11

• LM-CX 3,5x11


• LM 4,0 x 8


•Angiographic

• IVUS

• FFR

Good final result

Fig.7.a. IVUS LM-LAD Fig.7.b. IVUS LM-CX

Retrograde RIMA>RCA reopening of RCA CTO and through the same introducer anterograde RCA stenting •6F right radial

•Next day

Procedure RCA

•Engagement of RIMA

IM 6F GC

• Filder XT

•CTO balloon

Retrograde RIMA-RCA

•POBA RCA

Retrograde

•Engagement of RCA

HS 5F GC

•POBA RCA

• Stenting RCA

•Post-dilatation

Anterograde

•Angiographic

• IVUS and FFR

Good final result

Fig.8.a. Filder XT and OTW Fig.8.b. Retrograde POBA 2,0 mm

Fig.8.c. Retrograde POBA 3,0 mm


•Next day

Procedure RCA


IM 6F GC

• Filder XT

•CTO balloon

Retrograde RIMA-RCA

•POBA RCA

Retrograde


HS 5F GC

•POBA RCA

• Stenting RCA

•Post-dilatation

Anterograde

•Angiographic

• IVUS and FFR

Good final result

Fig.9.a. Anterograde 0,35” wire Fig.9.b. Anterograde 5F GC


•Next day

Procedure RCA


IM 6F GC

• Filder XT

•CTO balloon

Retrograde RIMA-RCA

•POBA RCA

Retrograde


HS 5F GC

•POBA RCA

• Stenting RCA

•Post-dilatation

Anterograde

•Angiographic

• IVUS and FFR

Good final result

Fig.10.a. POBA 3,0 mm Fig.10.b. POBA 3,5 mm Fig.10.b. POBA 4,0 mm


•Next day

Procedure RCA


IM 6F GC

• Filder XT

•CTO balloon

Retrograde RIMA-RCA

•POBA RCA

Retrograde


HS 5F GC

•POBA RCA

• Stenting RCA

•Post-dilatation

Anterograde

•Angiographic

• IVUS and FFR

Good final result

Fig.11.a Ostial RCA DES Fig.11.b Result DES Fig.11.c Mid RCA DES


•Next day

Procedure RCA


IM 6F GC

• Filder XT

•CTO balloon

Retrograde RIMA-RCA

•POBA RCA

Retrograde


HS 5F GC

•POBA RCA

• Stenting RCA

•Post-dilatation

Anterograde

•Angiographic

• IVUS and FFR

Good final result

Fig.12.a. POBA 3,5 HP

Fig.12.b. POBA 4,0 HP

Fig.13. Final result


•Next day

Procedure RCA


IM 6F GC

• Filder XT

•CTO balloon

Retrograde RIMA-RCA

•POBA RCA

Retrograde


HS 5F GC

•POBA RCA

• Stenting RCA

•Post-dilatation

Anterograde

•Angiographic

• IVUS and FFR

Good final result

Fig.14.a FFR RCA with Acist RXi

Fig.14.b IVUS RCA Fig.14.c IVUS RCA

Myocardial scintigraphy •6 months

Follow up

• Asymptomatic

Clinical

• No heart failure

Functional

• No ischemia

Scintigraphy

• Scintigraphy

• Angiography

• IVUS or OCT

Program after 12 m

CONCLUSIONS TAKE HOME MESSAGES

• the demonstration of ischemic evidence is important

In case of a patient with two previous cardiac surgeries

• Makes easy the measurement of FFR in all vessels before and after the procedure as it scores over any coronary wire

New rapid exchange Acist RXi with NAVUUS catheter for FFR

• Percutaneous approach is preferable as third surgery is accompanied with higher risk

In such complicated and complex case

• When the anatomy and the angle are suitable is acceptable and feasible

Dedicated self-expandable DES for the LM ostial stenosis

• Is possible for RCA ostial CTO reopening and stenting

Retrograde approach through by-pass graft RIMA-RCA

Anamnesis Cardiologic history - TOBI · Ostial LM stenosis RCA restenosis CABG LIMA>LAD; RIMA >RCA...

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Transcript of Anamnesis Cardiologic history - TOBI · Ostial LM stenosis RCA restenosis CABG LIMA>LAD; RIMA >RCA...