Management of Intraprocedural and Postprocedural Complications

Management of Intraprocedural and Postprocedural Complications
Order 5989833
1 A 69-year-old man with hypertension (HTN) and renal insufficiency (glomerular filtration rate [GFR] 65)
presents to your office for consult from an Internist.
He has been experiencing chest pain with exertion
and underwent stress thallium which showed anterior defect. He then had cardiac catheterization
that showed severe three-vessel disease with ejection
fraction (EF) of 45%. He refused coronary artery
bypass grafting (CABG) and presents to your office
for multivessel percutaneous coronary intervention
(PCI). He is concerned about his risk. What is his
risk of emergent CABG with percutaneous revascularization?
(A) 0.4%
(B) 1.5%
(C) 3.7%
(D) 5.0%
2 During the selective cannulation of the left main
coronary ostium, the blood pressure (BP) waveform,
as seen in the figure, was recorded. Which of the
following is the most likely explanation for the
waveform?
(A) The pressure waveform indicates that the catheter tip prolapsed into the left ventricle
(B) The pressure transducer contains air
(C) There is catheter kink
(D) The catheter is up against the wall
(E) The catheter is engaged into a diseased left main
artery
1000 ms
141 136
154 154
11:02:28 AM11:02:26 AM11:02:24 AM11:02:22 AM11:02:20 AM
0
20
40
60
80
100
120
134 142 139
100
63 55 57 55
140
160
180
200
Pl AO
131/53
64
ll
v
9
136
170
Management of Intraprocedural and Postprocedural Complications 171
3 A 67-year-old retired lawyer with diabetes mellitus
(DM), hyperlipidemia, and HTN presents to you for
a second opinion. He underwent cardiac catheterization for increasing exertional chest pain and was
found to have chronically occluded moderate-size
right coronary artery (RCA) and 50% left anterior
descending (LAD) artery, and circumflex (CX) lesions. He underwent PCI to RCA and had 2.5/28,
2.5/33, and 2.25/28 bare-metal stent. Drug-eluting
stents were not used because of the patient’s history of ulcers. Immediately after the intervention,
the patient started complaining of chest pain and
had inferior ST elevation. He underwent immediate
catheterization and was found to have occluded RCA.
However, the artery could not be successfully opened.
In the stent era, all factors have been correlated with
abrupt vessel closure, except:
(A) Stent length
(B) Small vessel diameter
(C) Poor distal run off
(D) Excessive tortuosity
(E) Unstable angina
Management of Intraprocedural and Postprocedural Complications
4 A 51-year-old woman presents to you for second
opinion. She underwent successful elective PCI to
CX for exertional chest pain. Her hospitalization
was uneventful until the time of discharge when
she was told that her creatine kinase-MB (CK-MB)
isoform was three times the normal limit. She was
discharged home and has been doing well but cannot
stop worrying. Which of the following statements is
true regarding procedure-related enzyme release?
(A) CK-MB elevation does not occur after angiographically successful uncomplicated coronary
interventions
(B) Routine monitoring of cardiac enzymes is not
necessary to detect patients who suffer from
myocardial injury after coronary intervention
(C) The incidence of CK-MB enzyme elevation
after angiographically successful percutaneous
intervention is >50%
(D) Elevation of CK-MB after PCI predicts increased
long-term cardiac mortality and morbidity
5 A 45-year-old patient with diabetes who was
hypercholesterolemic, hypertensive, and a heavy
(two-packs-a-day) smoker underwent a successful angioplasty and stent placement to mid-LAD
lesion. Before angioplasty, the patient received acetylsalicylic acid (ASA) 325, and glycoprotein (GP)
IIb/IIIa inhibitor treatment. The angioplasty procedure was uneventful. The Cypher 3.0 × 28-mm
stent was deployed at 16 atm. The final angiogram
showed a well-expanded vessel with thrombolysis in
myocardial infarction (TIMI) 3 flow. The following
morning, a routine troponin was 1.5 ng/mL. The
patient remained asymptomatic and his cardiac examination was normal. His electrocardiogram (EKG)
showed nonspecific ST–T-wave changes, which were
unchanged from the admitting EKG. The best course
of action for this patient now is as follows:
(A) Discharge the patient immediately with
β-blockers, nitrates, statin, ASA, Plavix, and an
angiotensin-converting enzyme (ACE) inhibitor
(B) Bring the patient back to the catheterization
laboratory for a repeat angiogram
(C) Transfer the patient to a coronary care unit
(CCU)
(D) Continue to monitor the patient in telemetry for
48 hours
(E) Check another set of troponin in 8 hours. If
the trend is down then discharge him on Plavix,
ASA, β-blockers, statins, and an ACE inhibitor
6 A 75-year-old patient traveled 4 hours by car
to get to the hospital for a 7:00 am, first case,
elective, complex, multilesion, multivessel coronary
intervention. Although the angioplasty procedure
was difficult to perform because of lack of adequate
guide support, finally after trying several guide
catheters, an Amplatz no. 3 guide catheter was
found to give a good guide support to deliver three
long Taxus stents. At the end of the procedure, the
operator informed the patient that he was successful
in opening all the blockages. The catheterization
laboratory staff moved the patient to the recovery
room.
Management of Intraprocedural and Postprocedural Complications
The patient was asymptomatic without any
complaint and had normal vital signs. Later, the
recovery room registered nurse (RN) noticed that
the patient became progressively lethargic and less
responsive to her. The physician in charge was
notified. After obtaining the vital signs, which were
noted to be unchanged, the most appropriate action
at this time should be:
(A) Have the RN check the patient’s EKG and his
vital signs again
(B) Give him naloxone (Narcan)
(C) Perform a screening neurologic examination or
obtain an urgent neurology consult
(D) Check the patient’s complete blood count
(CBC), blood sugar, blood urea nitrogen
(BUN), and creatinine level
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