Bilateral Embolic Protection Devices for High-Risk Cardiac Surgery in a Patient With Recent Embolic Stroke

Abstract

C erebral embolic protection devices (EPDs) such as carotid filters were first introduced as an adjunct to carotid artery stenting out of concern for increased rates of procedurerelated atheromatous plaque embolization compared with carotid endarterectomy. Here, we report the use of a carotid filter device for embolic protection during high-risk coronary artery bypass grafting and ventricular assist device explantation in a patient with a recent history of embolic cerebrovascular accident from severe aortic atherosclerosis. Case ReportA 67-year-old man with no known history of coronary artery disease presented to an outside hospital with acute shortness of breath. Initial chest x-ray demonstrated complete opacification of the lung spaces consistent with decompensated pulmonary edema. The ECG demonstrated pan-ST segment depressions with ST elevation in lead V1 and was concerning for severe left main coronary artery stenosis. He was transferred to Columbia University Medical Center in cardiogenic shock for emergent angiography and evaluation for coronary intervention.At catheterization, left ventriculography showed an ejection fraction of 15% to 20% with global hypokinesis. Coronary angiography revealed a right dominant system with a thrombotic 90% stenosis of a trifurcating distal left main coronary artery (Figure [A]). The right coronary artery was occluded proximally and filled retrograde via the left circulation (Figure [B]). Despite initial stabilization after aggressive diuresis, insertion of an intra-aortic balloon pump, and aspiration thrombectomy of the left main coronary artery, the patient continued to decompensate. A CentriMag biventricular assist device (BiVAD) was implanted (Thoratec, CA). During the BiVAD implantation, transesophageal echocardiography revealed that the aorta was severely atherosclerotic ( Figure [C]). On the first postoperative day, the patient was thought to have mild left lower extremity weakness, but this finding was attributed to ongoing postoperative sedation. The following day when the patient was fully awake, he was noted to have a left lower extremity motor deficit. No arrhythmic episodes were documented after his initial procedure. A neurology consultation was obtained and a head computed tomography was performed. The computed tomography showed multiple scattered hypodensities involving the posterior right frontal lobe, left occipital lobe, and bilateral cerebellar hemispheres consistent with embolic infarcts (Figure [D]). These findings, in combination with the patient's left lower extremity weakness, were presumed secondary to aortic manipulation during BiVAD implantation. His neurological status improved significantly during the next few days, and he had only minor residual deficits. In preparation for definitive cardiac management, he underwent a myocardial viability study that demonstrated global hypokinesis but no scar in the distribution of the left anterior descending artery. He was then scheduled for BiVAD explant and coronary artery bypass grafting.Given his calc...