ECMO Support Complicated with Early Multiple Stents Thrombosis Post Primary PCI- Case Report-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY
Introduction: 1yr PCI+ECMO in the setting of cardiac-arrest and cardiogenic shock is challenging. Data has shown promising results in
mortality reduction.
Case presentation: 57y man admitted
with NSTEMI. LVEF-35%. 6-hours later he developed LBBB and taken for
primary PCI. CAG: proximal occlusion-LAD, Tight lesion-Big ramus,
normal-LCX and CTO-RCA. PCI to LAD and ramus were done. After
stent-deployment, he developed
cardiac-arrest. CPR initiated, IABP inserted and TPM was placed, he
revived after 1.5hours of CPR. LVEF 10%. So peripheral VA-ECMO was
inserted for cardio respiratory support and we could be able to wean it
off successfully after 5 days from deployment.
He developed severe thrombocytopenia so, clopidogrel
stopped & aspirin continued. After 36hours of ECMO removal, sudden
clinicaldeterioration
was observed with severe shock again. EF 15%. Re look Angio revealed:
all stents occluded thrombi. Aspiration thrombectomy
done and hemodynamics was supported with IABP again. He also developed
pneumonia and septic-shock and VA-ECMO implanted again. This
time we could wean off ECMO. On the 30th Post cardiac arrest, ECMO was
explanted due to oxygenator clotting. Next day he was declared dead.
Conclusion: Our case is an example
where a seemingly well doing patient after ECMO implantation,
deteriorated all the way to death due to diagonally opposed balance
between the risk of bleeding due to DAPT and heparin and the risk of
stent thrombosis if that therapy is withdrawn.
Further studies are required to carve out the
anti-platelet strategy in patients with peri-arrest primary PCI+ECMO.
Timing of insertion of
ECMO may be crucial as if it is done earlier in such patients with
STEMI+cardiogenic shock may lead to a less complicated course and more
fruitful outcome.
Introduction
Primary PCI is the treatment of choice for patients with acute
ST elevation Myocardial Infarction (STEMI) and has been shown
to significantly reduce mortality. Primary PCI in the setting of
cardiac arrest is challenging, data has shown promising results
in mortality reduction but however shock, hypothermia and
changes in anti-platelet pharmacokinetics and stent thrombosis
in peri-arrest milieu are feared devastating complication [1,2].
Extra-corporeal Membrane oxygenation (ECMO) is on the move
as a supporting bridge for recovery but Data is scarce in this
population group about the appropriate strategy for anti-platelet therapy [3]. Despite advances in coronary revascularization
and widespread use of primary percutaneous interventions,
cardiogenic shock complicating an acute ST-elevation myocardial
infarction remains a clinical challenge with high mortality rates
[4]. Conservative management with catecholamines is associated
with serious limitations, including arrhythmias, increased
myocardial oxygen consumption, and inadequate circulatory
support. Clinicians have therefore turned to mechanical means
of circulatory support [5,6]. We present a case of early stent
thrombosis in a patient who underwent primary PCI for acute ST elevation MI and had cardiac arrest during the procedure; while
ECMO was inserted for support.
A 57 year gentleman, smoker, recently discovered to be
Diabetic and dyslipidemic was admitted with initial diagnosis
of NSTE-ACS. Initial ECG’s showed dynamic ST depression in
precordial leads. Initial Echocardiography showed Moderatesevere
LV dysfunction, LVEF -35%. Six hours later the patient
had chest pain again and developed acute LBBB and was taken
for primary PCI. Coronary Angiography revealed proximal total
occlusion of LAD, Severe disease in a good sized ramus, a normal
LCX and a totally occluded RCA filling retrograde from LAD by
collaterals. PCI to LAD (culprit vessel) was decided. Lesion was
successfully crossed, ballooned and flow regained (the vessel
was small caliber).However just after deployment of the stent
(still the vessel was patent with TIMI III flow), he developed
severe pulmonary edema, bradycardia and cardiac arrest (PEA).
Cardiopulmonary resuscitation was done (it was interrupted
with short periods of intrinsic activity) IABP was inserted and
TPM was placed and the patient was intubated and mechanically
ventilated, the patient revived after prolonged CPR (1.5 hours).
Re-Angio revealed still patent LAD and sub totally occluded
Ramus, which was patent before. PCI to Ramus was successful.
Subsequent Echocardiography showed severe LV dysfunction
with LVEF 10-15%. Due to continued hemodynamic deterioration,
it was decided to support the patient with ECMO. VA-ECMO was
inserted in left groin in the Cath Lab then the patient shifted to
CCU and we could able to come down with the inotropes and
the patient started to be awake and moving all limbs. In the first
night the CVP was increased up to 26mm H2O and CXR showed
massive left pleural effusion so left chest drain was inserted
and more than 2 liters of bloody effusion was drained after that
the CVP went down to 11mm H2O and the ABG improved but
repeated CXR revealed recollection again in left pleura and Hb
continued dropping despite of continuous blood transfusions
so he was taken to OR for exploratory left thoracotomy which
revealed big amount of blood clots and bleeding intercostal
artery and fracture ribs due to CPR and external cardiac
massage. After that he became stable again and Hb started to
build up. After stabilization of the patient and became generally
better with good ABGs, and good Hemodynamics he was taken
again to the Cath Lab electively for another trial to open the RCA
which was succeeded this time and RCA was opened and stented.
The LAD and Ramus artery stents were found to be patent with
TIMI III flow. The patient was shifted again to CCU and ECMO
weaning started gradually which was successfully done in the
5th day post implantation. Echocardiography showed EF 40%
after ECMO explantation.
During the course of ECMO, patient had developed severe
thrombocytopenia and severe anemia as well so, clopidogrel had
to be stopped, Aspirin was continued. However after 48 hours
of removal of ECMO, new suddenly clinical deterioration was observed with severe cardiogenic shock again. Echocardiography
showed EF-15%. A Re-look Angio showed that all the stents were
occluded with huge thrombi. Extensive aspiration thrombectomy
was done and hemodynamics was supported with IABP again.
Unfortunately patient also developed extensive bilateral
pneumonias (positive sputum for Acinetobacter boumani &
Pseudomonas carnii) and a VA-ECMO was deployed again but
due to septic shock this time. Patient had sepsis with prolonged
protracted course. This time patient could not be weaned off
ECMO despite repeated trials. On the 30th Post cardiac arrest
ECMO was explanted due to clotted ECMO’ oxygenator and
blocked flow and unfortunately in the next day the patient was
declared dead.
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