Acute MI: Incomplete Stent Expansion in the Setting of Cardiogenic Shock

1
Acute MI Incomplete Stent Expansion in the
Setting of Cardiogenic Shock

• DT is a 44 yo who presents to an outside hospital
  with 2 hours of severe substernal chest pain
• EKG demonstrated anterior ST segment elevation.
• Due to the long transport time to a hospital with
  primary PCI, he was given TNK at the local
  hospital. After TNK, he had a v-fib arrest with
  subsequent defibrillation, respiratory arrest
  requiring intubation, and cardiogenic shock
  requiring IV dopamine drip for hemodynamic
  support.
• Helicoptor transport to the BWH
• On arrival, persistent ST elevation and shock
• The patient was taken to cardiac catheterization.

2
(No Transcript)
3
(No Transcript)
4

• 6F 3.5XB guide
• Prowater guide wire
• LAD lesion pre-dilated with a 2.5 mm balloon
• Complicated by acute closure

5

• An Export catheter was used to successfully
  extract thrombus with restoration of flow

6

• A 3.0 x 28 mm Cypher stent was deployed in the
  mid LAD.
• Post-dilated with a 3.0mm balloon to 20 atms
• 0 residual stenosis and TIMI-3 flow.

7

• An IABP was not placed as his BP was maintained gt
  100 systolic on dopamine but was in the room
• Post-intervention, the patient was admitted to
  the CCU where his pressor support and sedation
  were successfully weaned off.
• He was brought back to the cath lab the next day
  for reassement of the LAD and for planned
  intervention of the proximal 1st diagonal branch.

8

• Angiography of LAD demonstrated a patent
  stent, but with a 50 irregular lesion within the
  stent.

9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
Take-Home Points

• Acute MI patients can be safely treated with drug
  eluting stents, but special attention needs to be
  made to proper sizing of stents
• Vasopressor, including dopamine, can influence
  the underlying vessel diameter as it is tapered
• Coronary vasodilation may occur as the pressors
  are withdrawn, leading to incomplete stent
  apposition