Impella 5.5 as a bridge-to-surgery in acute ischemic mitral regurgitation post-percutaneous coronary intervention: a case report.

IF 1.5 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Journal of Cardiothoracic Surgery Pub Date : 2024-11-06 DOI:10.1186/s13019-024-03019-9
Ioana Dumitru, Askin Uysal, Joel Shoemaker, Maria Sevillano, Leeandra Schnell, Samip Vasaiwala, Syed Osman Ali
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Abstract

Background: Acute ischemic mitral regurgitation (AIMR) is a significant complication of acute coronary syndrome that leads to severe and immediate hemodynamic deterioration and cardiogenic shock. Intra-aortic balloon pumps (IABP) are commonly used to support patients with AIMR as a bridge to surgery, though they may be insufficient in some cases.

Case presentation: A 74-year-old male presented with two days of indigestion and evident hypoxia, and an electrocardiogram revealed inferior and lateral ST-elevation myocardial infarction. Angiography demonstrated severe two-vessel coronary disease with a 100% thrombotic occlusion of the second obtuse marginal artery (OM2, culprit lesion) and an 80% stenosis of the proximal left anterior descending artery (LAD). Despite stenting of OM2, the patient remained hypoxic and hypotensive, necessitating escalated support via an IABP. A follow-up echocardiogram revealed severe mitral regurgitation presumed to be AIMR secondary to a ruptured posteromedial papillary muscle with a flail anterior leaflet (A2). Despite aggressive supportive measures with the IABP, the patient's hemodynamics continued to show cardiogenic shock and clinical status did not improve. However, the patient was required to abstain from surgery for a P2Y12 inhibitor therapy wash out period. Consequently, the IABP was upgraded to Impella 5.5 as bridge-to-surgery support on day 1 post-admission. Subsequently, the patient's hemodynamics improved, and he underwent a combined mitral valve replacement and coronary artery bypass grafting surgery on day 7 post-admission without incident. The Impella was successfully explanted on day 25 post-admission. Delay in explant was due to hypotension and respiratory status despite normalizing hemodynamics and echocardiogram revealing recovered left ventricular ejection fraction. The patient developed bacterial pneumonia and acute respiratory distress syndrome and expired on day 27 post-admission.

Conclusion: Although IABP is standard for supporting AIMR patients as a bridge to surgery, it may not provide sufficient hemodynamic support. This case supports a growing body of evidence that alternative forms of hemodynamic support should be considered if the traditional therapeutic modalities for AIMR do not adequately support patients. Clinicians may consider upgrading IABP to Impella to provide increased hemodynamic support and maintain AIMR patient stability while awaiting cardiac surgery.

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Impella 5.5 作为经皮冠状动脉介入术后急性缺血性二尖瓣反流的手术桥梁:病例报告。
背景:急性缺血性二尖瓣反流(AIMR)是急性冠状动脉综合征的一个重要并发症,可导致严重而直接的血流动力学恶化和心源性休克。主动脉内球囊泵(IABP)通常用于支持二尖瓣反流患者,作为手术前的过渡,但在某些情况下可能并不足够:一名 74 岁的男性患者因消化不良和明显缺氧两天前来就诊,心电图显示心肌梗死呈下部和侧部 ST 段抬高。血管造影显示严重的双血管冠状动脉疾病,第二钝缘动脉(OM2,罪魁祸首)100% 血栓性闭塞,左前降支动脉(LAD)近端 80% 狭窄。尽管为 OM2 植入了支架,但患者仍然缺氧且血压过低,需要通过 IABP 提供更多支持。随访超声心动图显示患者二尖瓣严重反流,推测为继发于后内侧乳头肌断裂和前叶(A2)脱落的二尖瓣反流。尽管使用 IABP 采取了积极的支持措施,但患者的血流动力学仍显示为心源性休克,临床状况没有改善。然而,患者被要求在 P2Y12 抑制剂治疗冲洗期暂停手术。因此,入院后第 1 天,IABP 升级为 Impella 5.5,作为手术前的桥接支持。随后,患者的血液动力学状况有所改善,并在入院后第 7 天顺利进行了二尖瓣置换和冠状动脉旁路移植联合手术。入院后第 25 天,成功取出了 Impella。尽管血流动力学恢复正常,超声心动图显示左心室射血分数恢复,但由于低血压和呼吸状况不佳,Impella仍延迟取出。患者出现细菌性肺炎和急性呼吸窘迫综合征,于入院后第 27 天去世:尽管 IABP 是支持 AIMR 患者作为手术桥梁的标准方法,但它可能无法提供足够的血流动力学支持。本病例支持越来越多的证据表明,如果 AIMR 的传统治疗方法不能为患者提供足够的支持,则应考虑使用其他形式的血液动力学支持。临床医生可以考虑将 IABP 升级为 Impella,以提供更多的血流动力学支持,并在等待心脏手术期间维持 AIMR 患者的稳定性。
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来源期刊
Journal of Cardiothoracic Surgery
Journal of Cardiothoracic Surgery 医学-心血管系统
CiteScore
2.50
自引率
6.20%
发文量
286
审稿时长
4-8 weeks
期刊介绍: Journal of Cardiothoracic Surgery is an open access journal that encompasses all aspects of research in the field of Cardiology, and Cardiothoracic and Vascular Surgery. The journal publishes original scientific research documenting clinical and experimental advances in cardiac, vascular and thoracic surgery, and related fields. Topics of interest include surgical techniques, survival rates, surgical complications and their outcomes; along with basic sciences, pediatric conditions, transplantations and clinical trials. Journal of Cardiothoracic Surgery is of interest to cardiothoracic and vascular surgeons, cardiothoracic anaesthesiologists, cardiologists, chest physicians, and allied health professionals.
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Bullectomy with video-assisted thoracic surgery and minimally invasive repair of pectus excavatum simultaneously. Drug-coated balloons versus drug-eluting stents in patients with in-stent restenosis: An updated meta-analysis with trial sequential analysis. Fungal endocarditis after transcatheter aortic valve implantation complicated with pseudoaneurysm of the ascending aorta. Impella 5.5 as a bridge-to-surgery in acute ischemic mitral regurgitation post-percutaneous coronary intervention: a case report. Correction: Clinical features between paroxysmal and nonparoxysmal atrial fibrillation: a comparative analysis in eastern China.
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