Complications of Myocardial Infarction
This is a case of a 61 year old woman with chest discomfort and evidence of an inferior, ST-elevation myocardial infarction, who develops persistent cardiogenic shock and respiratory failure after primary percutaneous coronary intervention. We discuss the
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Brandon M. Jones and Venu Menon
Case Presentation A 61 year old woman with a history of hypertension, tobacco abuse, and Wolf-Parkinson-White syndrome with prior ablation 15 years ago, presented to the emergency department via ambulance with 4 days of indigestion and generalized chest discomfort, with more severe pain lasting several hours. EMS noted her to be tachycardic with HR 102 bpm, and hypotensive with BP 83/61 mmHg. The following 12-lead ECG was obtained (Fig. 13.1). The initial physical exam was notable for an anxious and diaphoretic patient with elevated jugular venous pressure, crackles at the lung bases, and a left ventricular S3 with a soft systolic murmur adjacent to the lower left sternal boarder. Initial blood tests showed WBC 12.5,
Electronic supplementary material The online version of this chapter (doi:10.1007/978-3-319-43341-7_13) contains supplementary material, which is available to authorized users. B.M. Jones Cardiovascular Medicine and Interventional Cardiology, Cleveland Clinic Foundation, Cleveland, OH, USA V. Menon (*) Pulmonary and Critical Care, Geisinger Medical Center, Danville, PA, USA e-mail: [email protected]
hemoglobin 15.5 mg/dL, serum creatinine 1.2 mg/dl, and cardiac troponin I 6.06 ug/L. She was brought emergently to the cardiac catheterization laboratory where she was found to have 100 % occlusion of a dominant, mid-left circumflex artery. She underwent successful PCI with placement of two overlapping drug-eluting stents, and restoration of TIMI 3 flow to the infarct related artery (Table 13.1). At the conclusion of the case, the patient became agitated and pulse oximetry showed 88 % saturation despite administering 100 % oxygen by non-rebreather facemask. Blood-pressure was 78/58 mmHg at this time, and the patient required endotracheal intubation and the initiation of vasopressor medications to stabilize her blood pressure. Question What is the differential diagnosis for the patient’s hemodynamic and respiratory decompensation, and what should be done next to confirm the diagnosis? Answer The differential diagnosis must include mechanical complications of AMI including ventricular septal rupture (VSR) (Video 13.1), papillary muscle rupture leading to acute mitral regurgitation (MR) (Video 13.2), or free-wall rupture leading to pseudoaneurysm or cardiac tamponade (Video 13.3). Other etiologies to be considered include RV infarction, acute blood loss, iatrogenic hypotension secondary to medication, and cath lab complications such as aortic dissection or coronary perforation. The most
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_13
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Fig. 13.1 12-lead ECG Table 13.1 TIMI flow definitions TIMI Grade 0 (no perfusion) TIMI Grade 1 (penetration without perfusion)
TIMI Grade 2 (partial perfusion)
TIMI Grade 3 (complete perfusion)
There is no antegrade flow beyond the point of occlusion The contrast material passes beyond the area of obstruction but “h
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