Cardio-Renal Issues:  Complex cases to solve

Authors: Lorenzo Azzalini, Satoru Mitomo, Daisuke Hachinohe, Damiano Regazzoli, Antonio Colombo. Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy.

Moderator: Armando Pérez de Prado, Hospital Universitario de León. León, Spain.

Case A: 52 year old man

Cardio-Renal Issues: Complex cases to solve

Case A: 52 year old man

Kidney transplant in 2001 and 2015 (membranoproliferative glomerulonephritis), HCV infection.

Current eGFR 24 ml/min/1.73 m2.

Recent episodes of palpitations. Holter shows NSVT (220 bpm, monomorphic, RBBB morphology, left axis). Echo: LVEF 60%, no wall motion abnormalities, moderate MR and AR. The patient also complains of angina CCS 2.

Coronary angiogram shows: long disease on tortuous large Cx/marginal branch (Figure 1A, Video 1A). Creatinine is 2.7 mg/dl.

Case B: 76-year-old man

Cardio-Renal Issues: Complex cases to solve

Case B: 76-year-old man

Hypertension, family history of CAD, diabetes mellitus (insulin)

Severe CKD (baseline eGFR 25 ml/min/1.73 m2)

LVEF 55%, apical hypokinesia, severe functional MR

NSTEMI in June 2016: PCI with DES on ostial LM, mid LAD and mid D1. Residual disease on D1 ostium (moderate) and mid LAD CTO.

New admission for new onset AF in May 2017. Coronary angiogram demonstrates good result of prior PCI and progression of D1 ostial disease (now critical; Figure 1B, Video 1B). Due to advanced CKD (new eGFR 25 ml/min/1.73 m2), medical management of his residual CAD is chosen. Also, LMWH is started, and LAA closure is scheduled and performed in September 2017.

July (ambulatory exam): new eGFR 16 ml/min/1.73 m2

September 2017 (2 weeks after LAA closure): new admission for pulmonary edema (hs-TnT 821 ng/l, n.v. <14). Echo: LVEF 55%, new lateral wall hypokinesia, rest unchanged. eGFR 16 ml/min/1.73 m2

And now?

What to do in each case? Differences and similitudes?

6 Comentarios

  1. Armando Pérez

    New test in ForoEpic. Although our first author, Lorenzo, has a very nice Spanish, we have decided to keep the cases (YES, 2 cases to compare) in the original format, in English. This is an exploratory try to evaluate the interest of foreign language colleagues in engaging in ForoEpic. All commentaries, opinion, ideas, … are welcome. You only need to ask for an account to do it.

    Por supuesto, los comentarios en español también son bienvenidos, pero os pedimos un esfuerzo para expandir nuestra comunidad: practice your english!

    I think these 2 cases perfectly illustrate one of the most common issue of our patients: renal disease. Often overlooked, it is one of the strongest predictors of worse prognosis. And what’s more, we can even worsen the renal status with our interventions. That’s why a good discussion about the cases may expand our knowledge and our awareness on renal disease. So, time to talk, friends!

  2. Alfonso Jurado

    Thank you for these interesting cases that let us afford the underestimated issue of renal dysfunction.
    The first case has a severe renal dysfunction after kidney transplantation (eGFR 24 ml/min/1.73 m2), NSVT, normal LVEF, moderate MR, AR and CCS2 angina. In the angiography, one-vessel disease that affects to distal Cx and it is not a critical lesion, although it is long and tortuous.
    In this case it would be interesting to know the current medical treatment and the mechanism of MR. In my opinion, if he is under optimal medical treatment, and with this diffuse but not critical disease of a distal vessel it would be reasonable to do a functional study with iFR/FFR to guide treatment trying to stent only the more functionally severe segments. It can simplify the procedure and prevent future events.
    Of course, I would administer hydration before the procedure and use of the least possible amount of contrast. In addition, I would plan renal depuration measures if they were needed after PCI. I would re-evaluate valvular disease with follow-up echo. It is possible that this can become the main problem in the near future.

