Limits...
Cardiac arrest during percutaneous coronary intervention in a patient 'resistant' to clopidogrel - successful 50-minute mechanical chest compression.

Protasiewicz M, Szymkiewicz P, Sciborski K, Orda A, Karolko B, Jonkisz A, Lebioda A, Mysiak A - Postepy Kardiol Interwencyjnej (2013)

Bottom Line: We report a case of 72-year-old female patient with end-stage chronic kidney disease, undergoing percutaneous coronary intervention (PCI) that resulted in a cardiac arrest caused by a thrombus mediated flow limitation in the left coronary artery.With mechanical cardiopulmonary resuscitation (CPR) PCI of the left main artery was performed successfully during 50 min cardiac arrest.The patient was discharged from the hospital without compromising cardiac function and neurological deficits.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Medical University of Wroclaw, Poland.

ABSTRACT
We report a case of 72-year-old female patient with end-stage chronic kidney disease, undergoing percutaneous coronary intervention (PCI) that resulted in a cardiac arrest caused by a thrombus mediated flow limitation in the left coronary artery. With mechanical cardiopulmonary resuscitation (CPR) PCI of the left main artery was performed successfully during 50 min cardiac arrest. The patient was discharged from the hospital without compromising cardiac function and neurological deficits.

No MeSH data available.


Related in: MedlinePlus

Angiography of the left coronary artery with properly functioning previously implanted stents
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC3927116&req=5

Figure 0001: Angiography of the left coronary artery with properly functioning previously implanted stents

Mentions: A 71-year-old woman with end-stage chronic kidney disease (haemodialysis 3 times a week), with a history of non-ST-elevation myocardial infarction (NSTEMI) treated with PCI of the left main (LM)/left anterior descending (LAD)/circumflex (Cx) artery with two everolimus-eluting stents, with type 2 diabetes, long-standing history of hypertension, and moderate mitral regurgitation, was admitted to the Cardiology Department with a diagnosis of NSTEMI. The echocardiographic examination performed on admission was comparable to the previous study and demonstrated extensive wall motion abnormalities with decreased global ejection fraction (EF = 35%). The coronary angiography revealed right coronary artery occlusion (as before) and properly functioning stents in the LM and the proximal segments of the LAD and CX. The culprit lesion was a critical narrowing in the medial LAD (Figure 1). As the patient was already receiving aspirin and clopidogrel due to previous myocardial infarction (MI) a decision to perform ad hoc PCI was taken. Despite initial balloon predilatation of the stenosis (Trek 2.0 mm × 8 mm, 10 atm, Abbott Vascular), having good support of the guiding catheter, the stent could not be advanced through the ostium of the LAD. During prolonged manipulations formation of thrombus in the LM, proximal LAD and CX segments (ACT time after heparin bolus 70 U/kg equal to 267 s) occurred (Figure 2). The patient developed cardiogenic shock and subsequently cardiac arrest in the mechanism of pulseless electrical activity (PEA). Immediate manual resuscitation was started and after the patient was intubated a Lund University Cardiac Arrest System (LUCAS) device was engaged to continue automatic chest compression. Despite the administration of intracoronary bolus followed by intravenous infusion of abciximab along with multiple thrombus aspirations with an Export catheter (Medtronic, USA) the coronary angiogram remained unchanged. Spontaneous circulation had not returned. Despite the potential risk of bleeding, 5 mg of intracoronary alteplase was administered. After a few minutes the thrombus began to dissolve but only slight improvement of the flow was observed. Because of the suspicion of coronary artery dissection, a 4.5 mm × 20 mm stent at 15 atm (Resolute, Medtronic) in the LM/CX was implanted and finally kissing balloon inflation was performed with two 3.0 mm × 20 mm balloons (Sprinter, Medtronic). After the PCI spontaneous return of circulation and TIMI-3 flow in the left coronary artery were observed (Figure 3). The whole PCI lasted over 50 min during which ongoing LUCAS support was continuously used. After the procedure the patient with blood pressure of 160/80 mm Hg and heart rate 110/min on adrenaline and noradrenaline infusion was transferred to the intensive cardiac unit. Two days later the patient was extubated. Because of the double stent layer in left main coronary artery the patient was subjected to genetic examination of the CYP2C19 gene and light transmission aggregometry (LTA) was performed to assess platelet activity. There was no polymorphism within the CYP2C19 gene but the aggregometry test revealed excessive platelet aggregation of 63% after stimulation with 5 µg of ADP. With this result we decided to change antiplatelet therapy to a more potent platelet inhibitor – ticagrelor. This therapy resulted in proper, 40%, platelet aggregation. The echocardiography examination performed before discharge showed a slight improvement in left ventricular systolic function. No neurological deficits were diagnosed. The patient was discharged from the hospital 10 days later.


