June 9, 2014
Today was our
first day in the hospital here at the Taiwan International Health Training Center
(TIHTC). We arrived and were given our
schedules. This week my colleague, Student Doctor Anny Xiao,
and I were placed in Cardiology rotations.
Our preceptor for today was Dr. Huang in the Cardiac Catheterization
lab. The healthcare system here in
Taiwan is quite different from ours in the United States. Taiwan employs a universal healthcare system that
covers the medical costs of all Taiwanese citizens. One of our patients today likely needs a CABG
which would cost around the range of 50,000 USD in the United States. Here it is free. Furthermore,
the doctors actually brought the family of the patients into the
Catheterization lab and presented the cases to them using the radiological
images. We observed a total of 2 cases
today. The rest of this entry is a
summary of those cases.
Our first patient
was a 40 year old male who presented with chest pain, severe cold sweats, and
syncope. He has a PMH of Familial
hypercholesterolemia, 5 stents already placed in his coronary circulation, re-stenosing
of a number of those stents, and LDL readings in the range of greater than
400. He has a FH of a brother with Familial
Hypercholesterolemia who has undergone a triple bypass and 10 PCIs. The main stenosis is at the bifurcation of
the Left Anterior Descending and Left Circumflex artery. The worst of these is the Circumflex vessel
which was stenosed at 99%. The initial
treatment plan was to place a stent in the Left Circumflex and handle the other
less severe stenosis with thrombolytic therapy.
Unfortunately, the balloon angioplasty was attempted four times and was
unsuccessful four times. There was no opening of the stenotic vessel at all so
Dr. Huang stopped the procedure. He was
also worried of risk of rupture and cardiac tapenade. If this would have happened we would have
seen a decrease in blood pressure and cardiac arrest within 5 minutes. The revised treatment plan involved two
options. The first option was the use of
a Rotablator. This device spins at
6000RPM within the vessel to ablate the atherosclerotic plaque. We asked if there was possibility of emboli
but Dr. Huang said that plaques are broken up into pieces so small that macrophages
will just digest them. Also thrombolytics
would be used concurrently. The
Rotablator option was less popular with Dr. Huang because of risk of rupture of
the already damaged and weak vessel. In
addition, the Taiwan Universal health system does not cover the procedure. It would have cost 150,000 NTD or about 5000
USD. Option 2 was a mini Coronary Artery
Bypass Graft. In 80-90% of cases there
are no recurrences of the stenosing within 10 years. They planned to do the operation without
opening up the sternum and without stopping the heart (Beating Heart
Method). This option is fully covered by
the national healthcare.
Our second
patient’s history was not presented to us but we noticed PVCs on the EKG as
well as a high BP. We came to find out
that he had a Chronic Total Occlusion of the left Circumflex Artery leading to
collateral circulation from the Right Coronary Artery to the Left Circumflex
(due to angiogenesis from chronic myocardial ischemia and small anterograde
flow). A PICC line was attempted on the
patient’s right side but his arteries were too tortuous around the axillary
artery. The procedure was halted for
worry of possibility of dissection and rupture.
Following, a PICC line was attempted on the patient’s left side. The insertion was successful; however,
further complications were encountered.
The first 2 balloons inflated in hopes of opening the stenosed vessel
both ruptured without opening the lesion.
A 3rd, smaller, balloon did not rupture but the stenotic
lesion did not remain fully open. Again,
the further use of another larger balloon was avoided for worry of rupture of
the vessel. Two Methods were used in
trying to open the stenotic lesion. The
first method was the Buddy Wire Method, where a second wire is inserted along
with the wire used to advance the balloon and stent. The second wire helps to support and stabilize
the stent and balloon. Because the Buddy
Wire Method was unsuccessful, the Anchor method was employed. In this method, a balloon was inflated in the
proximal portion of the Left Anterior Descending artery to help stabilize and
support the wire guiding the balloon and stent into the Left Circumflex Artery. This too was met with no success.
Seeing the cases
in person has definitely helped solidify some of the concepts behind Angiography
and Interventional Catheterization techniques.
What was surprising to me was that both of the cases we saw were both
complicated. Things did not go to
plan. I am excited to see what tomorrow’s
experiences bring.
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