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Refractory Intraprocedural Ventricular Fibrillation From Left Circumflex Culprit Occlusion Managed With Culprit PCI
Vineet Madishetty1, Alexander Yaylayan1, Kevin Schneider1
1Internal Medicine/Cardiology, HCA Healthcare/USF Morsani College of Medicine, GME/HCA Florida Largo Hospital, Largo, Florida, USA.
Insights
Ventricular fibrillation (VF) caused by acute coronary syndrome (ACS) can be refractory and only resolve after prompt reperfusion of the blocked artery. Mechanical circulatory support, like Impella, can aid recovery from cardiac arrest.
Area of Science:
- Cardiology
- Interventional Cardiology
- Critical Care Medicine
Background:
- Ventricular fibrillation (VF) is a critical complication of acute coronary syndrome (ACS).
- ST-segment elevation in aVR with diffuse ST depression indicates global subendocardial ischemia but lacks specificity for certain coronary artery lesions.
- Prompt identification and correction of reversible ischemic triggers are essential for managing VF in ACS.
Purpose of the Study:
- To present a case of refractory, ischemia-mediated ventricular fibrillation (VF) during percutaneous coronary intervention (PCI).
- To highlight the role of culprit-vessel reperfusion in terminating refractory VF.
- To discuss the utility of mechanical circulatory support in managing severe circulatory collapse and facilitating recovery.
Main Methods:
- A 62-year-old male with a history of coronary stent placement presented with acute chest pain and signs of severe ischemia.
- Emergent coronary angiography revealed a heavily calcified left circumflex lesion, during which VF developed repeatedly.
- The patient underwent left circumflex stenting, Impella placement for circulatory support, and subsequent staged PCI of the LAD lesion.
Main Results:
- Recurrent VF episodes ceased only after successful stenting of the culprit left circumflex lesion, restoring TIMI Grade 3 flow.
- The patient met SCAI Stage E criteria for cardiogenic shock due to recurrent cardiac arrest and severe acidosis.
- Temporary Impella support facilitated hemodynamic recovery, allowing for device removal within 48 hours and successful staged PCI.
Conclusions:
- Refractory ischemia-mediated VF can be resolved by prompt culprit-vessel reperfusion.
- A preserved ejection fraction after reperfusion during mechanical support does not preclude prior severe cardiogenic shock.
- Short-term Impella support can serve as a bridge to recovery in patients experiencing recurrent arrest and transient circulatory collapse.
Background:
Ventricular fibrillation (VF) is a life-threatening complication of acute coronary syndrome (ACS) and requires rapid identification and correction of reversible ischemic triggers. ST-segment elevation in aVR with diffuse ST depression reflects global subendocardial ischemia but is not specific for left main or proximal left anterior descending disease.
Case Summary:
A 62-year-old male with prior coronary stent placement presented with acute chest pain, diaphoresis, nausea, and vomiting. An electrocardiogram demonstrated ST-segment elevation in aVR with ST depressions in V3-V6. Laboratory testing demonstrated severe metabolic acidosis (pH 7.07; bicarbonate 10.3 mEq/L), lactate 3.7 mmol/L, and high-sensitivity troponin rising from 427 to 4991 ng/L within 2 h. During emergent angiography, VF developed after left ventricular catheter manipulation and recurred repeatedly while attempting to cross a heavily calcified 99% proximal left circumflex (LCx) lesion. Over 20-30 min, 11 VF episodes required immediate defibrillation, manual chest compressions, and intravenous amiodarone. VF ceased only after LCx stenting restored TIMI Grade 3 flow. The patient's maximum intraprocedural shock severity met SCAI Stage E criteria because of recurrent cardiac arrest, multiple defibrillations, and severe acidosis. An Impella microaxial flow pump was placed for temporary postresuscitation circulatory support and maintained at P4. A postreperfusion echocardiogram obtained during ongoing support showed an LVEF of approximately 60%. The device was removed within 48 h after hemodynamic recovery. Staged intravascular lithotripsy-assisted PCI of the calcified mid-LAD lesion was performed on Day 4.
Discussion:
This case demonstrates that refractory ischemia-mediated VF may terminate only after culprit-vessel reperfusion. A preserved LVEF measured after reperfusion during mechanical support does not exclude earlier SCAI Stage E shock. Short-duration Impella support may serve as an individualized bridge during recovery from recurrent arrest and transient circulatory collapse.
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