CASE20220826_021

A Challenging Case Report:Intervention for Complex Native Coronary arteries in a Patient Undergone CABG under Extracorporeal Membrane Oxygenation Support for Twice Time

By Wuqiang Che, Jingang Zheng
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Presenter

Jingang Zheng

Authors

Wuqiang Che1, Jingang Zheng1

Affiliation

China-Japan Friendship Hospital, China1
High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk Intervention

A Challenging Case Report:Intervention for Complex Native Coronary arteries in a Patient Undergone CABG under Extracorporeal Membrane Oxygenation Support for Twice Time

Wuqiang Che1, Jingang Zheng1

China-Japan Friendship Hospital, China1

Clinical Information

Patient initials or Identifier Number

WDW

Relevant Clinical History and Physical Exam

A 58-year-old man was suffered from intermittent chest pain for 14 years and exacerbation 1 day. He received coronary angiography first time about 12 years ago and was diagnosed as severe coronary artery disease with multiple diffuse coronary lesions and received CABG. Coronary angiography was reviewed in our hospital in 2019, and showing severe lesions involving LM, LAD, LCX and RCA, LIMA-LAD was patent, and SVG-LCX was complete occluded. intensive drug therapy was administered. 

Relevant Test Results Prior to Catheterization

Total white blood cells 6.09*10^9/L, total neutrophils 3.79*10^9/L, hemoglobin 127g/L↓, creatine kinase isoenzyme MB 11.2ng/ml↑, troponin T 2.04ng/ml ↑, N-terminal B-type natriuretic peptide precursor 1990 pg/ml↑; Alanine aminotransferase 16IU/L, Aspartate aminotransferase 41IU/L, triglycerides 2.36mmol/L↑, LDL Protein cholesterol 1.98mmol/L, potassium 4.3 mmol/L, creatinine 103μmol/L, D-dimer 0.22mg/L, glycated hemoglobin 6.4%↑.

Relevant Catheterization Findings

Coronary angiography showed 50% stenosis at the distal segment of LM, calcification with a severe stenosis (95%) in the proximal LAD, occlude in the distal LAD; ostium of LCX stenosed 95%, and with long lesions of 70%-90% in the proximal and middle segment, and complete occlusion beyond the distal segment; 70%-90% stenosis in proximal and middle RCA, and distal segment was occlude, LIMA-LAD was patent, and SVG-LCX was complete occluded. 

Interventional Management

Procedural Step

The patient developed dyspnea after coronary angiography suddenly, with orthopnea, SpO2 decreased to 80%, BP ranged 180-220/90-120 mmHg, HR 130bpm, we considered him suffering acute left heart failure, and then emergency tracheal intubation was conducted. During the operation, the patient experienced repeated ventricular tachycardia and ventricular fibrillation. We decided to coronary intervention with ECMO support due to his complex vascular conditions and acute left heart failure. ECMO was implanted through the right femoral artery and venous, the flow rate is maintained at 3-3.5L/min. We planned to use DK-CRUSH for the treatment of LAD and LCX lesions, however, we failed to pass LCX lesions despite repeated rotational atherectomy, considering the severe calcification of the lesion and the risk of coronary perforation, we terminated the intervention procedure. The patient and family refused further treatment coronary artery disease including intracoronary laser ablation, second CABG or heart transplant. And the ECMO was removed the second day after intervention. The patient's condition gradually improved after conservative treatment, both endotracheal tube and IABP were removed. However, the patient suffered recurrent acute left heart failure and endotracheal intubation two weeks later. we successfully treated his coronary arteries lesions under ECMO Support for the second time, and he is recovering with no heart symptoms anymore.

Case Summary

ECMO is useful for the treatment of high-risk complex coronary heart disease and high-risk cardiovascular disease such as concomitant heart failure, malignant arrhythmia and so on. Rigorous ECMO assessment and management are essential for the safety of patients.