PCI, ECMO+IABP and mitral repair: interventional treatment in a HFrEF patient

Coronary artery disease Valve disease Clinical case

Authors: Amina Rakisheva1, Marat Aripov2, Baurzhan Aipov3
Affiliated institution: 1 IMS of the UIB, 2 Heart Center, UMC 3 Cardiology City Center, Almaty 
Reviewer: Emanuele Gallinoro, Cardiology Unit, Sant’Andrea University Hospital, Rome; Italy
 

Amina Rakisheva
Amina Rakisheva
Cardiologist
Kazakhstan
Marat Aripov
Marat Aripov
Clinical researcher
Kazakhstan
Baurzhan Aipov
Baurzhan Aipov
Interventional cardiologist
Kazakhstan
Case presentation

    A 63-year-old male (90 kg; BMI 28 kg/m²) with a history of hypertension presented with acute chest pain that began approximately two hours prior to admission.

    Pre-hospital assessment (ambulance):

    • Blood pressure: 40/0 mmHg
    • Heart rate: 112 b/min
    • Respiratory rate: 25/min
    • SpO₂: 89%

    He was transferred for urgent coronary angiography upon arrival to the emergency department.

    Urgent blood tests:

    • NT-pro-BNP=465 pg/mL
    • HsTrop I=25 ng/mL
    • HB= 1.37 g/dl
    • sCreat=1.61 mg/dl
    • CRP 2.24 mg/mL
    • ALT 42.7 ME
    • AST 243.4 ME
       
    PCI, ECMO+IABP and mitral repair: interventional treatment in a HFrEF patient

    Angio

    Coronary angiography revealed severe multivessel coronary artery disease, including LM occlusion, severe distal RCA occlusion, and 40% proximal PDA stenosis. During engagement of the guiding catheter to the LAD, the patient developed ventricular fibrillation. Successful resuscitation was achieved within 5 minutes. Veno-arterial ECMO was initiated at a flow of 2 L/min, followed by intra-aortic balloon pump (IABP) implantation.

    Three drug-eluting stents were implanted:

    • Two stents into the distal left main and the proximal LAD.
    • From the distal RCA into the proximal PDA.

    Wiring the LAD

    First stent was implanted

    We see a contrast stagnation after the LAD stenting

    The next stage was of RCA distal part stenting.

    The next stage was of RCA distal part stenting.

    Following weeks

    . The patient subsequently developed atrial fibrillation.

     

    PCI, ECMO+IABP and mitral repair: interventional treatment in a HFrEF patient: The patient subsequently developed atrial fibrillation.

    VA-ECMO and IABP were weaned and explanted using a stepwise approach. 

    The patient subsequently developed atrial fibrillation. Ultrafiltration therapy was initiated.

    Laboratory findings showed:

    • NT-proBNP: 35,000 pg/mL
    • Procalcitonin (PCT): 3.63 ng/mL
    • Hemoglobin (Hb): 8.9 g/dL*
    • Serum creatinine: 2.0 mg/dL
    • C-reactive protein (CRP): 10.0 mg/mL
    • ALT: 19 U/L
    • AST: 31.5 U/L
    • BUN: 24.3 mg/dL
    • AR minimal
    • MR severe, central jet (VC 0.9)
    • TR severe 
    • LVEF = 18%, EDV = 126ml, ESV = 103ml
    • Pericardial effusion ↑ from  mm to 25 mm
    • TAPSE 9 mm
    • S’ medial 4 m/s
    • S’ lateral 4.2 m/s
    • IVC 23 mm 
    • Akinesis of the anterior, anterior septal, anterolateral walls mainly at the level of the middle and apical segments. Akinesis of the apical segments
     

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Declaration of interest

    None

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