62- year- old male presented with class I angina and positive stress echo. Cardiac cath on June 4, 2013 revealed 2V + LM CAD, occluded LIMA to LAD and occluded SVG to OM and LVEF 55%. Patient had prior paclitaxel DES PCI of proximal LAD and now presents with 99% ISR. Patient was recommended to re-do CABG but declined. Patient is scheduled for complex PCI of unprotected distal LM, LAD and proximal LCX after OCT and near infrared spectroscopy with IVUS imaging.
Q&A
Q
What contributed to the transient LMCA occlusion?
A.
Most likely it was a small dissection at the level of dLM which closed both ostial LAD and particularly ostial LCx. This caused major cardiovascular collapse despite normal LVEF and non-dominant RCA was diffusely diseased.
Q
Dissection or thrombosis or both?
A.
Dissection 90% and 10% superadded thrombus likely contributed to acute closure.
Q
How often do you use ECMO? A. Once in 2-3 years.
A.
Soon we will be using a new portable ECMO designed to be placed in the cath lab called CardioHelp marketed by Maquette co.
Q
In your protocol, do you always attempt IABP before moving to ECMO?
A.
Yes as IABP will give some support while ECMO team is being mobilized as it will take minimum 20-25 minutes for ECMO to start working. IABP can be inserted in 1-2 minutes and Impella in 4-5 minutes and both will give some relief while ECMO is being inserted.
Q
How many ECMO procedures are done at your institution each year?
A.
Approximately 40-50 per year; all in CT surgery theater or ICU. We needed ECMO urgently in our cath lab 4 times in last 10 years including this case.
Q
What have been the results?
A.
Those ECMO pts are tough post CT surgery cases and some do get heart transplant. Of the 4 ECMO placed in our cath lab this decade so far, two survived (including this case) and other 2 expired.
Q
Do you have criteria for not considering ECMO in such situations?
A.
Only reason not to use ECMO will be lack of vascular access.
Q
Any age cut-off for ECMO?
A.
Not really as if pt needs cardiac procedure then they could get ECMO.
Q
What is the appropriate time delay in initiating ECMO?
A.
As short as possible but 20minutes will be the inherent delay in getting the ECMO inserted.
Q
Do you feel ECMO should be available at all facilities that offer CTS standby?
A.
I expect ECMO is the part of all CT surgery program. For the cath labs with or without CT surgery standby, recently FDA approved portable ECMO (CardioHelp made by Maquette) is now available. We have purchased the CardioHelp in our cath lab since our June case and has used it successfully in one elective high risk PCI case (dLM, LAD and prox LCx lesions in a hemodialysis pt with LVEF 15% and turned down by CTSurgery).
