Case Review, ECMO, AMI Cardiogenic Shock
Recovery from STEMI-to-Shock Downward Spiral
Alexander Truesdell, MD, presents a case of a 61-year-old male who presented with acute anterior STEMI. With heart rate in the 80s and blood pressure 120s, this patient was not clinically meeting any criteria for cardiogenic shock when transferred to the cath lab. The patient had multivessel occlusion and received a stent in proximal LAD. Unfortunately, it was a geographic miss and likely resulted in proximal edge dissection. The patient spiraled into cardiogenic shock with blood pressure in the 50s. After repeated boluses of epinephrine totaling 10 mg, the operator called in Dr. Truesdell.
Dr. Truesdell emphasizes that for patients in cardiogenic shock, the key is “restoring hemodynamics and not just focusing on coronary perfusion.” He explains that it is important to factor in circulatory support and ventricular support as well as coronary perfusion. In other words, to maintain vital organ perfusion and reduce myocardial oxygen demand as well as increase coronary flow. Thus, his first step in this case, after examining groin and aortoiliac angiograms, was to insert an Impella CP® heart pump to restore normal physiology before addressing the anatomy. Once the patient was hemodynamically stable, Dr. Truesdell performed an IVUS-guided LAD PCI, placing a 4.0mm x 12mm stent just proximal to the previously placed stent.
“You shouldn’t leave the safety of the cath lab or the OR until someone’s stable, and that includes making sure that they’re not going to later develop acute limb ischemia,” Dr. Truesdell notes. He describes how he put in a right IJ Swan and placed an A-Line, stating that it is incumbent upon the interventional cardiologist “to do those right heart cath hemodynamics in the cath lab, establish a baseline, repeat them in the cardiac intensive care unit.” Ongoing reassessment is key. “Just because you had initial success, doesn’t mean the patient’s going to continue to succeed. So, you have to keep reassessing the hemodynamics, lactate, the RV function and the LV function.”
In this case, pressers were weaned and the Impella® came out after five days. “Typically, even in shock, I will pre-close,” Dr. Truesdell explains, although he did not in this emergency case. He notes that the rate of groin infections for surgical closure following CABG is only 6% and that following ECMO, cardiac surgeons typically pre-close and leave the Perclose in for days. He therefore suggests that institutions discuss the use of pre-close due to the fact that it really helps facilitate removal. He also states that he favors balloon-occlusion dry-closure from the radial so as not to introduce a second access site.
This patient was discharged home on Day 20 with an ejection fraction of 30 to 35%, which was a marked improvement from the EF of 10% immediately post-procedure. He went to physical therapy and is currently preparing to enroll in cardiac rehab.