Title:
Hemodynamic collapse in a STEMI patient soon after PCI
Introduction
Mechanical complications of acute myocardial infarction, such as free wall rupture, mitral regurgitation, and ventricular septal defect, are well-known complications in patients with late arrival MI. The incidence of these complications is low, but the mortality rate is very high emphasizing the importance of early diagnosis and prompt initiation of therapy. Our next case presents late arrival anterior STEMI patient with such a complication.
Clinical Case
74 year old female, with a medical history of diabetes mellitus and hypertension, presented to the emergency room with a complaint of 24 hours of chest pain. The initial ECG showed anterior STEMI. She was urgently transferred to the cath lab. The angiogram demonstrated three-vessel disease, with 80% stenosis in proximal RCA, 50% stenosis in the LCX, and 100% stenosis in the mid LAD. It was decided to proceed with PCI to mid-LAD. After successful revascularization to the LAD, the patient was transferred to the ICCU for monitoring and additional examinations. Twenty minutes after entering the ICCU, there was a dramatic complaint of dyspnea and weakness. Tachycardia and sudden decline in blood pressure (90/40 mmHg) were observed. TTE was immediately done, showing pericardial fluid with signs of tamponade. An ultrasound-guided pericardiocentesis was done bedside with rapid improvement in the hemodynamic status. she was urgently moved back to the cath lab to search for epicardial coronary arteries perforation. The second angiogram showed no leakage from the epicardial vessels. Because of an increase in accumulation in the patient’s pericardial drain, an additional echo was done, showing doppler consists of free wall rupture. The patient was urgently transferred to the operating room for repair of the rupture. After the surgery, the patient was on high-dose vasopressors, and on mechanical ventilation. Continue to deteriorate, she died 3 days after the surgery.
Discussion
We present a case of a patient with late arrival STEMI complicated by a free wall rupture and pericardial tamponade. Pericardial tamponade after PCI in patients with late arrival STEMI raises a differential diagnosis. It can be related to the procedure or , as in this case, due to mechanical complications mechanical complications should be suspected in all AMI patients. A high index of suspicion should be in patients presenting with late arrival STEMI, older age, or in any patients that deteriorate despite successful revascularization. Once mechanical complication occurs, a rapid multidisciplinary team action collaboration is indicated in order to improve the patient’s outcome.