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08:45 CASE 7 - Galassi - 02. A Septal Perforation: The Best Of The Worst

Experts "Live" CTO Workshop 2014
25th Septemper 2014 in Madrid, Spain

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08:45 CASE 7 - Galassi - 02. A Septal Perforation: The Best Of The Worst

  1. 1. Alfredo R. Galassi MD, FESC, FACC, FSCAI Director of Cardiac Catheterization and Interventional Cardiology Unit Department of Medical Sciences and Pediatrics Division of Cardiology, Cannizzaro Hospital, University of Catania, Italy A Septal Perforation: The Best Of The Worst
  2. 2. CASE SUMMARY Clinical Presentation Exertional angina (CCSC II)and dyspnea (NYHA II) Patient: C-C, male, 59 yrs Risk Factors Hypertension Dyslipidemia Coronary Angiography Mid LAD CTO Non-invasive Testing 2D Echo: Hypokinesia in anterior territory, EF 50%
  3. 3. Coronary Angiography Target lesion: LAD
  4. 4. Antegrade Failed Attempt Target lesion: LAD
  5. 5. Collaterals Target lesion: LAD
  6. 6. Septal channels Sion Asahi Intecc Target lesion: LAD
  7. 7. Sion advancing through septal channels Sion Asahi Intecc Target lesion: LAD
  8. 8. Externalization RG 3 Asahi Intec Trapping balloon
  9. 9. Stent Implantation 2 DES Cre8 3.0x31 mm; Cre8 2.75x31mm
  10. 10. Final Result (time: 2.0 pm o’clock) Total procedural time = 18 min
  11. 11. After Corsair withdrawing
  12. 12. After Corsair withdrawing Septal perforation
  13. 13. 7 min later … Tachycardia and hypotension Septal fenestration and pericadial effusion TTE showed tamponade
  14. 14. Pericardiocentesis
  15. 15. Antegrade coil implantation
  16. 16. Retrograde coil implantation
  17. 17. Persistance of extravasation Second retrograde coil implantation
  18. 18. Further retrograde coil implantation in posterior descending artery
  19. 19. Absence of right ventricular perforation
  20. 20. Final Result Stable hemodynamic status HR 90 bpm; systolic pressure 110 mmHg Thus, protamin was administered (35 mg)
  21. 21. 1 hour later… tachicardia and hypotension suddenly developed Patiient was brought back to cath lab (time: 9.00 o’clock) TTE showed sudden increase in pericardium effusion and tamponade Angio revelaed again active bleeding in pericardium from septal fenestration
  22. 22. Further antegrade quick coil implantation (no heparin infusion) Because protamine administration and long-standing procedure pericardiocentesis drainage became difficult due to catheter clotting
  23. 23. Final Result (no active bleeding) TTE confirmed clots in the pericardium with signs of compression with unproductive drainage
  24. 24. Because of the incoming night and the unproductive drainage it was decided to transfer the patient for surgical pericardium assessment
  25. 25. Cardio-thoracic chest opening was performed after 10 hrs (time: 00.00 am o’clock) No active bleeding in the pericardium was observed, finally stopped! Surgical drainage of clots was performed
  26. 26. Outcome Patient was discharged 1 week later Two-month follow-up was uneventful He is running daily working activity
  27. 27. Take Home Messages - Septal channels represent reliable and relative safe collaterals to achieve successful retrograde CTO revascularization - Septal perforation is very often benign…… but not always; “septal collateral fenestration” might be dangerous - Coils are important tools in the armamentarium of CTO operators (they achieve perforation closure with no significant flow impairment in the main vessel) - Emergency cardiac surgery should be considered in rare cases