a case of bifurcation PCI with detailed review

2. CASE OF THE WEEK
BY
DR. M. ZARRAR ARIF
PGR CARDIOLOGY

3. HISTORY
PATIENT DATA
Name: Babar Abbas
Age / Gender : 45 y / Male
MOA : Medical Emergency
DOA : 11-03-2011
Address: 149 F Model Town, Lahore

4. HISTORY
PRESENTING COMPLAINTS
Chest pain for last 2 hours
HOPI
Patient was in usual state of health when
he developed complaints of sudden chest
pain, central in location, radiating to left
arm and neck, severe in intensity and was
associated with sweating. No complaints
of nausea, vomiting, palpitations or
dyspnoea.

5. HISTORY
Past History
Patient gives history of admission with
chest pain 2 days back for which he was
admitted in Ittefaq hospital and he was
advised stay for evaluation after an ECG
but he was discharged on his request.
No previous history of any other hospital
stay, surgical interventions etc

6. HISTORY
Drug History
Patient has been taking following
medications since last 2 days
Asprin 75 mg OD
Clopidogrel 75 mg OD
Atorvastatin 20 mg HS
Metoprolol 25 mg BD
Lisinopril 5 mg HS
No history of drug allergy.

7. HISTORY
Personal History
Patient has no history of smoking or any
other addiction
Occupational History
Patient is a school teacher by profession
Family History
No history of DM, IHD in the family

8. GPE
A middle aged man sitting in bed well
oriented in time place and person with
vitals
Pulse : 72 / min, regular, normal character
with no radio-radial and no radio-femoral
delay.
B.P : 160/100 mm Hg
Temp : 980 F
R/R : 16 / min
-ve for Pallor, clubbing, cyanosis.
JVP not raised.

9. SYSTEMIC EXAMINATION
Cardio Vascular System
On pre-cordial examination inspection
normal, on palpation apex beat in 4th
intercostal space with normal character, on
auscultation first and second heart sounds
normal with no added sound.
Respiratory System
Normal findings on inspection palpation
and percussion with normal vesicular
breathing bilaterally and no added sounds
on auscultation.

10. SYSTEMIC EXAMINATION
Gastro Intestinal System
Normal findings on inspection with no
palpable visceromegally and no area of
tenderness on palpation, normal bowel
sounds on auscultation.
Central Nervous System
Grossly intact HMF with no motor or
sensory loss

11. Provisional Diagnosis
• Acute Coronary Syndrome

12. INVESTIGATIONS
Investigation Result
Hb 14.3
B/Urea 30
S/Creatinine 0.9
S/Na+ 138
S/K+ 4
Troponin T (Kit Method) -ve

13. ECG
ECG findings are as below
It showed regular sinus rhythm with rate of
80/min, normal axis with normal PR, and
QT intervals with normal QRS.
STT changes were present in anterior
chest leads from V1-V4 in form of ST
segment depression and T wave
inversions, no ST elevations seen in any
leads.

14. FINAL DIAGNOSIS
UNSTABLE ANGINA

15. TREATMENT
Emergency management was done with
S/L angisid 0.5 mg stat
Asprin 300 mg stat
Clopidogrel 300 mg stat
Morphine 3mg stat
Metoprolol 25 mg stat
Infusion of isoket @ 10 u drops/min
Clexane 80 mg S/C Stat
Chest pain improved with medication and
ECG also showed improvement

16. TIMI RISK SCORE

17. CORONARY ANGIOGRAM
• Patient was offered coronary angiogram
as it was Class I A indication according to
AHA guidelines
• Recommendations for Coronary
Angiography in Unstable Coronary
Syndromes
Class I
High- or intermediate-risk unstable
angina that stabilizes after initial
treatment. (Level of Evidence: A)

18. REVISED TIMI RISK SCORE

19. DECISION
Patient was advised PTCA for his disease
and for the complete decision we will have
to review the type of lesion we r facing

20. How to define a bifurcation
lesion ?
• “A coronary artery narrowing occurring
adjacent to, and/or involving, the origin
of a significant side branch"
• A significant SB is a branch that you
don't want to loose in the global
context of a particular patient

21. Difficulties of Bifurcation PCI
• Risk of peri-procedural complications
• Relatively high re-stenosis
• Not all lesions are the same :
 - Size of vessels (Meaningful SB size ≥2.25mm)
 - Variable plaque distribution
 - Extent of SB disease
 - Variable angulations
• Higher risk of stent thrombosis
• PCI techniques are mainly based on
personal experiences from skilled
operators

22. Factors to be considered for
PCI strategy
• Anatomical factors
– LMCA bifurcation
– Location of plaque (Anatomical classification)
– Plaque or carina shift
– Angle between SB and MB
– Dynamic change in bifurcation anatomy
• Modalities for objective anatomical
evaluation
– QCA, IVUS, FFR
• Selection of devices and strategies
– DES vs. BMS
– Single vs. Double stent techniques
– Kissing balloon or not
– Dedicated bifurcation stents

23. Classification of
Bifurcation Lesions
• Plaque Location
• Plaque Extent
• Angle

24. Classifications of bifurcation
lesions

25. Medina
Classification

26. Limitations of
the Medina classification
• Does not take into account
1. Length of disease in the ostium of
the SB
2. Length of the LMCA before the
bifurcation
3. Trifurcation
4. Vessel angulation
• The LMCA differs from many
other bifurcation lesions due to
the importance of the SB (LCx)

27. Plaque Burden at the SB
Ostium

28. Trifurcation

29. Angulation

30. Fractal geometry and QCA

31. How to name a bifurcation lesion

33. Medina
Classification

34. SIDE BRANCH LOSS

35. Simple

41. Stents and Dedicated Delivery
Systems

43. Drug-eluting Stents in Bifurcation
Lesions – Safety Data

44. The Technique Matters more than the
Number of Stent ?

45. CONCLUSION
In cases where there is no lesion in the
side branch or a purely ostial lesion,
stenting the main branch with a jailed wire
in the side branch followed by provisional
T-Stenting of the side branch after guide
wire exchange appears to be the most
rational and successful strategy, provided
that final kissing-balloon inflations are
systematically performed.

46. KEEP YOUR GOAL IN SIGHT

47. WORK HARD

48. SUCCESS WIL BE YOURS

49. THANK YOU !!!