Impella Use in STEMI Patient

December 6, 2019

Successful Revascularization in Very Late Stent Thrombosis Case

Dr. Sagar Mallikethi Reddy discusses Impella use in a STEMI patient with very late stent thrombosis, incessant ventricular tachycardia (VT), and a very high LVEDP. This case also highlights a conservative approach to ensure closure post-procedure in an acute patient. Dr. Reddy is an interventional cardiologist at McLaren Hospital in Flint, Michigan.

The case Dr. Reddy presents is a very late stent thrombosis case in a 68-year-old female patient who had had a drug-eluting stent placed in proximal LAD 10 years prior to this case. EKG indicated anterior STEMI. While in the cath lab, she experienced recurrent ventricular tachycardia despite multiple defibrillator shocks that offered only temporary relief. The cath lab team prepared right radial access as well as right groin access. LVEDP was very high at 40 mmHg and an angiogram showed 100% occlusion of the proximal LAD where she’d had the stent placed 10 years prior.

In this interview, Dr. Reddy reviews some of the reasons for very late stent thrombosis (defined as thrombosis occurring 1 year after PCI). He notes that malapposition, neoatherosclerosis, uncovered stent struts, and underexpanded stents account for 80% to 90% of the cases of very late stent thrombosis.

Dr. Reddy describes how he decided to insert an Impella through the right groin to help with the high LVEDP while he performed several procedures and eventually restented the occlusion. Notably, the patient did not experience any VT after Impella was placed and Dr. Reddy notes the importance of the timely use of Impella to stabilize the ischemia induced ventricular arrhythmias before revascularization. “That suggests how well the Impella worked in terms of reducing the LVEDP and taking the stress off the heart,” he tells interviewer Dr. Shon Chakrabarti, “and it allowed me to buy some extra time to achieve optimal revascularization.”

After the procedure he performed a left heart cath and determined that LVEDP had dropped significantly to 15 mmHg. At this point he decided he could remove the Impella. With the peel-away sheath in place, he removed Impella and inserted a 0.035” wire to protect his access. As he was tightening the Perclose sutures, one of them broke. Fortunately, he had not tightened the knot on the first suture and was able to deploy an 8 Fr AngioSeal and then tighten the first Perclose suture to achieve hemostasis.

Dr. Chakrabarti comments that many physicians would not elect to use preclosure techniques in a time-sensitive setting in an acute patient with STEMI and cardiogenic shock. Dr. Reddy explains that he felt comfortable taking the extra 2 to 3 minutes as a safety net for achieving good hemostasis at the end of the case.

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To learn more about the Impella® platform of heart pumps, including important risk and safety information associated with the use of the devices, please visit: www.protectedpci.com/indications-use-safety-information/

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