SHA24/089003

Nasty Thrombosis Despite High ACT Dr. Mohammad Al Shehri, MD, FSCAI Consultant Cardiologist & Interventionist

Clinical Presentation 60 yrs, S/F. IDDM, HTN, Hypothyroidism for 20 years 2010 had been evaluated for chest pain, with T-wave ↓ on antero-lateral lead, treated medically Recently she had chest pain with LBBB for which she received reteplase in a peripheral hospital Referred to our hospital still with chest pain, for coronary angiography

Clinical Presentation, cont

Looking fair, Vitally stable Bruising on both arms (cannulae sites, prior hospital) Heart and Chest exam. Unremarkable

ECG: 12.9

ECG: 12.9

ECG: 14.9

Echocardiography Normal LV size, normal wall thickness, LVEF= 40% Borderline overall contractility with more hypokinesis in the anterior and lateral wall.

Mild MR, SPAP= 47 mmHg.

Lab. WBCs: 5.8 X 103

Creatinine: 86 umol/L

HB: 15.5 g/dl

AST: 40 U/L

HB: (next day): 12.7 g/dl

CK: 66 U/L

Platelets: 223

CKMB: 0.3 U/L

INR: 1.0

Troponin I: 0.04

Electrolytes: Normal

LDH: 246 U/L

Management We started on anti-ischemic treatment, including ASA, Clopidogrel and Enoxaparine 80 mg BD. She was hydrated overnight and taken next morning for coronary angiography.

IVUS vs FFR

For LAD lesion

IVUS showed: ulcerative plaque with moderate stenosis Should we treat ulcerative plaque with mild to moderate stenosis with angioplasty?

Export Suction Catheter in the LAD

• ACT>290 repeated several times

Post Cath.

There was no chest pain, but small hematoma at the right groin. Mildly tender left lumber region.

Routine ECG and next morning chest X-ray showed no new changes.

Next day Labs.

HB: (same day 10.2) → 9.3 g/dl Creatinine: ↑↑↑ 191 umol/L CK: 101 → 124 → 134 →104 U/L Trop I: 0.09 → 0.17 → 0.14 → 0.02 u/L

Post Cath.

Medications were modified and hydration continued, Nephrology consultation for CIN. There was increasingly severe left lumbar pain.

Vascular surgery was consulted, Abdominal ultrasound done, CT abdomen with oral but no IV contrast.

Provisional diagnosis

. Left

renal mass lesion with hemorrhage

:Hospital course Creatinine: 116 umol/L HB: 10.9 → 11.3 g/dl (after 2 units RBCs) The case was cleared from vascular surgery.

Referral was done for Urology.

Nephrology cleared the patient for MRI.

Case Progress Update TTE showed no new changes 10 days latter the patient underwent left radical Nephrectomy.

The patient discharged home 5 days latter.

Discharge medications included ASA, Clopidogrel, Statins and other anti-ischemic treatment.

The patient came to post PCI clinic 1 month latter asymptomatic, F/U Labs were normal.

Take Home message Hemoglobin drop is a real serious marker to be clearly investigated especially before PCI. Coronary thrombus can be simply aspirated, stent is not always needed.

Coronary thrombus with high ACT can be explained by underlined malignancy as in this case.

You can see uncommon site for retroperitoneal hematoma.