Types of the Wellen’s Syndrome

class: center, middle, inverse, title-slide

.title[
# Types of the Wellen’s Syndrome
]
.subtitle[
## Illinois Medical District Cath Conference
]
.author[
### Anish Shah, MD/MS<br>Marianna Sargsyan, MD<br>Adhir Shroff, MD/MPH
]

---

.pull-left[
### History

- Ms. LB is a 59 year old woman
- She presents with chest pain overnight - worsening, exertional, and typical
- Past medical history of __hypertension__, __hyperlipidemia__, __diabetes__
- Former drug use, and active __smoker__
- Additional history of untreated HCV, bipolar disorder
- In the emergency room, initial ECG shows concerning TWI in anterior leads
- Cardiology consulted for potential cath lab activation

]

.pull-right[
### Physical

- HR 95 bpm, BP 144/90, 95% on room air
- Thin woman in acute distress, alert and oriented
- +2 radial and +2 femoral pulse bilaterally
- Normal rate, regular rhythm
- S1/S2 with soft systolic murmur
- Initial ECG with Wellen's syndrome type 2, and subsequent ECG with Wellen's type 1
- Bedside echocardiography with anterolateral wall hypokinesis, LVEF of 25%
]

---
class: middle

.pull-left[

```r
knitr::include_graphics("lb-ecg-first.png")
```

<img src="lb-ecg-first.png" width="1131" />
]

.pull-right[

```r
knitr::include_graphics("lb-ecg-second.png")
```

<img src="lb-ecg-second.png" width="1131" />
]

Initial ECG and subsequent ECG approximately 30 minutes apart in setting of persistent chest pain.

---
class: middle

.left-column[
- Right radial artery with vasospasm
- Left radial artery used for 6F introducer sheath with US
- 5F JR-4 used for RCA selective angiography
]

.center[
.right-column[

```r
knitr::include_graphics("lb-01-rca.gif")
```

![](lb-01-rca.gif)
]
]
	
---
class: middle

.left-column[
- Exchanged for 5F JL-3.5 over wire
- LCA selective angiography performed in multiple views
]

.center[
.right-column[

```r
knitr::include_graphics("lb-02-spider.gif")
```

![](lb-02-spider.gif)
]
]

---
class: middle

.left-column[
- Ostial LAD deemed culprit lesion
- Started on IV cangrelor and heparin boluses 
- Exchanged to 6F XB-3.5 guide catheter
- BMW wire positioned in distal D1 artery
- Pilot 50 advanced to distal LAD
]

.center[
.right-column[

```r
knitr::include_graphics("lb-03-wire-lad-d1.gif")
```

![](lb-03-wire-lad-d1.gif)
]
]

---
class: middle

.left-column[
- Initial angioplasty with 2.5 x 12 mm SC balloon
- IVUS performed showing 360 degree of calcium in ostial LAD
]

.center[
.right-column[

```r
knitr::include_graphics("lb-ivus.gif")
```

![](lb-ivus.gif)
]
]
	
---
class: middle

.left-column[
- Proceeded with IVL
- 6F guideliner advanced for support
- 4.0 x 12 mm Shockwave balloon positioned
- 1 cycle at 4 atm and 4 cycles at 6 atm performed 
]

.center[
.right-column[

```r
knitr::include_graphics("lb-04-first-balloon.gif")
```

![](lb-04-first-balloon.gif)
]
]
	
---
class: middle

.left-column[
- Predilated lesion to 12 atm with NC balloon
]

.center[
.right-column[

```r
knitr::include_graphics("lb-05-stent-position.gif")
```

![](lb-05-stent-position.gif)
]
]
	
---
class: middle

.left-column[
- 4.0 x 18 mm DES deployed at 14 atm
- Post dilated with 4.5 mm NC balloon 
]

.center[
.right-column[

```r
knitr::include_graphics("lb-06-stent-deployed.gif")
```

![](lb-06-stent-deployed.gif)
]
]
	
---
class: middle

.left-column[
- Diagonal branch mildly pinched but with TIMI-3 flow
- Confirmed TIMI-3 flow in LAD 
- No evidence of dissection, perforation, or distal embolization
]

.center[
.right-column[

```r
knitr::include_graphics("lb-08-final.gif")
```

![](lb-08-final.gif)
]
]
	
---
class: middle, inverse

# Conclusion

.left[
The highly calcific nature of the ostial LAD benefited from IVL in the setting of a STEMI. The patient did well afterwards, with no further chest pain. Formal echocardiography with anterolateral hypokinesis and LVEF of 25%. Discharged with cardiac rehab, beta blockade, RAAS inhibition. 
]