Intra-aortic Balloon Pump As a Bridge to Heart Transplant After Non-ST-Segment-Elevation Myocardial Infarction in Palliated Hypoplastic Left Heart Syndrome

A 24-year-old male with past medical history of hypoplastic left heart syndrome and staged reconstructive surgery in infancy culminating in the Fontan circulation presented to the hospital with a chief complaint of chest pain described as an “elephant sitting” on his chest. Initial 12-lead electrocardiogram revealed 2-mm ST segment elevation in inferior leads, 3-mm ST-segment elevation in anterolateral precordial leads V3 and V4, and 2-mm ST-segment elevation in V5 and V6, with right axis deviation. He was transported emergently to the cardiac catheterization laboratory where coronary angiography revealed complete occlusion of multiple anomalous branches of the right coronary system with hazy appearance suggesting the presence of thrombotic material. An aspiration catheter was used successfully to reestablish TIMI grade III flow. The patient was treated with aspirin, brilinta (ticagrelor), and anticoagulation with vitamin K antagonism to prevent recurrent thromboembolic complications.

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Abstract 16851: ST Segment Variability as a Predictor of Clinical Deterioration in Hypoplastic Left Heart Syndrome

Circulation ◽

10.1161/circ.130.suppl_2.16851 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Eric L Vu ◽

Craig G Rusin ◽

Dan J Penny ◽

Kathy K Kibler ◽

Ronald B Easley ◽

...

Keyword(s):

Hypoplastic Left Heart Syndrome ◽

Clinical Deterioration ◽

Cardiac Conduction ◽

Control Group ◽

High Risk Population ◽

Left Heart ◽

Hypoplastic Left Heart ◽

St Segment ◽

Icu Discharge ◽

Left Heart Syndrome

Introduction: The interstage mortality rate for hypoplastic left heart syndrome (HLHS) is high at 12%. Modalities to predict clinical decline would be useful in this high risk population. Due to cardiac conduction system anomalies in HLHS, electrocardiogram (ECG) monitoring of the ST segment is confounded. Our aim is to develop a monitor of ST variability that predicts deterioration despite the presence of an abnormal ST segment baseline. Hypothesis: Increased ST variability is associated with clinical deterioration in HLHS. Methods: A prospective, observational study was conducted at Texas Children’s Hospital using interstage recordings of 5 lead ECG. From January 2013 to January 2014, 25 subjects were admitted with HLHS; 21 had requisite ECG data for inclusion. In 11 subjects, there were 17 deterioration events, defined as rapid response team (RRT) activation. Events included 13 instances of respiratory failure with intubation and 4 instances of chest compressions. The control group included 10 subjects with no deterioration. An approach to quantify variability was developed where the ST segment vector was resolved using 3 orthogonal leads (II, V5, and aVF) and variability quantified with two metrics: 1) Displacement: distance between ST vector tips at 30 s intervals and 2) Component range: sum of ST vector tip movement in 3 dimensions over 10 min intervals. Comparison was made with the four hour window prior to RRT activation in the deterioration group against the four hour window prior to ICU discharge in the control group. Results: Four hours prior to clinical deterioration, increased ST variability was noted in both methods. For the 30 s displacement method, subjects with deterioration had a median value of 0.059 mm [IQR: 0.039 - 0.075] compared with 0.037 mm [IQR: 0.025 - 0.053] in the control group (p = 0.023). For the 10 min component range method, subjects with deterioration had a median value of 3.0 mm [IQR: 1.8 - 4.5] compared with 1.9 mm [IQR: 1.0 - 2.8] in the control group (p = 0.031). Conclusions: ST variability is increased in HLHS subjects prior to deterioration. Although conduction abnormalities limit the utility of ST monitoring in this population, quantification of ST variability may have a role in advanced systems to monitor clinical deterioration.

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Contemporary trends in cardiogenic shock: Incidence, intra-aortic balloon pump utilisation and outcomes from the London Heart Attack Group

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872617741735 ◽

2017 ◽

Vol 7 (1) ◽

pp. 16-27 ◽

Cited By ~ 44

Author(s):

Krishnaraj S Rathod ◽

Sudheer Koganti ◽

M Bilal Iqbal ◽

Ajay K Jain ◽

Sundeep S Kalra ◽

...

Keyword(s):

Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Cardiogenic Shock ◽

Coronary Intervention ◽

Pump Therapy ◽

St Segment Elevation ◽

Intra Aortic Balloon Pump ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Percutaneous Coronary

Background: Cardiogenic shock remains a major cause of morbidity and mortality in patients with ST-segment elevation myocardial infarction. We aimed to assess the current trends in cardiogenic shock management, looking specifically at the incidence, use of intra-aortic balloon pump therapy and outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. Methods and results: We undertook an observational cohort study of 21,210 ST-segment elevation myocardial infarction patients treated between 2005–2015 at the eight Heart Attack Centres in London, UK. Patients’ details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society percutaneous coronary intervention dataset. There were 1890 patients who presented with cardiogenic shock. The primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2–5.8 years). Increasing rates of cardiogenic shock were seen over the course of the study with consistently high mortality rates of 45–70%. A total of 685 patients underwent intra-aortic balloon pump insertion during primary percutaneous coronary intervention for cardiogenic shock with decreasing rates over time. Those patients undergoing intra-aortic balloon pump therapy were younger, more likely to have poor left ventricular function and less likely to have had previous percutaneous coronary intervention compared to the control group. Procedural success rates were similar (86.0% vs 87.1%, p=0.292) although crude, in-hospital major adverse cardiac event rates were higher (43.8% vs 33.7%, p<0.0001) in patients undergoing intra-aortic balloon pump therapy. Kaplan-Meier analysis demonstrated significantly higher mortality rates in patients receiving intra-aortic balloon pump therapy (50.9% intra-aortic balloon pump vs 39.9% control, p<0.0001) during the follow-up period. After multivariate Cox analysis (hazard ratio 1.04, 95% confidence interval 0.62–1.89) and the use of propensity matching (hazard ratio: 1.29, 95% confidence interval: 0.68–1.45) intra-aortic balloon pump therapy was not associated with mortality. Conclusion: Cardiogenic shock treated by percutaneous coronary intervention is increasing in incidence and remains a condition associated with high mortality and limited treatment options. Intra-aortic balloon pump therapy was not associated with a long-term survival benefit in this cohort and may be associated with increased early morbidity.

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