A Survival Case of Cardiogenic Shock due to Left Main Coronary Artery Myocardial Infarction: Successful Cooperation with On-Site Percutaneous Coronary Intervention and Helicopter Emergency Medical Service

Abstract

A 54-year-old man was referred to a local hospital, located about 90 km from our hospital, with cardiogenic shock due to left main coronary artery infarction (LMCA-MI). Percutaneous coronary intervention (PCI) was performed under intra-aortic balloon pumping (IABP) support, but resulted in insufficient reperfusion and his condition worsened. The helicopter emergency medical service (HEMS) rapidly transported the patient to our hospital. After percutaneous cardio-pulmonary support system (PCPS) insertion, PCI could establish the coronary flow. A series of intensive therapies saved the patient. The cooperation of medical and emergency service system following revascularization and intensive care saved the patient with LMCA-MI accompanied by cardiogenic shock.Key words: cardiogenic shock, acute myocardial infarction, percutaneous cardio-pulmonary support system, trans-radial percutaneous coronary intervention, helicopter emergency medical service Case ReportA 54-year-old man was referred to the emergency department of Minamata City Hospital and Medical Center with severe chest pain lasting one hour, which had never been felt before. He had smoked 20 cigarettes a day for twenty years and was treated for hypertension and diabetes mellitus. His usual blood pressure was >150/90 mmHg using valsartan 80 mg daily, betaxolol hydrochloride 10 mg daily, long acting nifedipine 40 mg daily and his HbA1c was >7.5% using glimepiride 4 mg daily.In the emergency department of Minamata City Hospital and Medical Center, he felt clammy and seemed anxious. His blood pressure was 110/60 mmHg, pulse rate was 92 beats per minute (bpm), and respiration was shallow and rapid at 36 per minute. Arterial oxygen saturation was 99% during oxygen breathing at 3 L/min through a nasal cannula. Electrocardiogram (ECG) showed a sinus rhythm, right bundle branch block, left axis deviation, and ST-segment elevation in leads I, aVL, aVR, V1 through V6, and ST-segment depression in leads II, III, aVF (Fig. 1). He was diagnosed as acute myocardial infarction with cardiogenic shock and emergency cardiac catheterization was performed.A 6 Fr sheath was inserted through the right radial artery. The coronary angiogram showed total occlusion of the left main coronary artery (LMCA) without collateral supply and severe stenosis at the distal right coronary artery (Fig. 2). Intra-aortic balloon pumping (IABP) was inserted through the right femoral artery and trans-radial percutaneous coronary intervention (PCI) was carried out. First of all, two coronary soft guidewires were successfully passed into the

The outcomes of intra-aortic balloon pump usage in patients with acute myocardial infarction: a comprehensive meta-analysis of 33 clinical trials and 18,889 patients

“…More and more evidence, including the results from our study, has demonstrated that IABP insertion is associated with a higher incidence of severe bleeding and stroke. Four risk factors for complications following IABP insertion were identified from the Benchmark Registry: 51 age ≥75 years, female sex, peripheral arterial disease, and body surface area <1.65 m 2 . In the meta-analysis published by Sjauw et al, 13 a significantly increased rate of stroke secondary to IABP use was observed in patients suffering from AMI.…”

Aortic counterpulsation in cardiogenic shock during acute myocardial infarction

“…The magnitude of counterpulsation hemodynamic effect depends on several factors including the relation of balloon volume to aorta size, heart rate and rhythm and aortic compliance [17]. In addition, diastolic augmentation is most efficient the closer the balloon is to the aortic valve [18]. To minimize the risk of cerebral embolism, the ideal IABP position in modern practice is 1 or 2 cm distal to the origin of the left subclavian artery.…”

“…However, the data suggest that the degree of coronary artery stenosis and the state of coronary autoregulation causes significant variation in response to counterpulsation. Kimura et al [18], using an anesthetized canine model, showed that diastolic forward flow in the left anterior descending artery increased by 12% during counterpulsation. However, with partial ligation of the left main to create a critical stenosis, the effect of counterpulsation to augment left anterior descending artery flow was completely abolished [18].…”

“…Kimura et al [18], using an anesthetized canine model, showed that diastolic forward flow in the left anterior descending artery increased by 12% during counterpulsation. However, with partial ligation of the left main to create a critical stenosis, the effect of counterpulsation to augment left anterior descending artery flow was completely abolished [18]. In human subjects, data regarding augmentation of coronary flow by counterpulsation are inconsistent.…”

“…In-hospital mortality attributed to IABP placement in the Benchmark Registry was 0.05%. The Benchmark Registry identified four risk factors for major complications from IABP use: age ‡75 years; female gender; peripheral arterial disease; body surface area <1.65 m 2 [18]. In consideration of these data, some physicians are still hesitant to use the technique, afraid of reported complications.…”