Successful Short-Term ECPELLA Support as a Bridge to Recovery Following STEMI Complicated by Refractory Cardiogenic Shock Despite Emergency PCI

Abstract

Introduction Cardiogenic shock (CS) remains the leading cause of mortality (40 - 50%) in patients admitted with acute myocardial infarction (AMI). Early institution of complex mechanical support may preserve life. Case Report A 65-year-old male was admitted to the ED in CS after an acute inferior STEMI (ST-segment elevation MI) complicated by ventricular fibrillation (VF). He had a history of coronary artery disease (CAD), remote left anterior descending (LAD) STEMI complicated by VF arrest, and surgical LAD revascularization (normal left ventricular ejection fraction [LVEF] at that time). Multiple shocks were required during transit and upon admission to the catheterization suite for VF. Pertinent findings were blood pressure (BP) 78/52/63 (systolic/diastolic/mean) mmHg, wedge pressure 19 mmHg, cardiac index (CI) 1.3 L/minute/m2, LVEF 20%, patent LAD graft, 100% left circumflex culprit lesion and 90% right coronary artery stenosis. Left common femoral artery Impella CP support was expedited. At P9 level/ 3.1L per minute flow/mean arterial pressure 67 mmHg, two-vessel stenting was then performed. However, due to refractory cardiogenic shock, peripheral veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) was instituted immediately via right common femoral cannulation: 25F venous, 17F arterial, and 6F distal arterial reperfusion. Post-revascularization, he was transferred to the CCU on ECPELLA support: VA-ECMO at 3.7L/minute and Impella CP at P2 level with mean BP 91mmHg, wedge pressure 18 mmHg, CI 1.4 L/minute/m2. He improved rapidly with ECPELLA support and goal directed medical therapy. VA ECMO was decannulated within 36 hours and the Impella removed within 48 hours of the initiation of ECPELLA support. He was extubated within 12 hours of Impella removal and transferred to the Floor 5 days after admission on Milrinone 0.2 mcg/kg/min with CVP 9, MAP 77, CO 5.1, CI 2.8, and LVEF 30%. He was discharged home in stable condition 10 days following admission on guideline-directed medical therapy with a Life Vest. He returned to work two months after discharge. Summary Early multi-disciplinary collaboration and initiation of complex mechanical support such as ECPELLA can provide a survival advantage in very high risk patients presenting with AMI complicated by cardiogenic shock which has a very high mortality rate.