Presenter
Scott Brewster, MD, Mid-America Heart Institute, North Salt Lake, UT
Scott Brewster, MD, Mid-America Heart Institute, North Salt Lake, UT
Keywords: Acute Coronary Syndromes (ACS), Cardiogenic Shock and Hemodynamic Support
Title Who's your PAPi Introduction Right ventricular failure (RV failure) is a well-described complication of right coronary artery (RCA) infarction and is complicated by high levels of morbidity and mortality. We describe a case of RCA infarction complicated by RV failure treated with Impella RP. Clinical Case A 69-year-old gentleman with morbid obesity (BMI of 45), CKD stage IV, type 2 diabetes mellitus, and hypertension presented to the hospital with dizziness, lightheadedness, and minimal to no chest pain. He was found to have hypoxia, and the intake ECG showed inferoposterior STEMI and bradycardia in the 40s with variable AV conduction. The patient was rapidly brought to the cath lab where he was found to have a 100% proximal RCA occlusion. This was treated with aspiration thrombectomy via multiple pass of Penumbra CAT Rx catheter with moderate amount of thrombus being extracted. We subsequently predilated with a 2.5mmx15 mm compliant balloon followed by IVUS and ultimately 3.5x48 mm DES and a 4.0 x 20 mm DES post dilated with 4.0x12 mm NC balloon with good angiographic and IVUS outcomes. Despite adequate perfusion by angiography, the patient remained bradycardic and with borderline low blood pressures. A right-sided transvenous pacer was placed, and he was paced at 60-70 BPM. A Swan-Ganz catheter was placed with the following results: RA: 28 mmHg, RV: 43/28 mmHg, PA: 43/31 (33) mmHg, PCWP: 27 mmHg, Cardiac output: 3.2 ml/min, Cardiac index: 1.2 ml/min/m2, PAPi of 0.42 and PA saturation of 32%. Given his severely low PAPi, we elected to place an Impella RP device. Immediately post placement, the patient had dramatic increases in systemic BP and subsequent PA saturation of 66% on repeat draw. Over the next 48 hours, the patient continued to have dramatic improvement and was able to wean and remove the Impella RP, TVP, and discharge home six days later. Discussion RV failure in the setting of acute MI has high levels of morbidity and mortality. However, prior studies suggest the RV may actually have good recoverability and resiliency compared to left ventricular (LV) infarction and ischemia. Placement of Impella RP remains an infrequently used tool in many catheterization labs today and in few cases; however, with appropriate patient selection, it may provide an optimal bridge to RV recovery. Optimal timing, guidelines and use of percutaneous right ventricular assist devices such as Impella RP remains to be determined. Increased awareness and potential use of such devices will be the first steps in normalizing this as part of our interventional arsenal.