Early Implementation of Veno-Venous Hemofiltration and Use of Rotational Atherectomy in a Patient with ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: A Case Report

Monika Durak^*, Marek Tomala, Bartłomiej Adam Nawrotek, Andrzej Machnik and Jacek Legutko
^*Correspondence: Monika Durak, Department of Interventional Cardiology, Jagiellonian University Medical College Institute of Cardiology, Prądnicka 80 Krakow, Poland, Email:

Keywords

Rotational atherectomy • Injury • Cardiogenic shock

Introduction

Rotational Atherectomy (RA) is currently used for calcified lesions that cannot be crossed by a balloon catheter or are so severe that a stent cannot be delivered to the target location. However, in the context of STSegment Elevation Myocardial Infarction (STEMI), RA is not routinely used during primary Percutaneous Coronary Intervention (PCI) due to the risk of embolization caused by thrombus fragmentation. Prognosis of STEMI for Cardiogenic Shock (CS) depends on PCI effectiveness and pre-renal Acute Kidney Injury (AKI) [1]. The role of continuous Renal Replacement Therapy (RRT) in the treatment of CS after PCI has not been described. This case highlights the use of Continuous Veno-Venous Hemofiltration (CVVH) as a treatment option for acute renal failure.

Learning Objectives

1. This case demonstrates that RA can be a safe option for STEMI patients in cardiogenic shock if extreme precautions like using small burr sizes and low speeds are used.

2. CVVH may be the first-choice option in patients otherwise treated with Right Ventricular Mechanical Circulatory Support.

Case Report

A 61-year-old man with hypertension and hyperlipidemia presented to the emergency department after 8 hours of chest pain and an episode of syncope. His Blood Pressure (BP) was 80/66 mmHg and arterial oxygen saturation was 80%. An electrocardiogram showed complete atrioventricular blockage with a minimum heart rate of 31 beats/min (Figure 1). An echocardiogram revealed distension and hypokinesis of the Right Ventricle (RV), hypokinesis of the inferior wall, and a Left Ventricular Ejection Fraction (LVEF) of 50% (Figure 2, Movie 1). A temporary pacing wire was inserted into the apex of the RV. The patient was loaded with oral aspirin (300 mg) and ticagrelor (180 mg). Perioperatively, we used heparin with an activated clotting time >250 sec. Coronary angiography revealed significant proximal left main coronary artery stenosis at the level of the aorto-ostial junction, a tight lesion in the proximal to mid-segment of the left anterior descending artery extending into the vessel bifurcation causing a 50-60% diameter stenosis of the large diagonal branch, and a critical ostial lesion of the left circumflex artery (Movies 2-4). Occlusion of the proximal segment of the Right Coronary Artery (RCA) (Movie 5) caused the patient’s MI. The occlusion was crossed using a Judkins Right 4 (JR4.0/6 F) guiding catheter (Medtronic) and a Whisper ES wire (Abbott). The RCA was predilated sequentially with semi-compliant 2.0/15 mm and Non-Compliant (NC) 2.5/20 mm balloons (Movie 6), but lesion expansion was inadequate, and we changed to an Amplatz left (AL1.0/6 F) guiding catheter (Medtronic). Low-speed rotablation (140.000 rotations per minute (rpm)) was performed in three passages using a 1.25 mm burr with an extra-support Rota-wire (BSC, USA), (Movie 7). Attempts to fully expand a 3.0/20 mm NC balloon were unsuccessful (Movie 8). Subsequent rotablation with a 1.75 mm burr (Movie 9) was followed by expansion of a 3.5/15 mm NC balloon. A 3.5/38 mm Resolute Integrity zotarolimus-eluting stent (Medtronic) was deployed at the distal/mid- RCA (Movie 10).

Due to lack of peripheral flow in the large Right Ventricular Branch (RVB), the Whisper ES guidewire was run through the stent cell to the RVB, which was stented with a 2.5/38 mm Resolute Integrity stent using the T and small protrusion technique (Movie 11). Due to ostial RCA dissection, along with dissection of the right coronary sinus of Valsalva, the 3.5/38 mm Resolute Integrity stent was implanted to cover the RCA ostium, with a 4.0/38 mm Resolute Integrity stent overlapping distally (Movie 12). A 4.0/15 mm NC balloon was used to post-dilate the stents and establish a Thrombolysis in Myocardial Infarction (TIMI) grade 2/3 flow in the RCA and a TIMI 2 in the RVB, with a residual, stable contrast staining in the aortic wall (Movie 13). Due to the sinus of Valsalva dissection, we did not administer antiplatelet therapy using an IIb/IIIa blocker. The amount of contrast you used during the procedure was 400 ml. Hemodynamic parameters improved immediately after PCI (BP- 110/70 mmHg). However, continuous infusion of inotropes and vasopressors (norepinephrine, dobutamine) were required for 24 hours to maintain a mean arterial pressure of 60-65 mmHg. The A-V block resolved immediately after the procedure. Several hours later, the patient became anuric, and the potassium and lactate levels increased, indicating CVVH implementation. The patient’s general condition improved after 24 hours. On the third day post-admission, diuresis, forced by continuous furosemide infusion, returned and CVVH was stopped the next day. Noradrenaline was discontinued on the second and dobutamine on the fifth day in the Cardiology Intensive Care Unit (CICU). Highsensitivity troponin T levels were measured on admission to the CICU and 24 hours following the onset of chest pain, yielding values of 3.120 ng/mL and 30.510 ng/mL, respectively. The patient’s creatinine level on hospital admission was 99 μmol/L; the maximum value was 106 μmol/L. An echocardiogram 36 hours post-procedure showed improvement in RV size and global function (Movie 14). Due to significant stenosis in the left coronary artery, the patient underwent coronary artery bypass grafting six weeks after the MI. He did not report any complications at the 6-month follow-up (Movie 15).

