Cardiogenic Shock Following Successful CTO Revascularization

Abstract

<h3>Introduction</h3> The role of urgent mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is not well studied. This case highlights myocardial recovery in a patient with ventricular fibrillation following a CTO PCI supported with MCS. <h3>Case Report</h3> A 45 year-old man with recent non-ST elevation myocardial infarction, found to have triple vessel coronary artery disease treated with drug-eluting stent to LAD and OM1, due to patient preference, presents for an elective revascularization of CTO of RCA. Left ventricular function at time of discharge from his prior hospitalization was preserved. Revascularization of CTO was accomplished with placement of Resolute Onyx 3.5x38 mm stent and Resolute Onyx 3.0x26 mm stent to the mid RCA and a Resolute Onyx 3.0x22 mm stent to the distal RCA. There were no complications, and the patient was transferred to a telemetry floor. Soon after transfer he suffered cardiac arrest with ventricular fibrillation. He was defibrillated with return of spontaneous circulation however remained hemodynamically tenuous. Bedside echocardiogram demonstrated severe biventricular dysfunction. Coronary angiography showed stable anatomy with patent stents. Given declining hemodynamic status an Impella CP was placed emergently via the left femoral artery. He was transferred to the cardiac critical care unit where he subsequently developed monomorphic ventricular tachycardia with further hemodynamic deterioration. He was cannulated for VA ECMO and hemodynamic stability was achieved. Due to ongoing hemolysis, Impella CP was exchanged for an axillary Impella 5.5. As results of medical management and aggressive supportive care, subsequent echocardiograms demonstrated recovery of left and right ventricular function. He was decannulated from VA ECMO and Impella 5.5 after four days. Outpatient transthoracic echocardiogram performed four weeks later demonstrate preserved biventricular function. LV ejection fraction was measured at 55% and global longitudinal strain -16.7%. RV longitudinal strain -21.4%. He is tolerating guideline-directed medical therapy for heart failure. <h3>Summary</h3> This case describes ventricular fibrillation following CTO revascularization and highlights the positive outcomes associated with early recognition of deteriorating cardiogenic shock and rapid escalation of mechanical circulatory support.