Extracorporeal Membrane Oxygenation in a Young Female With Spontaneous Coronary Artery Dissection
Presenter
Katherine Bailey, MD, UCLA David Geffen School of Medicine, Los Angeles, CA
Katherine Bailey, MD, UCLA David Geffen School of Medicine, Los Angeles, CA
Title:
Extracorporeal membrane oxygenation in a young female with spontaneous coronary artery dissection
Introduction:
Spontaneous coronary artery dissection (SCAD) complicated by ventricular arrhythmias and hemodynamic compromise is a rare and technically challenging case for the interventionalist. The fragility of the vessel wall and the risk of propagation of the dissection through instrumentation make percutaneous interventions challenging despite the availability of intracoronary imaging and mechanical support. There are few reports on the utilization of extracorporeal membrane oxygenation (ECMO) in the setting of SCAD. This case describes the successful application of ECMO followed by PCI in a young female who presented with cardiac arrest secondary to SCAD.
Clinical Case:
A 38-year-old woman with no past medical history presented after sudden cardiac arrest at her workplace. Bystander CPR was started. The patient was found to have ventricular fibrillation by EMS and underwent defibrillation. The patient was transferred to the emergency department where veno-arterial (VA) ECMO was initiated for incessant ventricular fibrillation within 15 minutes of her arrest. She underwent emergent coronary angiography which revealed a 99% dissection lesion of the mid-distal left anterior descending coronary artery (LAD) extending to the apical LAD, consistent with SCAD with TIMI (thrombolysis in myocardial infarction) flow grade 1 past the lesion. Given the presentation of cardiogenic shock and concern for ongoing infarction, the decision was made to pursue percutaneous revascularization. Intravenous heparin and cangrelor were administered. A Balance guidewire was cautiously advanced and used to wire the LAD lesion. True-to-true lumen crossing was confirmed using gentle contrast injection through the distal end of an over the wire (OTW) balloon, as well as with intravascular ultrasound (IVUS), which demonstrated a clear dissection entry point in the distal LAD with significant subintimal hematoma. Serial pre-dilation was performed with a 1.5x20mm balloon with improvement in flow. Two overlapping 2.5x18mm and 2.25x38mm drug-eluting stents were used to cover the dissected segment of the LAD. IVUS demonstrated well-expanded, well-opposed stents and the final angiograms demonstrated TIMI-2 flow with no residual dissection. The patient was taken to the intensive care unit in sinus rhythm with no ventricular arrhythmias and not requiring vasopressors. Hypothermic protocol was initiated. On hospital day two, the patient was successfully decannulated from ECMO. Despite the above treatment, the patient remained comatose with cerebral edema and signs of severe anoxic brain injury on imaging. She was ultimately discharged to a long-term care hospital.
Discussion:
While conservative management is the preferred approach for most patients with SCAD, revascularization should be considered in patients with proximal coronary occlusion, hemodynamic compromise, or unstable arrhythmias. In this case, we describe the successful use of ECMO for mechanical support in the setting of SCAD complicated by incessant ventricular fibrillation and shock. ECMO was decannulated on hospital day 2 following PCI, which supports the efficacy of this modality in critically ill patients with SCAD. Further investigation of optimal management of SCAD complicated by hemodynamic compromise is necessary.