A Stitch in Time Saves Nine!
Presenter
Pooja M. Swamy, MD, FSCAI, Ascension St John Hospital, Detroit, MI
Pooja M. Swamy, MD, FSCAI, Ascension St John Hospital, Detroit, MI
Title:
A Stitch in Time Saves Nine!
Introduction:
We describe a case of RV failure in the setting of inferior STEMI and its management with prompt RV support.
Clinical Case:
61yr old male with history of hypertension presented with inferior STEMI and hypotension with blood pressure of 85/50 mm Hg and heart rate or 50 beats per minute in junctional rhythm that dropped to 40s. He received 1 mg of atropine following which he developed polymorphic ventricular tachycardia, terminated with defibrillation therapy. He was immediately taken to the cath lab. Invasive hemodynamic measurements demonstrated a cardiac power output(CPO) of 0.34 watts, pulmonary artery pulsatility index(PAPI)of 0.40, cardiac index of 1.43 l/min/m2, LVEDP of 15 mm Hg, mean arterial pressure of 61 mm Hg with a normal function LV gram. Impella RP was promptly inserted for RV support for RV failure. Coronary angiography demonstrated proximal RCA as culprit lesion, treated successfully with PCI. PAPI improved to 1.1, CPO to 1.3 and LVEDP was 22 mm Hg immediately post PCI. On the following day PAPI improved to 1.9.Impella RP was weaned and explanted. Patient had excellent recovery of RV function on echocardiogram and was discharged without any neurological deficits from initial hemodynamic compromise.
Discussion:
Early identification of RV failure in inferior STEMI and cardiogenic shock with RHC, and prompt treatment with RV support when CPO < 0.6 and PAP<0.9 before PCI to culprit lesion is prudent in improving cardiovascular outcomes.The understanding of RV failure and standardization of management strategies of cardiogenic shock is essential.