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JACC April 5, 2016

Volume 67, Issue 13

FIT Clinical Decision Making

REFRACTORY CARDIOGENIC SHOCK REQUIRING EMERGENCY MECHANICAL CIRCULATORY
SUPPORT AS BRIDGE TO DEFINITIVE THERAPY
Poster Contributions
Poster Area, South Hall A1
Sunday, April 03, 2016, 3:45 p.m.-4:30 p.m.

Session Title: FIT Clinical Decision Making: Non-Invasive Imaging and Valvular Heart Disease
Abstract Category: Heart Failure and Cardiomyopathies
Presentation Number: 1232-312

Authors: Beixin He, Yale University, New Haven, CT, USA

Background: Cardiogenic shock is defined as end-organ hypo-perfusion from decreased cardiac output. It is a known complication in
patients presenting with acute myocardial infarction. Despite technological advances in mechanical circulatory support, mortality remains
high. The challenge is appropriate selection of patients who could benefit from device therapy.
Case: A 62 year old male patient with poorly controlled insulin-dependent diabetes presented with an NSTEMI and underwent PCI to the
LAD and RCA with drug-eluting stents. His hospital course was complicated by complete heart block. Emergent left heart catheterization
demonstrated in-stent thrombosis to both the LAD and RCA stents. During the procedure, he was intubated for airway protection. He
developed refractory cardiogenic shock despite vasopressor support.
Decision Making: An intra-aortic balloon pump was inserted, and cardiac surgery was consulted for emergent mechanical circulatory
support. He suffered VT/VF arrest requiring cardioversion and multiple anti-arrhythmic medications. VA ECMO was rapidly initiated via the
left common femoral vessels. The patients hemodynamics stabilized on ECMO support. He underwent revascularization of the LAD and
RCA with bare metal stents. Serum lactate was 8.5mmol/L at the time of ECMO initiation and improved to 2.9mmol/L 12 hours later. Renal
function remained stable 48 hours after ECMO initiation. Neurologic status was intact. Attempts of ECMO turndown were unsuccessful,
and the patient ultimately received a HeartMate II left ventricular assist device. Intraoperative assessment revealed a very thin anterior
myocardium consistent with late presenting infarct. The patient recovered to discharge and is doing well in the outpatient setting.
Conclusions: This case illustrates the appropriate use of emergent mechanical support devices in refractory cardiogenic shock and
high risk percutaneous intervention. The patient showed signs of early improvement including hemodynamic stabilization and end-organ
perfusion. This case emphasizes the importance of recognizing positive clinical predictors because they can translate to successful
transition to definitive therapy.
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