Discussion

We present the case of a patient with STEMI in CS for whom RA allowed delivery of a stent to the Infarct-Related Artery (IRA), leading to a successful procedure and patient survival. To minimize the no-reflow risk, we used a small burr size (1.25 mm), a short burr time (10-15 sec), and a low rotation speed (140 rpm). However, the 1.25 mm burr was ineffective, and inadequate lesion expansion with a 2.5 NC balloon was observed. Using a 1.75 mm burr allowed for adequate dilatation with a 3.0 NC balloon followed by stent implantation. Use of RA in STEMI is described in only one published case regarding CS [2]. Previous work demonstrated successful RA in 10 cases of acute MI when standard balloon angioplasty failed. The paramount risk factor for no-reflow was calcified lesion length, while presence of MI was irrelevant [3]. Additionally, RA has been successfully used in 23 patients with severe Left Ventricular (LV) dysfunction. If a stent cannot be delivered, RA appears effective and safe for high-risk patients with significantly impaired LV-systolic function [4]. Indications for RRT include hyperkalemia and severe acidosis secondary to anuria, despite fluid resuscitation and intravenous diuretic treatment. Mortality for RV-CS patients is similar to that of LV-CS patients [5]. Furthermore, the occurrence of oliguria during the first 24 hours of CS worsens prognosis for these patients [1]. Prevention of AKI through early CVVH may improve the prognosis of patients with CS during acute MI [6,7]. Clinical use of RRT, including appropriate treatment indications and initiation and discontinuation timing, remains poorly defined. Using CVVH in our patient with acute RV failure-caused CS was effective in removing venous congestion (backward failure) and excess fluids. To our knowledge, using early RRT in the setting of CS treated with PCI has only been described by Marensi et al. [7] Temporary RV mechanical circulatory support is preferred for treatment of CS caused by RV failure, and 75% of patients treated thusly fully recover [8]. However, because of major bleeding in nearly 25% of this group [9], we decided to use CVVH first. Hemodynamic stabilization and diuresis restoration secondary to gradual improvement of RV function was likely associated with successful revascularization of the RVB [10].

Conclusion

RA of massive calcifications in the context of STEMI may remain the only option for stent delivery to the IRA, which is important for hemodynamically unstable patients. This case highlights the use of CVVH as a supportive therapy for AKI caused by RV infarction complicated by CS. CVVH may be the preferred first alternative treatment in patients otherwise treated with RV mechanical circulatory support.

References

1. Maria Koreny, Georg Delle Karth, Alexander Geppert and Thomas Neunteufl, et al. “Prognosis of Patients Who Develop Acute Renal Failure during the First 24 Hours of Cardiogenic Shock after Myocardial Infarction.” Am J Med 112 (2002): 115-119.
2. Jeremy Sayer and Refai Showkathali. “Rotational Atherectomy in a Patient with Acute ST-Elevation Myocardial Infarction and Cardiogenic Shock.” Int J Angiol 22 (2013): 203-206.
3. Kenichi Sakakura, Junya Ako, Hiroshi Wada and Ryo Naito, et al. “Comparison of Frequency of Complications With On-Label Versus Off-Label Use of Rotational Atherectomy.” Am J Cardiol 110 (2012): 498-501.
4. Hoyle L. Whiteside, Supawat Ratanapo, Arun Nagabandi and Deepak Kapoor. “Clinical Experience with Rotational Atherectomy in Patients with Severe Left Ventricular Dysfunction.” J Invasive Cardiol 18 (2006): 514-518.
5. Alice K. Jacobs, Jane A. Leopold, Eric Bates and Lisa A. Mendes, et al. “Cardiogenic Shock Caused by Right Ventricular Infarction.” J Am Coll Cardiol 41 (2003): 1273-1279.
6. Giancarlo Marenzi, Nicola Cosentino, Andrea Marinetti and Antonio M. Leone, et al. “Renal Replacement Therapy in Patients with Acute Myocardial Infarction: Rate of Use, Clinical Predictors and Relationship with In-Hospital Mortality.” Int J Cardiol 230 (2017): 255-261.
7. Giancarlo Marenzi, Emilio Assanelli, Jeness Campodonico and Monica De Metrio, et al. “Acute Kidney Injury in ST-Segment Elevation Acute Myocardial Infarction Complicated by Cardiogenic Shock at Admission.” Crit Care Med 38 (2010): 438-444.
8. Mark B. Anderson, James Goldstein, Carmelo Milano and Lynn D. Morris, et al. “Benefits of a Novel Percutaneous Ventricular Assist Device for Right Heart Failure: The Prospective RECOVER RIGHT Study of the Impella RP Device.” J Heart Lung Trans 34 (2015): 1549-1560.
9. Jonathan Hill, Adrian Banning, Francesco Burzotta and Alaide Chieffo, et al. “A Systematic Literature Review and Meta-Analysis of Impella Devices used in Cardiogenic Shock and High Risk Percutaneous Coronary Interventions.” Interv Cardiol 28 (2019): 1.
10. Marek Tomala, Tomasz Miszalski-Jamka, Wojciech Zajdel and Bartłomiej Nawrotek, et al. “Angiographic Result of Index PCI Determines the Presence of Right Ventricular Infarction in Patients with Acute Inferior Myocardial Infarction.” Int J Cardiovasc Imag 31 (2015): 1591-1601.