Erfolgreiche Therapie eines Patienten im therapieresistenten kardiogenen Schock mit intrakoronarer, autologer Knochenmarkstammzelltransplantation

Abstract

A 64-year-old man with known coronary 3-vessel disease (CAD) who had sustained an anterior myocardial infarction 14 years ago was admitted with signs of acute left heart failure associated with another anterior myocardial infarction. The electrocardiogram (ECG) showed ST-segment elevation from V1 to V6. Creatine kinase, troponin I and lactate dehydrogenase levels were elevated. Emergency cardiac catheterization revealed a coronary 3-vessel disease with severe stenosis in left anterior descending coronary artery (LAD). Left ventricular angiography demonstrated severe impairment of left ventricular contractile function with akinesia of the entire anterior wall of the left ventricle. Coronary angioplasty and stent implantations of the LAD were undertaken, but cardiogenic shock occurred requiring intubation, ventilation and intraaortic counterpulsation (IABP). It was possible to discontinue the latter after two days, but the cardiogenic shock persisted for six weeks, requiring increasing amounts of catecholamines and high inspiratory ventilation pressure (max Pinsp) and high positive end-expiratory wedge pressure (PCW). Nine days after autologous adult bone marrow derived stem cell injection into the right and left coronary artery, the left ventricular function gradually improved and the catecholamine amount gradually reduced. It was then possible to extubate the patient and transfer him to a general ward. Angiocardiography after one month demonstrated an increase of the ejection fraction from 17% to 28% and good coronary blood flow in the LAD. Intracoronary transplantation of adult autologous bone-marrow stem cells achieved safe and efficacious regeneration of ischemic and infarcted myocardium. It can be assumed that myocardial repair was associated with the stem cell transplantation and/or cytokine action. The intracoronary stem cell transplantation may reduce the mortality of otherwise treatment-resistant cardiogenic shock.