Case: Double Indication for Impella CP—High-Risk PCI and Acute MI Complicated by Cardiogenic Shock
Presenter
Rodrigo V. Wainstein, M.D., Ph.D., Hospital de Clinicas de Porto Alegre, Porto Alegre, ON, Brazil
Rodrigo V. Wainstein, M.D., Ph.D., Hospital de Clinicas de Porto Alegre, Porto Alegre, ON, Brazil
Title
Double indication for Impella CP: high risk percutaneous coronary intervention (HRPCI) and acute myocardial infarction complicated by cardiogenic shock (AMICS)
Introduction
We present a Impella CP case in post-cardiac arrest AMICS with extremely complex coronary anatomy and total AV block
Clinical Case
A 73yo male presented to the ER with 2h onset of chest pain. ECG showed ST depression in V2-V4 and ST elevation in AVR. Patient developed 2 cardiac arrests in VF (ROSC=15') and was brought to the cath lab on mechanical ventilation and norepinephrine drip (0.17 mcg.kg.min). Coronary angiogram showed a calcific 90% distal LM lesion, 90% ostial LAD lesion and two severe lesions in the mid-segment, 90% ostial Dg1 lesion, 95% ostial LCX lesion and 70% distal lesion. RCA was totally occluded. LVEDP was 18mmHg. Pre-PCI Impella CP and temporary pacemaker were positioned from right femoral approach. Initial plan was to perform Mini-Crush. However, after ZES deployment in the LCX ostium and stent crush with balloon dilatation of the LM it wasn't possible to advance another ZES to the LAD, even using Guideliner extension-catheter. Final angiograms showed 50-60% stenosis in the LM, no residual stenosis in the ostial LCX and TIMI 3 flow in all vessels. Post-PCI EF=55%. Impella CP was weaned after 36 hours. Heart team decided for CABG (LIMA to LAD and SVG to Dg/OM) 15 days after PCI. Patient was discharged home 7 days after surgery.
Discussion
HRPCI and AMICS are both indications for Impella CP. Pre-PCI Impella CP provided hemodynamic stability in this complex coronary anatomy case.