Saudi Critical Care Journal

CASE REPORT
Year
: 2022  |  Volume : 6  |  Issue : 3  |  Page : 75--77

ECPella: High-risk percutaneous coronary intervention in cardiogenic shock “case report”


Rayan Qutob1, Alanoud Hassan A. Alkhannani2, Arif Hussain3, Owayed Al Shammeri4, Alyaa Elhazmi5,  
1 Department of Internal Medicine, College of Medicine, Imam Mohammad IBN Saud Islamic University; Department of Adult Critical Care, Dr. Sulaiman Al-Habib Medical Group, Riyadh, Saudi Arabia
2 Department of Internal Medicine, College of Medicine, Imam Mohammad IBN Saud Islamic University, Riyadh, Saudi Arabia
3 Department of Cardiac Critical Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
4 Department of Cardiology, Dr. Sulaiman Al-Habib Medical Group, Riyadh, Saudi Arabia
5 Departments of Adult Critical Care, Dr. Sulaiman Al-Habib Medical Group; Department of Internal Medicine, College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia

Correspondence Address:
Rayan Qutob
Department of Internal Medicine, Imam Mohammad IBN Saud Islamic University, Riyadh
Saudi Arabia

Abstract

The utilization of mechanical circulatory support devices in high-risk percutaneous coronary interventions (PCI) has recently evolved. In Saudi Arabia, the use of such devices is under-reported. Here, we present a 36-year-old patient who was admitted to the hospital with a non-ST-elevation myocardial infarction with biventricular dysfunction. A high-risk PCI consist of unprotected left main stenting was performed with the assistance of venoarterial extracorporeal membrane oxygenation that allowed smooth and successful intervention. Two days later, Impella was used to augment the recovery of the myocardium. The implementation of this approach helped our patient hemodynamically and allowed the recovery of the myocardium.



How to cite this article:
Qutob R, A. Alkhannani AH, Hussain A, Shammeri OA, Elhazmi A. ECPella: High-risk percutaneous coronary intervention in cardiogenic shock “case report”.Saudi Crit Care J 2022;6:75-77


How to cite this URL:
Qutob R, A. Alkhannani AH, Hussain A, Shammeri OA, Elhazmi A. ECPella: High-risk percutaneous coronary intervention in cardiogenic shock “case report”. Saudi Crit Care J [serial online] 2022 [cited 2023 Feb 3 ];6:75-77
Available from: https://www.sccj-sa.org/text.asp?2022/6/3/75/362190


Full Text



 Introduction



Despite the fact that cardiovascular interventions and technologies have advanced, around a third of patients still face a risk of hemodynamic compromise. Mechanical circulatory support (MCS) devices have been proposed as an adjunct to high-risk percutaneous coronary interventions (PCI) combined with medications to improve outcome.[1],[2]

The available MSC devices are intra-aortic balloon pump (IABP), veno-arterial extracorporeal membrane oxygenation (VA-ECMO), Impella, and Tandem Heart. Each of these circulatory supports tackles one direction of cardiogenic shock at the expense of other directions [Table 1]. Understanding the pathophysiology of cardiogenic shock is paramount in choosing one MCS over the other.{Table 1}

 Case Report



A 36-year-old male with Type 1 diabetes mellitus. Patient and family were consented to report his case. He presented to the emergency department with chest tightness and palpitation for 1-week duration. There was no history of fever. On arrival at the emergency room, the patient's blood pressure was (119/80 mmHg), heart rate (120 beats/min), and oxygen saturation (96%). On a 12-lead electrocardiogram, sinus tachycardia was detected with no ischemia. The laboratory test results included positive troponin I (0.131 ng/mL), high gamma-glutamyl transferase (238 IU/L), raised aspartate aminotransferase (76 IU/L), and normal alanine aminotransferase (39 IU/L). The chest X-ray was normal; chest computed tomography with pulmonary embolism protocol revealed no evidence of pulmonary embolism. Moreover, transthoracic echocardiography revealed severe biventricular dysfunction, ejection fraction (EF) of 10%, severe global hypokinesia with no significant valvular pathology. Therefore, he was diagnosed with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). He underwent coronary angiography, which revealed a significant distal left main (LM) coronary artery disease (70% stenosis), mild distal right coronary artery disease. The left ventricular (LV) diastolic pressure was 35–40 mmHg (Normal <12 mmHg). The patient developed cardiogenic shock by the time of day of coronary angiogram requiring inotropic support. He was referred to the heart team for a consensus decision. The cardiac surgeon declined the case as the patient at very high risk with his current cardiogenic shock state.

