SIHD, Viability study, Mechanical Complications

Question 1

What did the COURAGE trial show?

Answer 1

• “Optimal medical therapy with or without PCI for stable coronary disease”
• “Clinical Outcomes Utilizing Revascularization and Aggressive Druge Evaluation” trial
• Trial:
  
  • Multicenter, open label, parallel-group, randomized, controlled trial ~2300 patients with stable CAD/angina
  • Mean follow up 4.6 years
  • 15 year follow up with no difference between 2 groups
• Clinical Question –>
  
  • In patients with stable CAD, how does optimal medical therapy plus PCI compare to opimal medical therapy alone in improving survival?
• Bottom Line –>
  
  • No differences in death and MI between optimal medical therapy plus PCI vs. OMT alone
• Guidelines
  
  • in the absence of clear indications for revascularization with PCI or CABG (eg, unprotected LM disease), guidelines support the use of FFR-guided revascularization among patients with stable CAD

Question 2

What components do noninvasive viability imaging studies depend on in assessing dysfunctional myocardium?

Answer 2

• Thallium-201 –> cell membran integrity
• Technetium-99m sestamibi –> intact mitochondrial function
• PET with fluorine-18 deoxyglucose –> preserved myocardial metabolism
• Myocardial contrast Echo –> microvascular integrity
• Gadolinium-enhanced MRI –> absence of scar tissu

Question 3

What is the usual presentation for ventricular septal rupture?

Answer 3

• chest pain
• cardiogenic shock

Question 4

What murmur is associated with ventricular septal rupture?

Answer 4

loud, holosystolic murmur

Question 5

When does ventricular septal rupture occur post MI?

Answer 5

• No fibrinolytic therapy –> 1 day or 3-5 days
• Fibrinolytic therapy –> within 24 hours

Question 6

What are factors that are associated with ventricular septal rupture?

Answer 6

• large MI’s
• elderly
• women
• persistent occlusion of infarct related artery and lack of collateral circulation

Question 7

What is the location of septal rupture in relation to infarct artery?

Answer 7

• anterior infarct –> apical septum
• inferior infarct –> posterobasal septum

Question 8

What will a RHC demonstrate in ventricular septal rupture?

Answer 8

• increase, or “step up” in O2 saturation at the level of the right ventricle
• oxygenated blood from the LV mixes with desaturated blood in the RV

Question 9

What is the major problem with percutaneous closure of a ventricular septal rupture?

Answer 9

• may result in enlargement of the defect
• surrounding tissue is often necrotic and fragile

Question 10

What are the three major mechanical complications that can occur after AMI?

Answer 10

• free wall rupture
• ventricular septal rupture
• papillary muscle rupture –> severe MR
• RV infarction**

Question 11

What is the incidence and mortality of free wall rupture in AMI’s?

Answer 11

• 1-6% incidence
• 15% of early mortality

Question 12

What is the timing of free wall rupture?

Answer 12

• 5 days (peak-incidence) in pre-fibrinolytic era
• early reperfusion –> within 48 hours from presentation

Question 13

What is the presentation of ventricular free wall rupture?

Answer 13

• tamponade
• PEA
• death

Question 14

What are the only indications for MV Surgery (IIb) for secondary MR?

Answer 14

Symptomatic, severe MR (stage D)

and

Persistent NYHA class III-IV symptoms