STEMI from Pericardial Drain RCA Compression after Balloon Pump Removal
Presenter
Akshat Mehta, M.D., Augusta University Medical Center, Augusta, GA
Akshat Mehta, M.D.1, Jared Mullins, D.O.2, Deepak Kapoor, M.D.1 and Alexander Warner, M.D.3, (1)Augusta University Medical Center, Augusta, GA, (2)Medical College of Georgia, Evans, GA, (3)Augusta University Medical Center, North Augusta, SC
Title:
STEMI from Pericardial Drain RCA compression after Balloon Pump Removal Introduction:
Pericardial catheters are a crucial tool in the management of pericardial tamponade resulting from coronary artery perforation during high-risk percutaneous coronary intervention (PCI). Concomitant shock can also be managed by the support of an intra-aortic balloon pump to increase cardiac output by decreasing afterload and increasing coronary perfusion pressure. Here we present a case of external right coronary artery (RCA) compression from a pericardial drain resulting in an inferior ST elevation myocardial infarction (STEMI) after intra-aortic balloon pump (IABP) removal. Clinical Case:
66-year-old female with hx of hypertension, diabetes mellitus, cerebrovascular accident, and coronary artery disease (CAD) with hx of MI who was transferred from an outside hospital with Acute Coronary Syndrome. Coronary Angiography revealed multi-vessel CAD. She was formally evaluated by cardiothoracic surgery and deemed too high risk for coronary artery bypass surgery. Staged high risk PCI was performed on the ostial, proximal, and mid left anterior descending artery (LAD), and proximal and mid RCA. During the procedure, she became acutely hypotensive, and IABP was placed. It was then discovered that she had coronary perforation in the mid-LAD and a covered stent was placed. Echocardiogram revealed a large pericardial effusion with RV diastolic collapse consistent with tamponade. Pericardiocentesis was performed and pericardial drain was placed. She was stabilized and transferred to the cardiovascular intensive care unit. The next day repeat echocardiogram was performed which showed severe aortic insufficiency and the decision to remove the IABP was made. Shortly after balloon pump removal, the patient developed complete heart block with ST elevations in leads II, III, and aVF on ECG. The catheterization lab was activated. Coronary angiography showed TIMI 0 flow in the RCA distal to an overlapping pericardial drain where prior catheterization previously showed TIMI 3 flow. RCA was ballooned, followed by pericardial drain repositioning, and finally placement of a drug eluding stent. Intravenous ultrasound was also used which alluded to external stent compression. Discussion:
This patient had a complicated course with a STEMI after IABP removal. It is suspected that the IABP was augmenting coronary perfusion pressure enough to prevent RCA occlusion from pericardial drain compression seen on fluoroscopy. This case demonstrates a rare complication of pericardial compression that led to coronary occlusion. Operators should be aware of this potential complication and act swiftly to correct the position.