Title
Ischemic Cardiogenic Shock and Temporary Mechanical Circulatory Support Bridge to Decision
Introduction
Despite the advances in therapeutic interventions regarding ACS-CS, in-hospital mortality remains higher than 50%. Acute myocardial infarction
is the most common underlying cause of CS. Temporary MCS is mandatory in the management of this critical scenario. Early intervention with adequate patient and device's selection may improve outcomes. The setup of a Mobile ECMO Team is a feasible and safe strategy to transfer patients to specialized centers.
Clinical Case
We report the case of a 52-year-old man with no cardiovascular history, who had been hospitalized for 7 days due to SARS-CoV-2 pneumonia, and was readmitted 24 hours later due to an extensive anterior STEMI. Coronary angiography revealed a thrombotic occlusion of the left anterior descending artery, which was treated with one drug eluting stent. He had to undergo a new PCI due to hyperacute stent thrombosis. During the procedure, the patient developed CS. Vasopressor and inotropic therapy was initiated. Bedside echocardiography showed severe LVSD. Right heart catheterization revealed a severely depressed CI, so an IABP was placed for hemodynamic support. During ICU stay, he persisted hemodynamically unstable even though vasopressors doses were increased. He was hypotensive with jugular venous distension, ventricular gallop, lung crackles, peripheral edema and cold extremities on physical examination. The patient developed lactic acidosis, acute kidney and liver injuries. Hemodynamic measurements indicated that the patient was still in shock. The EKG revealed sinus tachycardia and an anterior sequela; and the chest X-ray showed pulmonary edema. Three days later, we were contacted to request a referral for an ECMO implant. He was evaluated by multidisciplinary heart team and considered for VA ECMO as a bridge to decision. Our Mobile ECMO Team was composed of two cardiologists and two surgeons. Peripheral cannulation through femoro-femoral access was performed.´Ground time´ lasted 19 hours, fluid replacement therapy was started and vasopressors doses were decreased. The patient was transferred to our center under ECMO support for further management. Ambulance transfer took 18 minutes (18 km). On ECMO running day 3, an echocardiogram was performed and showed preserved ventricular diameters, EF was 35%, akinesis in the apical and mid septum; mid anterior, and apical anterior segments; and severe diffuse hypokinesis of the rest of the segments. As days went by, vasopressors doses were decreased and there was an improvement in kidney and liver function, as well as in perfusion parameters. The patient was successfully weaned from VA ECMO after 5 days. A week later, a new echocardiogram showed persistent severe LVSD. During the period of hospitalization, he was assessed for a heart transplant. GMDT for HFrEF was initiated.
Discussion
Cardiogenic shock remains a challenging condition with high mortality rate. Temporary MCS is a useful strategy implemented in these vulnerable patients as a bridge-to-decision, whether it’s recovery, or heart transplantation. The cornerstone of successful therapy with MCS is timely and appropriate patient selection. Institutions without ECMO capabilities should be supported in their identification of potential ECMO candidates who could be benefit from Mobile ECMO programs.