P303 ECMO–PROTECTED HIGH RISK PCI IN UNUSUAL CLINICAL AND ANATOMICAL SCENARIO

Abstract

Abstract Background Non–emergent complex high–risk indicated procedure (CHIP) identify complex PCI according with clinical, anatomical and procedural features and prevent intraprocedural hemodynamic compromise represents a major issue. The aortic valve bypass (AVB) has been an uncommon surgical option performed by creating a heterotopic second left ventricular output bypassing native stenotic aortic valve with flow redistribution between the native left ventricular outflow tract and the apical–aortic bypass. AVB was phased out in “TAVI–era”. Case Report A 78 years–old obese and hypertensive male, with pulmonary fibrosis and previous AVB for severe aortic stenosis judged at unacceptable high surgical risk 10 years before, was admitted to the emergency department for chest pain and palpitation. Patient was in Killip class I. ECG showed rapid atrial fibrillation without ST–segment elevation. Atrial tachyarrhythmia, chest pain and palpitation spontaneously simultaneously resolved. A type 2 NSTEMI–ACS was suspected according to clinical features and pathological Hs–troponin. Multimodality imaging documented normal systolic function, normally operating AVB, paradoxical low flow severe native aortic valve stenosis, a chronic type B aortic dissection from distal anastomosis of AVB retrogradely extended to left subclavian artery origin and a wide aneurysm of the abdominal aorta (Fig. 1). Coronary angiography documented severely calcific multivessel disease. Prompt and complete revascularization was considered mandatory and a surgical redo was discarded. The use of an intraprocedural hemodynamic support was advisable, but anatomical context represented substantial contraindication to IABP and Impella. Heart Team decided to perform VA–ECMO–protected–PCI. After lesion preparation double kissing crush was performed on LMCA and single stents were implanted in proximal LAD and proximal RCA (Fig. 2). Despite signs of transient hemodynamic instability the patient tolerated the procedure thanks to the ECMO support. Complete myocardial revascularization was obtained without complications and the subsequent clinical course was uneventful. Discussion In this CHIP patient, hemodynamic support was vital to allow a safe complete myocardial revascularization. ECMO is a demanding system, not routinely used for “protected PCI”; however, the case here reported underlines that ECMO can be a feasible option, prerequisite in uncommon cases where other standard tMCS are contraindicated.