Introduction: 1yr PCI+ECMO in the setting of cardiac-arrest and cardiogenic shock is challenging. Data has shown promising results in mortality reduction.
Case presentation: 57y man admitted with NSTEMI. LVEF-35%. 6-hours later he developed LBBB and taken for primary PCI. CAG: proximal occlusion-LAD, Tight lesion-Big ramus, normal-LCX and CTO-RCA. PCI to LAD and ramus were done. After stent-deployment, he developed cardiac-arrest. CPR initiated, IABP inserted and TPM was placed, he revived after 1.5hours of CPR. LVEF 10%. So peripheral VA-ECMO was inserted for cardio respiratory support and we could be able to wean it off successfully after 5 days from deployment.
He developed severe thrombocytopenia so, clopidogrel stopped & aspirin continued. After 36hours of ECMO removal, sudden clinical-deterioration was observed with severe shock again. EF 15%. Re look Angio revealed: all stents occluded thrombi. Aspiration thrombectomy done and hemodynamics was supported with IABP again. He also developed pneumonia and septic-shock and VA-ECMO implanted again. This time we could wean off ECMO. On the 30th Post cardiac arrest, ECMO was explanted due to oxygenator clotting. Next day he was declared dead.
Conclusion: Our case is an example where a seemingly well doing patient after ECMO implantation, deteriorated all the way to death due to diagonally opposed balance between the risk of bleeding due to DAPT and heparin and the risk of stent thrombosis if that therapy is withdrawn.
Further studies are required to carve out the anti-platelet strategy in patients with peri-arrest primary PCI+ECMO. Timing of insertion of ECMO may be crucial as if it is done earlier in such patients with STEMI+cardiogenic shock may lead to a less complicated course and more fruitful outcome.
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