The importance of right heart catheterization in-patient with acute myocardial infarction complicated by cardiogenic shock.
Presenter
Shabib Abdullah Al Aasmi, M.D., National Heart Center ,Oman, Muscat, Oman
Shabib Abdullah Al Aasmi, M.D.1, Mohanad Shehadeh, M.D.2, Mohamed Salah Abdelghani, M.D.3, Abdulrahman Arabi, MD4 and Cheik Ahmed, MD4, (1)National Heart Center ,Oman, Muscat, Oman, (2)Hamad Medical Corporation, Doha, Qatar, (3)Hamad Medical Corporation, doha, doha, Qatar, (4)Heart Hospital, Hamad Medical Corporation, Doha, Qatar
Keywords: Cardiogenic Shock
Title
The importance of right heart catheterization in-patient with acute myocardial infarction complicated by cardiogenic shock.
Shabib AlAasmi, MD , AbdulRahman Arabi MD .
Introduction:
Ventricular septal rupture (VSR) is a rare but lethal complication of myocardial infarction (MI). This occurs 2-8 days after an infarction and often precipitates cardiogenic shock. The differential diagnosis of post infarction cardiogenic shock should exclude free ventricular wall rupture and rupture of the papillary muscles and this can be excluded by right heart catheterization after ST- elevation myocardial infarction ( STEMI).
Clinical Case
This 65-year-old gentleman who is a heavy smoker admitted with chest pain, which has been going on for 3 days. ECG shows clear evidence of Inferior ST elevation Myocardial infarction; he was taken to cath lab for primary PCI.
Coronary angiogram shows 100% occluded proximal RCA with 60% to proximal mid LAD lesion and 50% to OM 2 lesion.
He had successful PCI to RCA with the drug-eluting stent.
During the procedure he was hypotensive and Tachycardia and for that a right sided heart studies was done showed the Holly RV pressure with RVEDP of 25 mmHg and LVEDP of 36 mmHg and oxygen saturation from RA and RV showed a step up in saturation from 47% to 86% suggestive of possible shunt across at the ventricular septum the left. He had a low cardiac output [2.6 L/m].
Intra-aortic balloon pump was inserted through the right femoral artery. Urgent echocardiogram was done which showed dilated RV with normally functioning LV and clear Ventricular Septal Defect of approximately [1 cm] across mid ventricular septum with left-to-right shunt. The case was discussed with Cardiothoracic surgeon to close VSD surgically then decided to be done by percutaneous closure due to high risk closure surgically. Patient underwent percutaneous closure successfully but he was on cardiogenic shock with multi organ failure and ECMO team was consulted but due to severe peripheral vascular disease bilateral lower limb could not be done and Patient unfortunately arrested and died.
Discussion
Patient was admitted as case of acute inferior ST elevation myocardial infarction complicated by cardiogenic shock and ventricular septal rupture.
He had tachycardia with hypotension and the decision was to revascularize RCA and then right heart catheterization was done, as he was hemodynamically unstable. and echocardiography was not done before cardiac catheterization as he was on severe pain and shifted to cath lab immediately as life saving procedure.
Has been decided to do percutaneous closure of ventricular septal rupture rather than surgical closure due to high risk and also ECMO was not initiated due to severe peripheral vascular disease bilateral lower limbs so this case was challenging for the management
Take home message from this case that is worth to do right heart catheterization if the patient was in shock and hypotensive to rule out mechanical complications and this may change the decision of management.