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CASE PRESENTATION

Case Presentation

A 56-year-old woman with hypertension and hyperlipidemia presented to the emergency room complaining of sudden-onset central chest pain and shortness of breath. She was found to have an inferior ST-segment elevation myocardial infraction. She was immediately taken to the cardiac catheterization laboratory and received a drug-eluting stent in the right coronary artery with Thrombolysis in Myocardial Infarction (TIMI) grade III flow. Her heart rate was 115 bpm, and blood pressure was 80/60 mmHg. Dopamine was initiated in the catheterization lab and was titrated to maximum dose. Her blood pressure did not improve, and she continued to feel short of breath. At this point, a Swan-Ganz catheter was placed, and her pulmonary capillary wedge pressure was 20 mmH2O, right atrial pressure was 12 mmHg, and cardiac index was 1.9. Echocardiogram showed left ventricular ejection fraction of 45%, moderate to severe mitral regurgitation, and no pericardial effusion. She was initiated on intra-aortic balloon pump (IABP) and taken to the critical care unit. Her hemodynamics were stabilized initially, and she continued to improve on subsequent days. Her vasopressor requirements were decreased, and she was weaned off IABP.

KEY POINTS

  • Temporary mechanical circulatory support can be used in cardiogenic shock patients to stabilize hemodynamics.

  • Percutaneous right and left support devices are considered as a temporary measure to unload ventricles during the periprocedural period in high-risk cases.

  • Efforts are ongoing to improve the pump flow, catheter caliber, and ease of placement.

TEMPORARY MECHANICAL CIRCULATORY DEVICES

Over the past decade, mechanical circulatory support (MCS) has emerged as an important focus in the management of cardiogenic shock. Multiple randomized and observational trials have been ongoing to study the impact of MCS on survival outcomes in shock patients. Although initially introduced as an emergency device, MCS now has a role in elective high-risk cases, perioperative management, and transplant cases. Depending on the patient’s clinical scenario and need for hemodynamic support and the operator’s experience, several types of MCS are available (Table 4-1).

TABLE 4-1.Types of Percutaneous MCS

PERCUTANEOUS LEFT VENTRICLE CIRCULATORY SUPPORT DEVICES

Intra-Aortic Balloon Pump

There are several modalities to support pump failure in cardiogenic shock. Intra-aortic balloon pump (IABP) is one of the first MCS devices used in cardiac patients. IABP is a pulsatile intravascular left ventricular circulatory support system designed to provide cardiac output. It can be emergently placed percutaneously either at bedside or in the cardiac catheterization ...

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