2020 Scientific Sessions

Title

SINGLE ACCESS FOR MECHANICAL CIRCULATORY SUPPORT AND LEFT MAIN BIFURCATION PERCUTANEOUS CORONARY INTERVENTION IN ACUTE MYOCARDIAL INFARCTION WITH CARDIOGENIC SHOCK

Introduction

Mechanical circulatory support (MCS) is increasingly used for hemodynamic support in unstable patients. Single access technique allows for the use of a single arterial puncture where MCS and percutaneous coronary intervention can be performed through one vessel minimizing the risk for vascular access sites and complications. We present a case where this technique was used in a hemodynamically unstable patient requiring MCS support and left main (LM) bifurcating PCI in the setting of myocardial infarction.

Clinical Case

An 82 year old man with no past medical history presented with severe chest pain. Physical exam revealed a JVP of 12 cm, a 2/6 holosystolic murmur at the apex and systolic blood pressure of 85 mmHg.

ECG revealed no ST elevations, and TTE was significant for a LVEF of 25% with apical, septal and anterior akinesis. Troponin was elevated to 20.6 ng/mL. Cardiac catheterization revealed serial high grade (95-99%) lesions from the LM into the LAD and subtotal occlusion of the mid-LAD with TIMI-1 flow. There was severe ostial/proximal LCx disease, CTO of the distal LCx, and CTO of the proximal RCA. The PDA/PL were supplied via mature septal and epicardial collaterals from the LCx. Left ventricular end diastolic pressure was severely elevated to 36 mmHg.

Patient was deemed not to be a surgical candidate due to frailty, low EF and cardiogenic shock. An intra-aortic balloon pump (IABP) was placed at an outside hospital due to progressive cardiogenic shock with right heart catheterization revealing improvement in filling pressures prior to transfer to our institution. Here, due to concern for decompensation during LM bifurcation PCI, IABP was exchanged for Impella CP.

To minimize vascular access and complication risk, the Impella CP sheath diaphragm was punctured with a micropuncture needle and a 7 French sheath advanced through the 14 French Impella sheath. Overlapping 3.5 x 38 mm and 3.0 x 38 mm drug eluting stents (DES) were deployed from the proximal to mid LAD. A Culotte two-stent bifurcation strategy was used for the LM beginning with a 3.5 x 22 mm DES from the ostial LM into the proximal LCx. We crossed through the LM-LCx DES into the LAD to deploy a 3.5 x 15 mm DES from the ostial LM into the proximal LAD. With re-established TIMI 3 flow from the LM into the LAD/LCx, hemodynamics stabilized, allowing us to wean and remove the Impella.

Discussion

Our case demonstrates the feasibility of performing complex, Impella supported LM bifurcation PCI via single access in a hemodynamically unstable patient presenting with cardiogenic shock due to acute myocardial infarction. We demonstrate the feasibility and successful restoration of flow from the LM to the LAD/LCx while providing a favorable hemodynamic response allowing for the removal of MCS support post-procedure. The use of single access in this subset of patients provides an opportunity to allow operators to decrease vascular access sites and complication risks in unstable patients.