Cardiogenic Shock Algorithm From Inova Heart and Vascular Institute
Presenter
Behnam N. Tehrani, M.D., Inova Heart and Vascular Institute, Oakton, VA
Behnam N. Tehrani, M.D., Inova Heart and Vascular Institute, Oakton, VA
Title:
Acute Myocardial Infarction Complicated by No-Reflow and Cardiogenic Shock
Introduction:
Despite advances in early reperfusion, coronary no-reflow (CNR) can be seen in up to 10% of primary PCI cases. It is associated with increased infarct size, severe LV dysfunction and heightened mortality. We present a case of CNR complicated by cardiogenic shock requiring MCS to augment coronary perfusion.
Clinical Case:
52 y/o male presents to outside hospital with chest pain x 1 hour. In the ED, he had VF arrest with ROSC after one defibrillation. 12-lead EKG demonstrated ST elevation in v3-v6 and he developed refractory hypotension requiring pressors. Emergency coronary angiography demonstrated a 100% thrombotically occluded mid LAD which was unable to be recanalized despite angioplasty and thrombectomy. He had recurrent Vfib. LVEDP was 35 mm Hg. PA catheter confirmed cardiogenic shock with cardiac index 1.6 L/min/m2 and CPO 0.6 W. IABP was placed and he was airlifted to a tertiary medical center cath lab where IABP was exchanged out for Impella CP and he was admitted to the CICU. He stabilized hemodynamically and Impella was explanted at 48 hours. Repeat coronary angiogram at 96 hours demonstrated spontanenous recanalization of the mid LAD. He was initiated on optimal medical therapy and discharged home on day 6.
Discussion:
Coronary no-reflow is a known complication of primary PCI which can be associated with poor outcomes. In addition to standard pharmacologic therapies, LV unloading with Impella should be considered in cases of cardiogenic shock to reduce LVEDP and improve coronary perfusion pressures.