STEMI, NSTEMI and Cardiac Arrest Case presentation

Sam Dawkins, MD PhD Cedars-Sinai Heart Institute, Los Angeles, CA Controversies and Advances in the Treatment of Cardiovascular Disease Los Angeles, CA

Background

• 72 year old male

• Sudden onset shortness of breath with chest tightness

• Hypertension and hyperlipidemia

• No other significant past medical history

Background

• 72 year old male

• Sudden onset shortness of breath with chest tightness

• Hypertension and hyperlipidemia

• No other significant past medical history

• Ambulance transfer direct to cath lab

• On arrival

SaO2 88% on 15L

HR 105 sinus rhythm BP 110/55

Background

• 72 year old male

• Sudden onset shortness of breath with chest tightness

• Hypertension and hyperlipidemia

• No other significant past medical history

• Ambulance transfer direct to cath lab

• On arrival

SaO2 88% on 15L

HR 105 sinus rhythm BP 110/55

What is the strategy?

• PCI? Which vessel? Multivessel?

• Support – Impella, balloon pump?

• Anesthesia?

10

Procedure

• General anesthesia

• Intra-aortic balloon pump sited

• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent

• Guide wire to circumflex for guide stability

• Unable to cross proximal LAD lesion

11

Procedure

• General anesthesia

• Intra-aortic balloon pump sited

• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent

• Unable to cross proximal LAD lesion

• Eventually wired LAD with Fielder XT and Corsair backup

12

Procedure

• General anesthesia

• Intra-aortic balloon pump sited

• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent

• Unable to cross proximal LAD lesion

• Eventually wired LAD with Fielder XT and Corsair backup

• Intravascular ultrasound to confirm true lumen

13

Procedure

• General anesthesia

• Intra-aortic balloon pump sited

• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent

• Unable to cross proximal LAD lesion

• Eventually wired LAD with Fielder XT and Corsair backup

• Intravascular ultrasound to confirm true lumen

• Balloon dilatation of proximal LAD

14

Procedure

• General anesthesia

• Intra-aortic balloon pump sited

• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent

• Unable to cross proximal LAD lesion

• Eventually wired LAD with Fielder XT and Corsair backup

• Intravascular ultrasound to confirm true lumen

• Balloon dilatation of proximal LAD

15

Procedure

• General anesthesia

• Intra-aortic balloon pump sited

• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent

• Unable to cross proximal LAD lesion

• Eventually wired LAD with Fielder XT and Corsair backup

• Intravascular ultrasound to confirm true lumen

• Balloon dilatation of proximal LAD

• Drug eluting stent to proximal LAD

16

Procedure

• General anesthesia

• Intra-aortic balloon pump sited

• Balloon dilatation and PCI to mid circumflex with 3.0 x 12 drug eluting stent

• Unable to cross proximal LAD lesion

• Eventually wired LAD with Fielder XT and Corsair backup

• Intravascular ultrasound to confirm true lumen

• Balloon dilatation of proximal LAD

• Drug eluting stent to proximal LAD

17

What next?

• Stop and transfer to ICU?

• PCI to the right coronary artery?

18

Procedure

• Wire to distal vessel

• Balloon dilatation

19

Procedure

• Wire to distal vessel

• Balloon dilatation

• 3.0 x 28 drug eluting stent

20

Procedure

• Wire to distal vessel

• Balloon dilatation

• 3.0 x 28 drug eluting stent

21

Clinical Course

• Transferred to ICU

• TTE

Severe left ventricular impairment (EF 20%)

Anterior akinesis, hypokinesis elsewhere

No significant valvular pathology

• Balloon pump removed after 24 hours

• Failed attempt to extubate after 48 hours

• Falling blood pressure with pulmonary edema, requiring pressor support

22

Clinical Course

• Transferred to ICU

• TTE

Severe left ventricular impairment (EF 20%)

Anterior akinesis, hypokinesis elsewhere

No significant valvular pathology

• Balloon pump removed after 24 hours

• Failed attempt to extubate after 48 hours

• Falling blood pressure with pulmonary edema, requiring pressor support

• Extubated day 9

• Discharged day 29

23

Key points for discussion

• Use of circulatory support in STEMI

• Management of respiratory compromise in the cath lab

• Non-culprit PCI in STEMI / cardiogenic shock