急性心肌梗死左主干闭塞急诊PCI一例.pptxVIP

急性心肌梗死左主干闭塞急诊PCI一例第1页/共16页 HistoryFemale, 53yrs.Chest pain followed by unconsciousness in a shopping center near our hospital 3 hrs ago.No history of HT, HL, DM or smoking.CPR with mechanical ventilation was performed in ambulance and emergency roomECG: ST segment elevation in leads of I, avl and V1-6.After consciousness and spontaneously breathing were recovered, mechanical ventilation was removed.第2页/共16页 Emergency angiography was performed:Stenosis of 90% in LM, and stenosis of 50% in ostial LAD and LCXNormal RCA without collateral flow第3页/共16页 Q1:E-CABG?E-PCI?2 stent?1stent?Protection wire in LCX?In emergency setting: “The simpler, the better”“1wire, 1balloon, 1 stent”第4页/共16页 GC:6F JL 4.0 (Laucher), GW: BMW, Balloon: 2.5×15 (Sprinter) 第5页/共16页 Cypher stent of 3.5×23 was implanted (18-22atm) 第6页/共16页 Significant stenosis in ostial LCX第7页/共16页 Q2:POBA in LCX, finished by kissing balloon ?Provisional stent in LCX?T stent?Mini Crush ?第8页/共16页 After crossed by Runthrough wire, ostial LCX was pre-dilated by balloon of 2.0 and 2.5mm.While a balloon of 3.5mm (Maverick) in LM, a Cypher stent of 3.0×18 was implanted(14 atm) with a little segment extruded into LM 第9页/共16页 After the ballon and wire in LCX were removed, the balloon of 3.5 in LM was dilated to crush the stent in LCX第10页/共16页 After rewired by Runthrough wire, the stent cell in ostial LCX was re-opened by balloon of 2.0mm第11页/共16页 Finished by kissing ballooning (balloon of 3.5 mm in LAD, while balloon of 3.0 mm in LCX )第12页/共16页 Final result第13页/共16页 PCWP immediately after PCI was 20 mmHg, and CI was 2.1L/min/m2.2 days later, melena occurred.Hemoglobin decreased (from 125g/l to 68g/l ), and PCWP was 5 mmHg.800 ml RBC was transfused.Thrombin, aluminium phosphate and ice saline was injected through gastric-tube, and omeprazole was injected intravenously. Aspirin, clopidogrel and LMWH were continued to avoid SAT in stent.第14页/共16页 3 days later, upper gastrointestinal hemorrhage stopped.Dopamine, IABP an