PercutaneousCoronaryInterventionsforPatientswithRelativeContra-indications:SeverelyDepressedLeftVentricularFunctionGreatWallInternationalConferenceonCardiology.Beijing11.5.2005ThachNguyenMDFACCFACPFSCAIWhatisthemostCommonCauseofDeathamongPatientsUndergoingPCI?InWhichScenarioIWillDoPCIEvenTheEFIsLow(<25%)?3Scenario1:AMI(EF<25%)PatientA:STSegmentElevation.HeartRate=70andBloodPressure130/80PatientB:STSegmentElevationinInferiorleads,2,3,FandV2R,V3R=RVMIHR:120BP:80/60.Mortality=?PatientC:STSegmentElevationinAnteriorleadsV1-V6.HR:120BP:80/50HowmuchisthemortalityafterPCI?Scenario2:StableAngina(EF<25%)PatienthaslowEFhoweverthereisalargeareaofischemiaonNuclearscanWhatDoThese2setsofPatientsHaveinCommon?ModerateRiskPatient(EjectionFraction<25%)1.FrankHeartFailureNo2.MitralRegurgitationMild3.DiagonalorPosteriorDescendingArteryorObtuseMarginalOPENWhyIamInterestedinPatencyofPDAandDiagonalBranch?RightdominantRCAPDALeftdominantPDALADLCxLAOviewsScenario3:StableAngina(EF<25%)PatienthaslowEFandnoothernon-invasivedataResearchQuestion22.IsmitralregurgitationapassiveeventsecondarytoleftventriculardilationoritisanimportantpartofLVremodelingasprogrammedbyintelligentdesign?Scenario4:WhichOneIrefusetoDo?DilatedcardiomyopathyandfrankheartfailureScenario4:WhichOneIrefusetoDo?CLINICALCRITERIASeveredilatedcardiomyopathywithModeratetosevereMitralRegurgitationModeratetosevereTricuspidRegurgitationModeratetosevereaorticregurgitationScenario4:WhichOneIrefusetoDo?HEMODYNAMICCRITERIASeveredilatedcardiomyopathywithElevatedLVEDPClosedDiagonalandclosedPosteriorDescendingArteryfromeitheradominantRCAordominantObtuseMarginalbranchResearchQuestion3.3.Wecanopenandsecureagoodepicardialflowhowever,Istronglybelievethatthemicrovascularsystemisregulatedmorebyreceptorsthanbypassivegradientbetweenupstreamanddownstreampressure.InpatientswithdiffusetriplevesseldiseaseandsevereLVdysfunction,theproblemisnotjustflowdisturbancesanditismoresuspectedbyinabilityoftranslationfromenergybroughtbybloodflowtocontraction.WhatDoILookWhenIComeToEvaluateaPatientwithVeryLowEjectionFraction(<25%)ForPCI?WhenIStartthePCI,HowIKnowIamGettingintoTrouble?1.SlowRateofRise2.WideningofQRSTHEPATIENTISGOINGINTOSHOCKCheckLVEDPandRateofRiseConclusionsConclusions:1.Whatisthepatientsubsetwithhighestmortality?2.HowtoknowwhichAMIpatientswilldieinthenearfuture?3.Whichpatienthasend-stagedilatedcardiomyopathywhohashighriskofmortalityandnohopeofrecovery?4.Howtorecognizeapatientwhoisgoingintoshockorinshock?
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