Keep Calm and Carry On: Effective Use of ECPR for STEMI in an Agitated Patient
Presenter
Samantha Michelle Espinosa, MD, Brigham and Women's Hospital, Boston, MA
Samantha Michelle Espinosa, MD, Brigham and Women's Hospital, Boston, MA and Dilip Pillai, MD, Mayo Clinic Florida, Jacksonville, FL
Title:
Keep Calm and Carry On: Effective Use of ECPR for STEMI in an Agitated Patient
Introduction:
Extracorporeal Cardiopulmonary Resuscitation (ECPR) is a useful tool for patients with persistent cardiac arrest, particularly with a probable reversible cause. We present a case of ECPR in a patient with STEMI.
Clinical Case:
A 50 year old woman with current tobacco use and family history of premature coronary artery disease presented to the ER for 6 hours of substernal chest pain with radiation to the arms. She was hemodynamically stable but in significant distress. An initial ECG confirmed inferior ST elevations with anteroseptal ST depressions consistent with inferoposterior infarct and she was referred for emergent coronary angiography via right radial access.
Angiography revealed severe stenosis in a large left circumflex (LCX) and obtuse marginal (OM) branch with TIMI 3 flow. No significant disease was noted in the LAD or RCA. Given her ongoing severe chest pain, ST elevations and agitation, an aortic root angiogram was performed which was negative for dissection. The decision was made to proceed with percutaneous coronary intervention (PCI) of the LCX and OM via an Xb 3.5 6F guide catheter, treated successfully with one 3.0 x 28mm drug eluting stent (DES) with excellent angiographic results and improvement in ST elevation. Unfortunately the patient remained agitated and disoriented with moderate sedation, and abruptly pulled her right arm up from the lab table. She continued to have pain and recurrent ST elevation. Repeat angiography confirmed a guide catheter-related left main (LM) dissection extending into the mid LCX and retrograde into the aortic root. Before a second DES could be deployed, the patient deteriorated into ventricular fibrillation (VF) arrest. CPR was initiated and she remained in persistent VF despite multiple defibrillations. A LUCAS device was placed for continuous chest compressions. After discussion with cardiothoracic surgery, the decision was made to emergently initiate VA extracorporeal membrane oxygenation (ECMO) for ECPR support. The right femoral vein and left femoral artery were cannulated and ECMO was started but she remained in persistent VF. Angiography showed progression to TIMI 1 flow in both the LCX and LAD. A 4.0 x 12mm DES was successfully deployed in the LM into LCX with restoration of TIMI 3 flow in the LCX and LAD. The patient was defibrillated again and successfully maintained sinus rhythm. TEE confirmed initial improvement in left ventricular function with LVEF 35%, and the extent of the ascending aortic dissection with no residual flap or color flow from the LM into the aortic root. The patient recovered in the ICU and was decannulated from VA-ECMO on hospital day 2. LVEF recovered to 56%. Cardiac CTA confirmed aortic intramural hematoma without dissection flap. She was discharged in stable condition on hospital day 7.
Discussion:
This case demonstrates the importance of patient cooperation and adequate sedation in PCIs to minimize risk of guide dissections. We also demonstrate ECPR promptly and effectively being initiated, allowing for the completion of PCI and recovery from VF arrest.