Category: Cardiology
Posted: 9/29/2013 by Ali Farzad, MD
(Updated: 3/10/2014)
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The primary goal in management of STEMI is rapid coronary revascularization. STEMI's are occasionally complicated by ventricular fibrillation (VF) arrest. High quality chest compressions and early defibrillation will improve survival. But what can be done in cases where conventional ACLS measures fail and patients have shock-refractory VF?
Some have suggested that emergent PCI with ongoing CPR en route may be beneficial. This option may be considered in close consultation with cardiology if the arrest is thought to be driven by ongoing ischemia and infarction. However, definitive data is lacking and this has only been described in a handful of case reports.
There may also be a role for venoarterial ECMO to aid in perfusion of vital organs and limit the risk of multisystem organ failure. The ECMO circuit can also help facilitate therapeutic hypothermia after the culprit vessel(s) is revascularized and rhythm is restored.
Chances for survival are highest in younger patients, those that do not have chronic illnesses, and those who received immediate CPR after arrest.
Summary:
Consider emergent consultation for salvage PCI and ECMO in select cases of shock-refractory ventricular fibrillation associated with STEMI
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A recently published case report (attached) presents a fascinating case where salvage PCI and ECMO were used for shock-refractory VF. The patient survives with good neurological outcome. It highlights the multidisciplinary cooperation and resources necessary to utilize these heroic practices.
Brown DFM, Jaffer FA, Baker JN, Gurol ME. Case records of the Massachusetts General Hospital. Case 28-2013. A 52-year-old man with cardiac arrest after an acute myocardial infarction. N Engl J Med. 2013;369(11):1047–1054. doi:10.1056/NEJMcpc1304164.
