Parenteral Antiplatelet Agents in Three Patients Receiving VA-ECMO Support to Maintain Drug-Eluting Stent Patency

Abstract

Introduction The following cases summarize three patients administered intravenous (IV) antiplatelet therapy during their venoarterial-extracorporeal membrane oxygenation (VA-ECMO) support with successful maintenance of drug-eluting stent (DES) patency. Case Report A 36-year-old male was cannulated for VA-ECMO following a cardiac arrest. Subsequently, a DES to the left anterior descending (LAD) artery was placed with Impella CP® support. The patient was started on bivalirudin and eptifibatide 1 mcg/kg/min while awaiting advanced therapy decisions. The following day he was emergently evaluated for in-stent thrombosis due to rising troponin levels. The eptifibatide was changed to cangrelor 4 mcg/kg/min; however the stent was patent. Six units of packed red blood cells (PRBC) were administered prior to discontinuation of cangrelor and successful decannulation from ECMO on day 3. A 62-year-old male presented with an ST-segment elevation myocardial infarction. An Impella CP® was placed in the setting of cardiogenic shock, followed by peripheral VA-ECMO. Three DES were placed and he was initiated on ticagrelor. With a decrease in platelet and hemoglobin levels, he was switched to cangrelor 0.75 mcg/kg/min due to potential procedural intervention. The Impella CP® device was removed as platelets continued to drop. A right lower extremity compartment fasciotomy was performed. ECMO weaning was not possible, and the patient expired on hospital day 5 secondary to multisystem organ failure. A 49-year-old male with ST-segment elevations underwent percutaneous coronary intervention (PCI) with placement of two DES to the LAD. After a ventricular fibrillation event, the patient was taken back to the catheterization lab. During the procedure the patient suffered two cardiac arrests, intra-aortic balloon pump (IABP) placement, and PCI to the RCA. The patient remained unstable and was subsequently cannulated for peripheral VA-ECMO. Bivalirudin and cangrelor 0.75 mcg/kg/min were initiated while oral antiplatelet therapy was held. The following day the patient received 2 units of PRBC and the IABP was removed. On hospital day 5, bivalirudin and cangrelor infusions were stopped and ECMO was weaned successfully. Summary Eptifibatide and cangrelor appear to prevent in-stent thrombosis but may increase bleeding in patients on ECMO.