Cardiac arrest during percutaneous coronary intervention in a patient 'resistant' to clopidogrel - successful 50-minute mechanical chest compression.

Protasiewicz M, Szymkiewicz P, Sciborski K, Orda A, Karolko B, Jonkisz A, Lebioda A, Mysiak A - Postepy Kardiol Interwencyjnej (2013)

Angiography of the left coronary artery with properly functioning previously implanted stents
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3927116&req=5

Figure 0001: Angiography of the left coronary artery with properly functioning previously implanted stents
Mentions: A 71-year-old woman with end-stage chronic kidney disease (haemodialysis 3 times a week), with a history of non-ST-elevation myocardial infarction (NSTEMI) treated with PCI of the left main (LM)/left anterior descending (LAD)/circumflex (Cx) artery with two everolimus-eluting stents, with type 2 diabetes, long-standing history of hypertension, and moderate mitral regurgitation, was admitted to the Cardiology Department with a diagnosis of NSTEMI. The echocardiographic examination performed on admission was comparable to the previous study and demonstrated extensive wall motion abnormalities with decreased global ejection fraction (EF = 35%). The coronary angiography revealed right coronary artery occlusion (as before) and properly functioning stents in the LM and the proximal segments of the LAD and CX. The culprit lesion was a critical narrowing in the medial LAD (Figure 1). As the patient was already receiving aspirin and clopidogrel due to previous myocardial infarction (MI) a decision to perform ad hoc PCI was taken. Despite initial balloon predilatation of the stenosis (Trek 2.0 mm × 8 mm, 10 atm, Abbott Vascular), having good support of the guiding catheter, the stent could not be advanced through the ostium of the LAD. During prolonged manipulations formation of thrombus in the LM, proximal LAD and CX segments (ACT time after heparin bolus 70 U/kg equal to 267 s) occurred (Figure 2). The patient developed cardiogenic shock and subsequently cardiac arrest in the mechanism of pulseless electrical activity (PEA). Immediate manual resuscitation was started and after the patient was intubated a Lund University Cardiac Arrest System (LUCAS) device was engaged to continue automatic chest compression. Despite the administration of intracoronary bolus followed by intravenous infusion of abciximab along with multiple thrombus aspirations with an Export catheter (Medtronic, USA) the coronary angiogram remained unchanged. Spontaneous circulation had not returned. Despite the potential risk of bleeding, 5 mg of intracoronary alteplase was administered. After a few minutes the thrombus began to dissolve but only slight improvement of the flow was observed. Because of the suspicion of coronary artery dissection, a 4.5 mm × 20 mm stent at 15 atm (Resolute, Medtronic) in the LM/CX was implanted and finally kissing balloon inflation was performed with two 3.0 mm × 20 mm balloons (Sprinter, Medtronic). After the PCI spontaneous return of circulation and TIMI-3 flow in the left coronary artery were observed (Figure 3). The whole PCI lasted over 50 min during which ongoing LUCAS support was continuously used. After the procedure the patient with blood pressure of 160/80 mm Hg and heart rate 110/min on adrenaline and noradrenaline infusion was transferred to the intensive cardiac unit. Two days later the patient was extubated. Because of the double stent layer in left main coronary artery the patient was subjected to genetic examination of the CYP2C19 gene and light transmission aggregometry (LTA) was performed to assess platelet activity. There was no polymorphism within the CYP2C19 gene but the aggregometry test revealed excessive platelet aggregation of 63% after stimulation with 5 µg of ADP. With this result we decided to change antiplatelet therapy to a more potent platelet inhibitor – ticagrelor. This therapy resulted in proper, 40%, platelet aggregation. The echocardiography examination performed before discharge showed a slight improvement in left ventricular systolic function. No neurological deficits were diagnosed. The patient was discharged from the hospital 10 days later.

Bottom Line: We report a case of 72-year-old female patient with end-stage chronic kidney disease, undergoing percutaneous coronary intervention (PCI) that resulted in a cardiac arrest caused by a thrombus mediated flow limitation in the left coronary artery.With mechanical cardiopulmonary resuscitation (CPR) PCI of the left main artery was performed successfully during 50 min cardiac arrest.The patient was discharged from the hospital without compromising cardiac function and neurological deficits.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Medical University of Wroclaw, Poland.

ABSTRACT
We report a case of 72-year-old female patient with end-stage chronic kidney disease, undergoing percutaneous coronary intervention (PCI) that resulted in a cardiac arrest caused by a thrombus mediated flow limitation in the left coronary artery. With mechanical cardiopulmonary resuscitation (CPR) PCI of the left main artery was performed successfully during 50 min cardiac arrest. The patient was discharged from the hospital without compromising cardiac function and neurological deficits.

No MeSH data available.


Related in: MedlinePlus