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1、Percutaneous Coronary Interventions for Patients with Relative Contra-indications: Severely Depressed Left Ventricular Function Great Wall International Conference on Cardiology. Beijing 11.5.2005 Thach Nguyen MD FACC FACP FSCAIWhat is the most Common Cause of Death among Patients Undergoing PCI? In
2、 Which Scenario I Will Do PCI Even The EF Is Low (25%) ? 3Scenario 1: AMI (EF25%) Patient A: ST Segment Elevation. Heart Rate=70 and Blood Pressure 130/80Patient B: ST Segment Elevation in Inferior leads, 2,3,F and V2R, V3R = RV MI HR:120 BP: 80/60. Mortality = ?Patient C: ST Segment Elevation in An
3、terior leads V1-V6. HR:120 BP: 80/50 How much is the mortality after PCI?Scenario 2: Stable Angina (EF25%) Patient has low EF however there is a large area of ischemia on Nuclear scan What Do These 2 sets of Patients Have in Common? What Do I Look When I Come To Evaluate a Patient with Very Low Ejec
4、tion Fraction (25%) For PCI ? Evaluation of Patient with Very Low Ejection Fraction (25%) before PCI 1. Does the Patient Have Frank Heart Failure ?2. Does the Patient Have Moderate Mitral Regurgitation ?3. Does the Patient Have Moderate Tricuspid Regurgitation ?4. Is the Diagonal closed and/or a lar
5、ge Posterior Descending Artery from a dominant RCA or dominant Obtuse Marginal closed ? Moderate Risk Patient (Ejection Fraction 25%) 1. Frank Heart Failure No2. Mitral Regurgitation Mild 3. Diagonal or Posterior Descending Artery or Obtuse Marginal OPEN Why I am Interested in Patency of PDA and Dia
6、gonal Branch? Right dominantRCAPDALeft dominantPDALADLCxLAO viewsScenario 3: Stable Angina (EF25%) Patient has low EF and no other non-invasive data Pre-Operative Evaluation? 1. Does the Patient Have Moderate Mitral Regurgitation ?2. Does the Patient Have Moderate Tricuspid Regurgitation ?3. Is the
7、Diagonal closed and/or a large Posterior Descending Artery from a dominant RCA or dominant Obtuse Marginal closed ? Moderate Risk Patient (Ejection Fraction 25%) 1. Frank Heart Failure No2. Mitral Regurgitation Mild to moderate3. Tricuspid Regurgitation Mild to moderate 4. Diagonal or Posterior Desc
8、ending Artery or Obtuse Marginal OPEN Research Question 1. 1.Which branch occlusion causes more mitral regurgitation? The PDA to the posterior papillary muscle The Diagonal to the anterior papilary muscle Research Question 2 2. Is mitral regurgitation a passive event secondary to left ventricular di
9、lation or it is an important part of LV remodeling as programmed by intelligent design? Scenario 4: Which One I refuse to Do?1.Dilated cardiomyopathy and frank heart failure Scenario 4: Which One I refuse to Do?CLINICAL CRITERIASevere dilated cardiomyopathy withModerate to severe Mitral Regurgitatio
10、n Moderate to severe Tricuspid Regurgitation Moderate to severe aortic regurgitation Scenario 4: Which One I refuse to Do?HEMODYNAMIC CRITERIASevere dilated cardiomyopathy withElevated LVEDPClosed Diagonal and closed Posterior Descending Artery from either a dominant RCA or dominant Obtuse Marginal
11、branch Why ? Research Question 3. 3. We can open and secure a good epicardial flow however, I strongly believe that the microvascular system is regulated more by receptors than by passive gradient between upstream and downstream pressure. In patients with diffuse triple vessel disease and severe LV
12、dysfunction, the problem is not just flow disturbances and it is more suspected by inability of translation from energy brought by blood flow to contraction. What Do I Look When I Come To Evaluate a Patient with Very Low Ejection Fraction (25%) For PCI ? When I Start the PCI, How I Know I am Getting
13、 into Trouble ? 1. Slow Rate of Rise 2. Widening of QRS THE PATIENT IS GOING INTO SHOCKCheck LVEDP and Rate of RiseConclusions Conclusions: 1. What is the patient subset with highest mortality? 2. How to know which AMI patients will die in the near future? 3. Which patient has end-stage dilated cardiomyopathy who has high risk of mortality and no hope of recovery?4. How to recognize a patient who is going into shock or in shock?
