Contrast Induced Arrest

Contrast Induced Arrest

Dr. Ho LAM

Tuen Mun Hospital, Hong Kong

An 86- year- old lady with past medical history of DM, HTN, Hyperlipidemia, Gout, CVA, renal impairment was admitted for syncope and lying on the floor. She was found with inferior STEMI and cardiogenic shock. Inotrope was given in A&E and patient was transferred to Cath Lab for primary PCI.

 

ECG (Figure 1)

 

A&E record before inotrope (Figure 2)

 

Coronary angiogram showed ostial left main 50% lesion, distal left main 50% lesion. LAD showed pLAD 70% lesion and m-dLAD 90% lesion.LCx showed ostial LCx 50% and mLCx 90% lesion.

 

Coronary angiogram was difficult to perform. JL 4 6F could not engage LM. JL 3.5 6F was barely able to engage left main after aggressive manipulation of the catheter. The size of aorta was small. (Movie 1, Movie 2)

 

RCA could not be found with JL 3.5, JR 4, JL 4, pigtail and AL 1. 0, even AL 0.75 could only get closer but could not engage RCA. RCA ostium was found to be at left side. (Movie 3, Movie 4, Movie 5, Movie 6, Movie 7)

 

We decided to use SAL 1 GC to engage RCA. The angiogram was better and we could delineate the critical pRCA lesion. dRCA flow was TIMI 0-1. (Movie 8, Movie 9)

 

However, contrast went into left side and right side at the same time during contrast injection. The patient developed PEA and cardiac arrest. CPR was started. (Movie 10, Movie 11)

 

The heart was stationary. CPR started at once.

 

SAL was not engaged to RCA yet and guiding direction and ostial RCA was almost opposite to each other. How could we wire the RCA quickly during CPR?

 

The wire was shaped in a big curve and wire tip hit the wall of aorta and changed direction for fishing into RCA. (Figure 4)

 

pRCA lesion was quickly predilated with 1.5 balloon and stented with size 2.75 x 18 to restore flow in RCA first (Movie 12). Guide extension catheter was used to provide support and to prevent loss of guiding. However, patient’s airway was difficult for intubation and LUCUS was used for effective CPR. (Movie 13, Movie 14)

 

Despite all the effort, guiding was lost during CPR.

 

Patient was successfully resuscitated. Intubation was done successfully and patient’s heart moved again with blood pressure.

 

Final angiogram was done to check RCA flow. RCA flow was improved to TIMI II-III, covering blood flow to distal RCA. During the finally angiogram, contrast went into both left and right side. Patient developed cardiac arrest again. CPR was started again.

 

Fishing wiring in a fashion of “Aorto-coronary reverse wiring” to RCA was done. CPR stopped for a while during wiring because wire had to be in true lumen without going under stent strut by wire feeling. Then CPR by LUCUS was continued. (Movie 15, Movie 16)

 

RCA coronary angiogram was repeated and lesions in RCA was clearly identified. All were stented. (Movie 17, Movie 18, Movie 19)

 

After stenting, patient developed no reflow. IC adenosine and IC adrenaline were given and flow in RCA was normalized. (Movie 20, Movie 21)

 

Patient’s BP was still low despite inotropes and ECG still showed high ST elevation. RCA flow was fully restored. (Figure 5)

 

From angiogram, impaired blood flow in LAD was suspected. PCI to left side was decided. JL 3.5 guiding was used. Engagement to left main was difficult and need guide extension catheter to help.

 

PCI to mLAD critical lesion was done. (Movie 22)

 

Patient was recovered with reasonable hemodynamic and was alert again to move her hand. (Movie 23)

 

Final coronary angiogram showed LAD flow was good. (Movie 24, Movie 25)

 

ECG on cardiac monitor showed significant reduction in ST elevation also. (Figure 6)

 

IABP was inserted after the procedure to reduce inotrope usage. IABP and ventilator were wean off in few days. (Figure 7)

 

Patient was survived with mental recovery for more than 2 years.

 

 

 

Discussion

 

Abnormal anatomy in PPCI is always challenging, especially some cases that cannot use typical methods to settle.

 

Depending on location of the ostial RCA, JL 3.5, EBU 3.0, JR 5, LCB, RCA and AL can be considered. In old aged patient with small aorta, SAL is also a good choice.

 

Usually, a small balloon which is supported by guide extension catheter is recommended. Stent with good deliverability should be used.

 

Rapid revascularization and hemodynamic support to avoid patient entering a point of no return is important to reduce mortality in shock patient.

 

Shock in the elderly is particularly problematic as ECMO and Impella will not be offered usually. The management and PCI approach should incorporate those realistic things. LUCUS can be a good choice in those cases with arrest.

 

The role IABP is still controversial. IABP has not been considered as a key for mortality reduction in shock for years in our center. The usage of IABP is minimized in post PCI support or in selected situations. Often, IABP will increase delay for revascularization and hinder CPR, particularly during VT/VF. And we found that IABP cannot support real shock or cardiac arrest cases.

 

The PCI approach in shock and cardiac arrest should be individualized. There is no fix rule.

 

The highly specialized Cath Lab nursing team has helped a lot in the management by providing good CPR and inotropes injections. That is the key to prevent patient entering a point of no return. (Figure 8)