North Texas Research Forum 2024



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North Texas


Medical City Fort Worth



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acute coronary syndrome, cardiogenic shock


Cardiology | Cardiovascular Diseases | Internal Medicine | Medicine and Health Sciences


Background: Acute coronary syndrome patients presenting with Cardiogenic shock carry a very high mortality risk >70% without appropriate intervention in a timely fashion. Here we present a patient requiring an axial pump mechanical circulatory support despite having an apical thrombus. Case report: 55-year-old male with past medical history of type 2 diabetes mellitus and medication noncompliance was transferred from outside facility for high risk ACS with EKG showing ST segment elevation in inferior and anterolateral leads. Lab showed hsTroponin more than 125K, BG 556, HCO3 17, and Beta hydroxybutyrate of 41.87 indicating DKA. Emergent coronary angiography showed mid LAD artery 100% occlusion, proximal D1 branch 90% occlusion , mid left circumflex 99% occlusion with filling slow, and mid RCA 100% occlusion with left to right septal collaterals. LVEDP was 36-39 mmHg. LV gram demonstrated LVEF of 5-10%, and severe global hypokinesis. Impella CP placed via right CFA, and VA ECMO cannulated by cardiothoracic surgery for hemodynamic stability. Transthoracic echocardiogram showed LVEF 20-25%, severe diffuse hypokinesis, and an organized apical thrombus thought to be a pseudoaneurysm on ventriculogram. CT Surgery deemed the patient not a candidate for CABG given lack of targets, therefore patient was transferred to a higher level facility to be evaluated for Impella 5.5 and LVAD support. After removal of VA ECMO circuit and upgrade to Impella 5.5 device, the patient continued to improve hemodynamically and subsequently received DES to LAD and left circumflex. Ultimately RCA revascularization with subsequent impella removal a few days later. He remained on anticoagulation throughout his admission and post for LV thrombus. Soon after he was stable enough and transferred to a LTACH facility with a life vest and triple therapy. Little over a month later repeat transthoracic echocardiogram showed improved EF of 30-35%. Discussion: This case vignette demonstrates an unconventional management of cardiogenic shock in the setting of apical thrombus requiring mechanical support. Although it remains controversial regarding the use of axial pump MCS in patients with LV apical thrombus, it was used in this case as the thrombus was considered to be organized and non mobile and position of the support device was periodically monitored and ensured it stayed away from the thrombus cap. This allowed our high risk non surgical candidate patient to undergo staged high risk PCI and a fighting chance of survival. Further studies are required to explore the use of MCS in such clinical situations.

Original Publisher

HCA Healthcare Graduate Medical Education

MCS Assisted High Risk Multi-Vessel Percutaneous Intervention in Cardiogenic Shock Patient with LV Thrombus



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