ST-Elevation Myocardial Infarction With Cardiogenic Shock and Severe Acute Ischemic Mitral Regurgitation Rescued by Primary Coronary Intervention Under Hemodynamic Support With Impella

A 62-year-old female returned to the Cardiovascular Center, Miyazaki Medical Association Hospital by air ambulance due to ST-elevation myocardial infarction (STEMI) with severe cardiogenic shock 3 days after percutaneous coronary intervention (PCI). She had successfully undergone drug-eluting stent implantation for a diffuse calcified lesion in the left anterior descending artery (LAD; Figure A). Emergency coronary angiography identified the thrombotic in-stent occlusion under dual antiplatelet therapy with aspirin and clopidogrel (Figure B). Due to the marked hemodynamic deterioration, an Impella (ABIOMED, Danvers, MA, USA) was immediately inserted. Following intracoronary thrombus aspiration and balloon dilatation, coronary flow of Thrombolysis in Myocardial Infarction (TIMI) Grade 3 was achieved.

Figure.

(A) A 2.5-mm × 48-mm everolimus-eluting stent (white dotted line) was successfully implanted to the proximal left anterior descending artery (LAD) for stable angina pectoris. (B) Emergency coronary angiography after introduction of the Impella revealed the subacute stent thrombosis at the proximal part of the stent (white arrowhead). (C,D) Severe ischemic mitral regurgitation (IMR; white arrowheads) in the emergency room (C) was significantly reduced immediately after running of the Impella 2.5 (D). (E) Severe hypokinesis in the LAD territory at the onset (left ventricular ejection fraction [LVEF] 20%) improved 2 weeks after primary percutaneous coronary intervention (PCI; LVEF 52%), resulting in a significant improvement in IMR. (F) Left ventricular systolic function was preserved and IMR was barely observed at the 1-year follow-up after primary PCI.

Serial echocardiography images are shown in Figure C–F. Severe acute ischemic mitral regurgitation (IMR) with extensive wall motion abnormality in the LAD territory was observed in the acute phase. Immediately after running of the Impella, IMR was barely observed. Left ventricular (LV) systolic function markedly improved 2 weeks after the revascularization under Impella support, and was maintained in the chronic phase.

A recent study reported that LV unloading with the Impella before PCI improved mortality by minimizing the infarct size.¹ This is the first report showing that LV unloading with the Impella before PCI improved LV systolic function and IMR in a STEMI patient with a stent thrombosis complicated by cardiogenic shock. The procedures in this study were performed in accordance with the Declaration of Helsinki.

Disclosures

None.

Supplementary Files

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