Treatment of Cardiogenic Shock and Refractory Ventricular Fibrillation: Pulling Out All the Stops

Abstract

We report the case of a 62-year-old woman who presented with an acute inferior wall myocardial infarction complicated by cardiogenic shock and refractory ventricular fibrillation. Following prolonged resuscitation in the emergency room, she was transferred to the cardiac catheterization laboratory where, as a first step, mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (ECMO) was established. Next, a right heart catheterization study was performed, followed by coronary angiography and angioplasty of the infarct-related artery. Promptly on transfer to the intensive care unit, a hypothermia protocol was initiated. By postprocedure day 1, the patient's ventricular fibrillation had resolved, mean arterial pressure was >65 mm Hg, and pulmonary artery diastolic pressure was 10 mm Hg. Echocardiography demonstrated complete recovery of left ventricular systolic function. Lactate levels had fallen from 11.0 mmol/L (pre-ECMO) to 1.2 mmol/L. The patient was successfully weaned off pressor and ECMO support within 24 hours of the percutaneous coronary intervention procedure. She was extubated on postprocedure day 2 and discharged home on day 6. At 26-month follow-up, she remains well, angina free, neurologically intact, and without evidence of heart failure. The treatment algorithm used in this case should be considered favorably in the management of patients presenting with acute myocardial infarction complicated by cardiogenic shock and refractory ventricular fibrillation.

Keywords

ventricular fibrillation - ECMO - angioplasty - right heart catheterization - acute myocardial infarction - coronary artery - cardiogenic shock

Publication History

Article published online:
15 March 2023

• References

• 1 Baran DA, Grines CL, Bailey S. et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock: this document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv 2019; 94 (01) 29-37
• 2 Hochman JS, Sleeper LA, Webb JG. et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med 1999; 341 (09) 625-634
• 3 Banning AS, Adriaenssens T, Berry C. et al; Collaborators. Veno-arterial extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock: rationale and design of the randomised, multicentre, open-label EURO SHOCK trial. EuroIntervention 2021; 16 (15) e1227-e1236
• 4 Ostadal P, Rokyta R, Kruger A. et al. Extra corporeal membrane oxygenation in the therapy of cardiogenic shock (ECMO-CS): rationale and design of the multicenter randomized trial. Eur J Heart Fail 2017; 19 (2, suppl 2): 124-127
• 5 Catalano MA, Pupovac S, Manetta F, Kennedy KF, Hartman A, Yu PJ. Contemporary national utilization of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest. J Card Surg 2022; 37 (04) 818-824
• 6 Glazier JJ, Kaki A. Improving survival in cardiogenic shock: is Impella the answer?. Am J Med 2018; 131 (10) e403-e404
• 7 Tsao NW, Shih CM, Yeh JS. et al. Extracorporeal membrane oxygenation-assisted primary percutaneous coronary intervention may improve survival of patients with acute myocardial infarction complicated by profound cardiogenic shock. J Crit Care 2012; 27 (05) 530.e1-530.e11
• 8 Maury P, Mansourati J, Fauchier L, Waintraub X, Boveda S, Sacher F. Management of sustained arrhythmias for patients with cardiogenic shock in intensive cardiac care units. Arch Cardiovasc Dis 2019; 112 (12) 781-791
• 9 Vahdatpour C, Collins D, Goldberg S. Cardiogenic shock. J Am Heart Assoc 2019; 8 (08) e011991
• 10 Burkhoff D, Moscucci M, Henriques JPS. Percutaneous circulatory support: intra-aortic balloon counterpulsation, Impella, TandemHeart, and extracorporeal bypass. In: Moscucci M. ed. Grossman & Baim's Cardiac Catheterization, Angiography, and Intervention. 8th ed.. Philadelphia, PA: Lippincott Williams &Wilkins; 2014: 601-625
• 11 Yannopoulos D, Bartos J, Raveendran G. et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet 2020; 396 (10265): 1807-1816
• 12 Glazier JJ, Kaki A. The Impella device: historical background, clinical applications and future directions. Int J Angiol 2019; 28 (02) 118-123
• 13 Basir MB, Schreiber T, Dixon S. et al. Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: the Detroit cardiogenic shock initiative. Catheter Cardiovasc Interv 2018; 91 (03) 454-461
• 14 Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest. Circ Heart Fail 2018; 11 (09) e004905
• 15 Unoki T, Tamura Y, Nakayama T. et al. Combined use of VA-ECMO and IMPELLA (ECPELLA) as a possible strategy to improve outcomes in patients who underwent E-CPR. Eur Heart J 2020; 41 (Suppl. 02) ehaa946.1861
• 16 Levy B, Girerd N, Amour J. et al; HYPO-ECMO Trial Group and the International ECMO Network (ECMONet). Effect of moderate hypothermia vs normothermia on 30-day mortality in patients with cardiogenic shock receiving venoarterial extracorporeal membrane oxygenation: a randomized clinical trial. JAMA 2022; 327 (05) 442-453
• 17 Fugate JE, Moore SA, Knopman DS. et al. Cognitive outcomes of patients undergoing therapeutic hypothermia after cardiac arrest. Neurology 2013; 81 (01) 40-45