Case description
A 24-year-old obese man collapsed after a night out. No basic life support was performed, but paramedics arrived at T = 2 min. The patient’s first recorded rhythm was ventricular fibrillation (VF). He was intubated and arrived at our emergency department in refractory VF at T = 34 min. We proceeded with extracorporeal cardiopulmonary resuscitation. Femoral vein dilatation was hard and extracorporeal membrane oxygenation (ECMO) was running at T = 79 min. After return of spontaneous circulation, the electrocardiogram showed inferior ST-elevation myocardial infarction. Coronary angiography showed thrombosis of the proximal right coronary artery. Manual thrombectomy failed and rheolytic thrombectomy was applied after which coronary flow was restored. We performed optical coherence tomography (OCT) that revealed focal spasm, red thrombus, and proximal plaque without rupture (Figure 1, see Supplementary material online, slide set for angiograms and full OCT videos). Hence, no stent was implanted and the patient was transferred to the ICU. Screening for amphetamine and cocaine was positive, the cholesterol profile was normal. He was treated with aspirin, heparin, atorvastatin, and targeted temperature management. On Day 1, the ECMO was removed. The patient was extubated at Day 4, discharged after 4 weeks, and achieved full neurologic recovery after 6 weeks. He admitted to have regularly used amphetamine and cocaine. Repeat angiography and OCT showed extensive plaque with spasm but again no evidence of (healed) plaque erosion or rupture (Figure 2). A calcium antagonist was added to the therapy.
Figure 1.
Right coronary angiography and optical coherence tomography at presentation. Immediately after rheolytic thrombectomy: focal spasm, residual red thrombus, and proximal plaque without rupture.
Figure 2.
Right coronary angiography and optical coherence tomography after 6 weeks. Control: extensive plaque with spasm but again no evidence of (healed) plaque erosion or rupture.
Substance abuse and sudden cardiac death are increasingly prevalent among young adults.1,2 Extracorporeal cardiopulmonary resuscitation buys time to unravel the diagnosis and salvage the patient, where OCT may guide the therapy.3 The pathophysiology in this patient was explained by cocaine/amphetamine-induced accelerated atherosclerosis, coronary spasm and thrombosis, and VF.
Supplementary material
Supplementary material is available at European Heart Journal - Case Reports online.
Slide sets: A fully edited slide set detailing this case and suitable for local presentation is available online as Supplementary data.
Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.
Conflict of interest: none declared.
Supplementary Material
References
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