Title
:
Pulling Out the Big Guns- Atherectomy in a Case of Cardiogenic Shock (CS)
Introduction
:
We describe a case of an octogenarian with CS and multi-vessel calcified CAD treated with atherectomy and creation of external fem-fem bypass with native heart recovery.
Clinical Case
:
80-year-old male was transferred from a 'spoke' hospital with Intra-aortic Balloon Pump (IABP), in
SCAI stage-C CS and multi vessel calcified CAD. EF was 20% with proximal LAD CTO and severely diseased calcified Lcx. RCA was a large dominant vessel with severely calcified lesions in mid and distal segments. After
shock-team discussion, patient was taken to the Cath lab.
Right heart catheterization- CPO 0.7, PAPI 0.94. IABP was swapped out for Impella CP. Temporary pacemaker was placed. After conforming absence of thrombus with
IVUS,
rotational atherectomy and PCI was performed to mid and distal RCA with excellent angiographic result. Patient had no pulsatility and was dependent on Impella. At the end of the case, it was noted that patient did not have Doppler pulses owing to the
occlusive large bore Impella sheath. After obtaining antegrate access, an
external fem-fem bypass was created to perfuse the limb. On day 3, CPO was 1.2, PAPI was 2.3. Impella was weaned off, removed in the Cath lab by
dry closure. Patient was discharged to rehab on day 5.
Discussion
:
Learning points: -
Hub and Spoke Model for CS - Shock-Team Discussion - Treatment of calcified coronary lesions with atherectomy in the setting of CS - Importance of limb perfusion- external fem-fem bypass