Given the significant risk of complications and mortality during any revascularization procedure, a multidisciplinary meeting was held, and the decision was made to do high-risk PCI with MCS in the form of VA-ECMO. Because the patient has significant hemodynamic instability with severe biventricular failure, VA-ECMO (Xenios Novalung, Germany) was inserted while the patient awake (femoral vein diameter 23 mm and femoral artery 17 mm) under ultrasound guidance. The high-risk PCI was successfully performed (Unprotected LM stenting) while the patient was on ECMO with a flow of 2.5 L/min [Figure 1]. It is worth noting that during the procedure the patient lost pulsatility with every balloon inflation in the distal LM instantaneously, but he was awake and the mean arterial pressure was maintained above 65 mmHg by adjusting ECMO flow.{Figure 1}

The patient improved markedly right after the PCI and was able to stop all inotropic support 2 h after the LM stenting. The next day, the patient's color and urine output were normal and we planned to wean him from VA-ECMO. Although his hemodynamics were stable during the weaning trial but halted for another 24 h due to concern of the ECHO finding of still severe biventricular dysfunction. On the 2nd day post-PCI, the clinical condition deteriorated further requiring him to be back to the inotropic support (norepinephrine and dobutamine). The cardiogenic shock recurs again with even worse form. He had significant chest discomfort, confusion, oliguria, loss of pulsatility on the arterial tracing, hypoxia, and the lactate level increased to 3.5 mmol/L. The echocardiogram showed spontaneous echo contrast in the LV cavity and a closed aortic valve on ECMO flow of 2 L/min. We decided to decompress the left ventricle using Impella CP device.

The patient was electively intubated to avoid harlequin syndrome and shifted back to the cardiac catheterization lab to assess the coronary circulation and insert the additional mechanical support device. Angiography showed patent coronary arteries, an IMPELLA CP® (Abiomed, Danvers, USA) was inserted into the femoral artery with a set flow rate of 2.6 L/min [Figure 2]. The patient's pulse pressure increased within 24 h of the ECPella support suggesting better stroke volume. His condition improved significantly, and an echocardiogram 8 days after admission revealed improved LV systolic function with an LVEF of 35%–40%. IMPELLA was removed 3 days after insertion and ECMO was removed on the 8th day after insertion. He had a rubidium positron emission tomography scan 9 days after admission that showed satisfactory perfusion and viability of all segments and another coronary angiogram done just before discharge home showed patent LM artery stent. He was discharged on heart failure medical therapy.{Figure 2}

 Discussion



A case of biventricular failure with NSTE-ACS due to severe distal LM coronary artery disease (70%) is presented in this report. PCI was considered a high-risk procedure, and it was carried out with the help of VA-ECMO. Current clinical practice guidelines from the American College of Cardiology/American Heart Association recommend revascularization for all patients with a 50% stenosis of the LM coronary artery, regardless of symptomatic status, or associated ischemic burden.[3] A high-risk PCI may refer to a range of procedures performed on patients who have unprotected LM, intervention of the last patent vessel with an LVEF of <35%, complex 3-vessel disease, or comorbidities such as severe aortic stenosis or mitral regurgitation.[4] Our case should be considered among extremely high-risk PCI which definitely requires further mechanical assistance to be carried out safely and time is crucial to implement any kind of assistance. We have chosen VA-ECMO initially as the patient had severe biventricular failure suggesting long-standing severe heart failure and now has global ischemia secondary to distal LM disease. The IABP will not give the enough support in such severe biventricular dysfunction (EF 10%). The Tandem heart support was not available in the center, and the ECPella was not performed at the index procedure due to cost issues as well as an attempt to minimize the complications associated with the use of MCS.

A single-center ECMO experience for complicated high-risk elective PCIs was presented by Tomasello et al.[5] A total of 12 patients with high-risk PCI with ECMO support were successfully performed with no serious cardiac or cardiovascular events. At 6 months, no deaths or myocardial infarctions had occurred. Two patients needed further revascularization, and one required chronic hemodialysis. Another study looked at whether PCI with ECPella support can reduce myocardial damage in STEMI patients with severe cardiogenic shock Society for Cardiovascular Angiography and Interventions (Stage E). It found that ECPella-PCI patients had a significantly longer door to recanalization time and a higher total MCS flow during PCI. According to the findings, ECPella -PCI appears to minimize myocardial damage.[6]

Ideally, the use of ECMO should be limited to the duration of the procedure to minimize the complications and expenses associated with it. Furthermore, the time of de-cannulation should be determined on a case-by-case basis. Our case report demonstrates that the duration of ECMO plays a crucial role in reducing complications such as reperfusion injury after high-risk PCI, explaining why our patient was not de-cannulated immediately after PCI and had to wait 8 days before his EF improved to 30% and that greatly improved his chances to be discharged home. There is a debate which mechanical device should be removed first in ECPella support and in our patient the heart team decided to remove the IMPELLA first. In retrospect, we believe that continuing on VA-ECMO support for 8 days was indeed a good decision.

In conclusion, to the best of our knowledge, this is the first report in Saudi Arabia presenting the experience with ECPELA in high-risk PCI. MCS devices are becoming increasingly popular, and they have demonstrated encouraging results in the management of high-risk PCI. In order to maximize benefit, more focus should be made on patient selection and timing of de-cannulation. More research is needed to reinforce the existing evidence of MCS efficacy in high-risk PCI and to broaden its implementation.

Learning point

The use of MCS in high-risk PCI should yield promising results in NSTE-ACSWhen considering MCS in high-risk PCI, the timing of ECMO de-cannulation should be optimizedMore complex procedures might be performed percutaneously with the advancement of circulatory support devices.

Acknowledgments

The authors would like to acknowledge the multidisciplinary team of ICU, Cardiology, perfusions, nursing at Dr. Suliman Al-Habib Medical Group in the patient's care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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