Impella in Elderly LM STEMI Theodore L. Schreiber, MD, FACC, FASCI, FCCP President, Detroit Medical Center Heart Hospital

Disclosure Statement of Financial Interest I, Theodore L. Schreiber, MD, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Background An 84 years old African-American female. Past medical history: Hypertension. Peripheral vascular disease. Coronary artery disease: In 2013 intervention with stent into proximal LAD sub total occlusion. Resolute 3.0x18 and 2.5x14 stents. Proximal RCA with chronic total occlusion. Chief complain: Presented to the Detroit Receiving Hospital with shortness of breath. Suffered cardiac arrest at the DRH emergency department: CPR initiated. Defibrillated for ventricular fibrillation. Coded for proximally 10 minuets.

Electrocardiogram Sinus rhythm, left axis, mild ST elevation AVR, III, ST depression V3-V6, I, AVL.

Cath Lab January 22, 2017 Recurrent cardiac arrest with pulse less electrical activity. 15 minutes of CPR and ACLS protocol. Defibrillated for ventricular fibrillation. Total code time approx 25 minutes. Impella CP mechanical circulatory device was inserted emergently with gaining hemodynamic and electrical stabilization.

Cath Lab January 22 2017 Coronary angiography: Diffuse LM long, 90% lesion. Proximal and mid LAD with patent stents. Left circumflex with diffuse proximal and distal 70% stenosis. Mid Ramus 80% stenosis. RCA with a known to be chronic total occlusion. No coronary intervention performed for hemodynamic and electrical stabilization, normalized ECG and unknown mental status in a frail elderly patient after prolonged CPR. Trans venous temporary pacemaker was placed for bradycardia. Patient was admitted to the cardiac intensive care unit for additional treatment.

Cath Lab January 22, 2017

Cath Lab January 22, 2017

First day of admission Patient neurological status improved she was awake and following commands, precluded from hypothermia protocol.

Angioplasty January 23, 2017 – LM

Angioplasty January 23, 2017 – LAD & KBS

Angioplasty January 23; 2017 Angioplasty to LM: Successful angioplasty to LM using a Resolute 3.5x18 stent. During stent deployment the Ramus wire was pulled out. IVUS assessment of the LM-LAD. Post dilatation into the stent was performed using NC 4.0x8.0 balloon with good results and reduction of stenosis from 90% to 0%. Angioplasty to Ramus: Successful angioplasty to Ramus using a Xience 2.5x23 stent with good results and reduction of stenosis from 90% to 0%. Kissing balloon: The stent 2.5x23 balloon LM-Ramus. A 2.5x20 balloon LM-LAD. A Quinton catheter was inserted into the femoral vein.

IVUS

Final Result

Angiography January 24, 2017 Patent stents in LM-LAD and Ramus. Diminished flow to the left lower extremity around the Impella 14f sheath.

Save a life, Save a Limb or why not Save Both! Peripheral Angioplasty January 26, 2017 for left lower extremity ischemia Semi internal fem-fem bypass: A Glide advantage wire was advanced into the left deep femoral artery. A 5f/55cm sheath was advanced from the right femoral 8f sheath into the left deep femoral artery and the side arms of the right femoral 8f sheath was connected to the side arm of the 5f sheath. Distal left lower extremity flow was documented. Save a life, Save a Limb or why not Save Both!

Fem Fem Bypass

Left Antegrade FEM-FEM sheath Bypass Left Femoral impella sheath Right Fem

Impella removal, January 28, 2017 The Impella was pulled out of the LV and body. A new 14f sheath was inserted after the pill away sheath was removed. A Platinum plus 0.018 wire was advanced into the aorta through the Impella side branch. An 8f sheath was advanced into the left femoral artery and immediately replaced into 14f sheath over a suprecore wire. Using right femoral 8f/45cm cross over sheath. A 7.0x20 balloon was used for left iliac artery temporary internal tapenade. Two preclose were deployed at the left femoral artery. For residual significant bleeding at the puncture site, severe thrombocytopenia with low hemoglobin level a 8f/20mm long covered stent was deployed at the left CFA and sealed the puncture site and gained hemostasis. For sub total occlusion of the left SFA with slow flow below the knee. laser atherectomy was performed along the left SFA and popliteal arteries. Balloon angioplasty with a 4.0x300 balloon with good results and reduction of stenosis from 90% to less then 20%.

Balloon Tamponade

Post 14f sheath removal: Residual bleeding treated with covered stent

Left lower extremity perfusion

Patient Complications For prolonged intubation and mechanical ventilation patient was unweanable and required tracheostomy. For ischemic left lower extremity: A semi internal bypass was performed while the Impella sheath was at place. Left lower angioplasty was performed. Ischemic bowel that precluded feeding and was complicated with severe bleeding.

Hematological complications Patient suffered bleeding: Through long lasting sheath: 14f at the left femoral artery. 7f in the right femoral artery. 8f at the right femoral vein. Severe GI bleeding with a diagnosis of ischemic bowel. Overall transfusions: 16 units of packed cell. 50 units of platelets. One unit of FFP.

January 23, second day of admission:

January 25, forth day of admission:

February 8, 18 day of admission:

Hospital Course and Final Result

January 22-29 Mixed venous saturation (simplified Fick for cardiac output)

Hemoglobin level through out admission.

Platelets level through out admission.

Creatinine level through out admission.

Lactate level through out admission.

LV recovery by echocardiography January 23, second day of admission: LVEF of 25%. Anterior and lateral akinesis. January 25, forth day of admission: LVEF of 25-30%. February 8, 18 day of admission: LVEF of 65-70%. Normalization of anterior and lateral motion. Normal global longitudinal strain of 18.8%.

Patient complications Respiratory: Prolonged assisted ventilation. Tracheostomy. Renal: Acute kidney injury which required renal replacement therapy with CRRT and now with hemodialysis. Infection: Multiple episodes of sepsis. Gatrointestinal: Ischemic colitis with severe GI bleeding. Need for prolonged NG tube feeding. Feeding with TPN. Loss of body mass and low albumin level.

Patient complications Left lower extremity: Ischemia with threatened loss. Left lower extremity salvage balloon angioplasty. Rhabdomyolysis. Multiple blood products: Packed cells, 16 units. Platelets 30 units. FFP, single unit.

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