CABG or PCI for this left main NSTEMI?

This elderly woman of 76 y.o. is admitted directly in the cath lab from the emergency department for chest pain and an ECG showing important ST depression in the anterior leads. She is sent directly to the cath lab due to limit blood pressure at 90mmhg. Coronary angiography found a distal calcified left main sub-occlussion (block of calcium in the distal LM). Syntax score 17, CRUSADE high, GRACE high. PCI was decided a few hours later, during the Heart Team meeting. After wiring the CX, rotablation was performed, followed by pre-dilatation and LM-CX stent implantation. POT, side branch (LAD) balloon and RE-POT was performed, with a good angiographic result at the end of the procedure. Would you have treated otherwise?

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What happens after a cardiac catheterization?

What happens after a cardiac catheterization?

If the catheter was inserted in the arm, at the end of the procedure the catheter and sheath are removed. The incision will be closed through compression bandages. You will be forced to keep the arm still for at least one hour. You will be observed for several hours to ensure that you feel good after the procedure. You may receive medication to relieve discomfort in the arm after the anesthetic effect disappears. You will be given instructions on how to take care of your arm when you return home. Tell your nurse if you see blood or feel any numbness or tingling sensations in the fingers.

If the catheter was inserted in the groin at the end of the procedure catheter and sheath are removed and the incision is closed by compression or with a “plug” of collagen (accelerates the formation of a clot in the artery), and then bandaged . A sterile dressing and compression will be put on the groin area to prevent infection or bleeding. You will need to not move position of the foot for 3-6 hours in order to prevent bleeding. Head can not be raised more than the level of pillows (about 20 degrees). Do not raise your head off the pillow (try not to look ahead), as this can contract the abdominal muscles and can promote bleeding from the puncture site. Do not try to stand. Nurse will check the bandage regularly. Warn her if you see blood orif you experience a sensation of humid, warmth at the punction site, or if your toes begin to tingle or feel numb. You may receive medication to relieve discomfort in the groin after anesthesia passes.

Your nurse will help you step out of bed when you are allowed to get up (after at least 6 hours of stretched leg position). Ideally, you should stay in bed 12 hours. You will then be allowed to get out of bed, you can go to the bathroom. If you need assistance seek the help of a nurse. An video of the exam can be found here.

You will need to drink plenty of fluids to remove the dye in the body. You may feel the urge to urinate more frequently. This is normal. If a urinary catheter was not placed during the procedure, you have to use a urinal until you are able to get up from bed.

Your cardiologist will tell you if you are able to return home or will have to stay overnight. Usually after a “radial” puncture is not required staying overnight in the hospital unless you experience chest pain or heart arythmias. Treatment, including medications, dietary changes, and future procedures will be discussed with the doctor before going home. You will also talk to your doctor, says Alexandru Mischie about proper wound care, your work, but also about recovery and whaterver subjects you have in mind.

What happens during cardiac catheterization?

What happens during cardiac catheterization?

What happens during cardiac catheterization?

A nurse will insert an intravenous line in your arm so that medications and fluids can be administered through the vein during the procedure. The nurse will clean the skin (and possibly shave), the place where the catheter will be inserted (arm or groin). Sterile fields are used to cover the site and help prevent infection. It is important to keep your arms and hands to your sides and not touch the sterile field. Electrodes (small, flat, sticky patches) will be placed on the chest. The electrodes are attached to an ECG device that provides electrical diagram of the heart.

A urinary catheter may be necessary for the procedure says dr.cardiologist Alexandru Mischie.

You may be given a mild sedative to help you relax, but be awake and conscious throughout the procedure. The cardiologist will use a local anesthetic to anesthesiate the catheter insertion site, explains Alexandru Mischie.

The room where the surgery will take place is cool and dim. You will sit on a special table. If you look up you will see a large room and several TV monitors. You can view the images during the procedure on those monitors.

The catheter will be inserted sometimes through the groin (called the “femoral” approach) or to the hand region (called the “radial” approach). Before inserting the catheter, a local anesthetic (Xylocaine) will be injected into the area where the catheter enters the artery, to numb the area. The artery will be punctioned with a needle, afterwards the cardiologue will introduce a sheath. Although you may feel pressure when the incision is made or when the sheath and the catheter inserted, you should not feel pain, if you do feel pain, tell your doctor. Subsequently, the physician pushes the catheter to the place where heart arteries are.

When the catheter is placed in a coronary artery, a small amount of dye to be injected through the catheter into the arteries or in the heart chambers. When the dye is injected into the heart, you may feel hot or pressure for a few seconds. This is normal and will disappear in seconds. Please tell your doctor or nurse if you feel itching or tightness in the throat, nausea, chest discomfort, or any other symptoms. For videos regarding the procedure click here.

X-ray tube will be used to make films and photographs of the arteries and heart chambers. The images that are produced are called angiographic images. They reveal the exact extent and severity of all coronary arterial blockages. Your doctor may ask you to pull air deep to hold your breath, or cough during the procedure. Generally you will be asked to hold your breath while the X-rays works.

As soon as all data is collected, the catheter will be removed.

What are the possible decisions after cardiac catheterization?

What are the possible decisions after cardiac catheterization?

For patients with severe angina or myocardial infarction, or those who have significantly abnormal noninvasive tests for CAD, cardiac catheterization help the physician in selecting the optimal treatment (which may include medications, balloon angioplasty, stent angioplasty or coronary artery bypass graft surgery).

Cardiac catheterization is the only test that allows accurate quantification, the extent and severity of CAD, in order to make optimal treatment decisions.

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