    The second case presents a 76 yo diabetic patient with similar renal dysfunction (eGFR 25 ml/min/1.73 m2) and near normal LVEF 55% with apical and lateral hypokinesia. However it´s a more complex patient as he presents severe functional MR, and more complex coronary disease: mid LAD CTO and critical lesion in ostial D1 (very good vessel).
    I cannot play properly video 1B…don´t know if it´s my computer… Are Cx and RCA OK?
    In addition he presented AF with indication of chronic anticoagulation. LAA closure was performed. A very good indication in my opinion.
    Initial conservative management failed as the patient was readmitted for pulmonary edema. At this admission, did the patient remain in AF? Was he at rate control strategy? Is it possible that uncontrolled AF was the trigger of this admission?
    If AF is controlled, and medical treatment is optimal, an invasive option seems to be performed. The main problem is the severe functional MR.
    I suppose that cardiac surgery is not an option: surgical risk, distal LAD affection, need for anticoagulation if mitral valve cannot be repaired…
    I would do a percutaneous treatment of coronary disease trying to use the least possible amount of contrast and with renal protection measures (as commented in previous patient). I would re-evaluate the patient with echo and if MR remains similar and HF is not controlled, he might be a good candidate for Mitraclip.

    • Armando Pérez

      Hi, Alfonso, thanks for your commentaries. Indeed, a valuable contribution. Sorry about the video 1B problem; while we are fixing it, you can see the video running at our SmartPhone and Tablet versions.

  3. lorenzo

    Thanks Armando for the introduction, and Alfonso for his comments.

    First, I would like to spend a few words on CKD patients in the cath lab. Over the past few years, I have been witnessing a steady increase in the proportion of such patients. In particular, at San Raffaele, we see a lot of patients (elderly but also younger, sometimes) with very advanced renal failure and who require PCI. These two patients had CKD stage IV but none of them had been prepared with an AV fistula for dialysis, nor that was the plan in the immediate future. Therefore, the classic “let’s wait a few months until the patient ends up in dialysis anyway, and then we do the PCI” is not valid, since for example the second patient has been in class IV CKD for over a year, and has never needed dialysis, and we do not know when he is going to require it.

    Having said that, the first patient is a no brainer: single-vessel disease, clearly significant, in a young patient with angina. This must be treated. The decision whether to treat or not the second one is tougher. The lesion most amenable to treatment, ostial D1, looked borderline in a PCI in 2016, but in a new coronary angiogram last May it looked significant. Still, it is an elderly patient who has no angina, and presents with a non-prognostic lesion on D1. However, he has presented two episodes of pulmonary edema in the last year. None of them was triggered by AF. This lesion seems feasible percutaneously, without using too much contrast. The CTO appears off-limits to most operators, in this setting. Finally, surgery is not an option due to very high surgical risk and almost certain need for dialysis due to extracorporeal circulation and SIRS.

    I am really curious about hearing more voices on how people would manage these patients. Come on, guys, let us know your thoughts!

  4. Armando Pérez

    Let me spark the fire:

    Anybody using RenalGuard Device? Maybe a control measure for this kind of patients

    I can remember an interesting idea: retrieving the contrast after having depicted the coronary arteries with a catheter placed in the coronary sinus. As far as I have found, the clinical study was halted before completion. Budget issues? Clinical results? Challenging technique? More info here: https://clinicaltrials.gov/ct2/show/NCT01168024

    Come on, friends, thoughts are welcome

  5. lorenzo

    Yeah, Armando, CINCOR was pulled from market and replaced with DyeVert Plus (http://ospreymed.com/technology/) which is much easier to operate (it is an external system connected to the injector that gauges the contrast media to the exact amount needed to opacify the coronaries and avoids excess injected volume to be lost in aorta). This device has a featured symposium at TCT, for those interested.

    I never tried RenalGuard, I think it is a nice idea, but it is not feasible to employ in a high-volume cath lab: you need several units, you must wait until urine flow is high enough before starting PCI, you need a dedicated nurse taking care of the workflow, etc.

    Come on, guys, let’s make this thing a large debate and not just a conversation among three people. After all, CKD and CIN are very common problems in the cath lab and todo el mundo tiene que mojarse!

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