2023 SCAI SHOCK

Introduction: A 65 year old man presented to the ER via EMS with abrupt onset chest pressure. He had reported increasing dyspnea and presyncope in the preceding 3 days. A 12 lead EKG demonstrated inferior STEMI and the cath lab was emergently activated. One week prior to presentation he had been diagnosed with advanced esophageal cancer and had had a percutaneous gastric tube placed for supplemental tube feeding due to pathologic weight loss.

Clinical Case: Coronary angiography was performed which revealed an occlusion of the proximal right coronary artery with TIMI 0 flow. There were no significant lesions in the left coronary artery. The patient's blood pressure was rapidly decreasing and LVEDP was elevated to 28 mmHg. An impella CP device was placed emergently via right femoral artery with improvement in hemodynamics and the patient was intubated due to agitation and for airway management. Uncomplicated PCI was performed to the RCA with placement of two drug eluting stents with excellent results. TIMI 3 flow was restored and EKG changes improved however the patient remained persistently hypotensive, requiring escalating doses of vasoactive infusions to maintain a MAP >55 mmHg. The leading diagnosis at this point was shock to acute RV failure, and a right heart catheterization was performed which showed elevated diastolic pressures. The patient was transferred to the ICU and a bedside echocardiogram was performed which demonstrated a large circumferential pericardial effusion and evidence of pericardial tamponade. On echo, bubbles were noted in the pericardial fluid. An emergent bedside pericardiocentesis was performed with echocardiographic guidance. Upon accessing the pericardial space with a micropuncture needle there was immediate return of viscous, yellow, foul-smelling purulent fluid. An 8 French fenestrated drain was placed in the pericardium and approximately 700 cc of similar purulent tube feeds with particles of food was aspirated from the pericardial space. The pericarial effusion was no longer present on echo and there was immediate improvement in the patient's hemodynamics and normalization of blood pressure. The patient's vasoactive medications were discontinued and he was started on broad-spectrum antibiotics. A consultation was performed by a thoracic surgeon for consideration of pericardial washout. The patient was treated aggressively in the ICU for 48 hours but developed recurrent shock physiology more consistent with sepsis. Given the patient's poor prognosis with respect to his esophageal cancer he was transition to comfort care and expired.


Discussion This patient presented with inferior STEMI and shock due to pericardial tamponade, which was not initially recognized since the patient was being treated for inferior STEMI. The infected pericardial space occurred because of a fistula between the pericardium and the esophagus related to advanced malignancy. It is possible that the elevated pericardial pressure along with the ongoing bacterial inflammation in the pericardial space contributed to the right coronary occlusion. In a patient presenting with acute coronary syndrome and hypotension it is important to consider all possible etiologies of shock, taking into consideration in all relevant elements of the clinical history.