Hybrid Beating-Heart Infarct Zone Reperfusion During Emergency Coronary Bypass for ST-Elevation Myocardial Infarction
Joseph M. Arcidi, Jr.1, Peter W. Kluge2, Craig J. Santolin3, Mark H. Ereth4, Anton I. Kidess2.
1Providence St. Joseph Heart Institute, Eureka, CA, USA, 2OakLeaf Clinics/HSHS Sacred Heart Hospital, Eau Claire, WI, USA, 3Marshfield Medical Center, Eau Claire, WI, USA, 4Mayo Clinic/HSHS Sacred Heart Hospital, Eau Claire, WI, USA.
OBJECTIVE: Reperfusion delay impacts prognosis in STEMI patients with cardiogenic shock requiring emergency CABG, particularly in those with right ventricular (RV) infarction. We utilized a hybrid beating-heart/cardioplegic arrest method to expedite reperfusion in this scenario.
METHODS: This 58yo man underwent emergency 3-vessel CABG after successive transfer from 2 hospitals, nearly 6 hours after developing an inferior STEMI during stress testing, then distal (dominant) RCA dissection with inability to establish guidewire-dependent perfusion [image]. He had 3-vessel disease with particularly diffuse LAD involvement, and pressor-dependent cardiogenic shock with central cyanosis on IABP support. The RV was grossly hypokinetic and dilated, and immediate decompression with cardiopulmonary bypass did not reduce ST-segments. We urgently performed a beating-heart distal saphenous vein anastomosis to a 2.0mm non-dissected PDA, then perfused arterial pump return continuously through the vein at 100ml/min using the retrograde cardioplegia line. PDA perfusion was continued during skeletonized LIMA harvest, then cardioplegic arrest was used to complete the remaining anastomoses.
RESULTS: Despite evident RV infarction, the patient was weaned from bypass with modest multiple inotropic support. On POD 1 hypoxemia from right-to-left shunting across a patent foramen ovale responded to dobutamine with immediate cessation of other catecholamines. He was extubated on POD 2 and discharged home on POD 8. At 5 months echocardiography showed mild RV hypokinesis and a 37% LVEF.
CONCLUSIONS: In our challenging patient, beating-heart expedited infarct zone reperfusion a) provided measured flow using the existing bypass circuit, b) enabled internal mammary harvest, and c) potentially mitigated the expected magnitude of RV infarction.
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