Title
Cardiac Arrest During Acute MI Revascularization: Mobile VA-ECMO and Progressive Mechanical Support Enable Survival
Introduction
This case demonstrates the complexities of managing cardiogenic shock following acute myocardial infarction complicated by cardiac arrest, multiorgan dysfunction, and transport challenges. It highlights the life-saving role of mobile VA-ECMO deployment, progressive mechanical support strategies, and careful hemodynamic staging in a critically ill patient.
Clinical Case
A 47-year-old male presented to the ED after experiencing chest pain while playing ice hockey. Shortly after arrival experienced a cardiac arrest warranting cardiac catheterization during which, he suffered multiple cardiac arrests. A DES was placed to OM1, and an Impella CP was inserted to provide immediate circulatory support. However, he remained hemodynamically unstable and unsuitable for transfer. In the early, a cardiothoracic surgeon from the receiving transplant center obtained emergency privileges, flew to the referring facility, and cannulated the patient for VA-ECMO at bedside. The patient was transported via helicopter while on ECMO to the tertiary care center. Upon arrival, evidence of severe metabolic derangement and end-organ injury continued: lactate 7 mmol/L, AST 263, ALT 208, free hemoglobin 120, LDH 1021, and troponin-I 123. He was managed with targeted temperature management (TTM), and cooled to 34°C. . ECMO flow was maintained at 4.3 L/min, sweep 4, with the Impella CP functioning at P3 (1.7 L/min) as an LV vent. Over the next 48 hours, the patient’s status remained tenuous. On hospital day 2, the team performed a surgical upgrade: the Impella CP was replaced with an Impella 5.5 (flow 4.2 L/min at P7), and VA-ECMO was successfully transitioned to VV-ECMO, reflecting improved cardiac function and persistent respiratory failure. VV ECMO was able to be removed after roughly two weeks. On HD 7, the patient returned to the cath lab for complete revascularization prior to planned weaning of support. Serial imaging over the next several weeks demonstrated progressive recovery of myocardial function, allowing full MCS withdrawal which occurred by HD 14.
Discussion
This case underscores several key principles in the management of AMI cardiogenic shock. The patient initially decompensated during PCI, prompting rapid initiation of percutaneous support. The addition of Impella CP helped stabilize the circulation temporarily; however, profound shock and cardiac arrest necessitated escalation to VA-ECMO. The timely cannulation for ECMO and safe air transfer under full support was a critical turning point. The integration of Impella CP (and later 5.5) as a venting strategy reduced LV afterload and preserved myocardial recovery potential. Upgrading from CP to 5.5 and converting VA-ECMO to VV-ECMO reflected favorable recovery of biventricular function and a strategic pivot from full circulatory to isolated pulmonary support. This level of care reflects SCAI shock staging progression and the evolving use of multiple MCS modalities tailored to each phase of illness. TTM was employed in the post-arrest setting. Sequential revascularization and support withdrawal based on functional improvement ensured patient safety and minimized device-related complications. This case illustrates the importance of early recognition, coordinated transport, and dynamic mechanical support strategies in the management of profound cardiogenic shock and post-arrest care.