M M

63-year-old male, known diabetic for the last 8 years, on and off treatment, presented with retrosternal burning for the last 3 days and severe breathlessness and sweating for the last 4 hours.HR 112/min, BP 96/70, Saturation 85% on room air,  increased to 95% on BiPAP support.

ECG showed LBBBEcho: global LV dysfunction with EF of 30%, moderate MRABG showed a pH of 7.13 with lactates 5.5 mmol/LAttendants not consenting to intubation,patient is not able to lie flat.Managed on BIPAP for 6 hours but graduallybecame exhausted, finally intubated and put on mechanical ventilation.Was hypotensive by then, requiring twoinotropes, anuricBedside IABP inserted, with some improvement inhemodynamics and started forming some urine.Was taken up for coronary angiography

A coronary Angiogram showed significant disease at the Left Main ostium and Proximal LAD. [Figure A, Figure B] the left circumflex had proximal plaquing. the RCA showed diffuse plaquing with significant stenosis in the PLB. 

The patient was put on ECMO support and advised CABG. A surgical opinion was taken and high surgical risk was explained to the attendants who did not give consent for surgery. After 5 days on ECMO, the attendants agreed to high-risk angioplasty of LM and LAD.Since the patient had IABP in the right femoral artery, the ECMO return cannula in the left femoral artery was used for arterial access and the tubing was punctured with 6F sheath. [Figure 3]The LM was engaged with 6 F guiding catheter, the LAD lesion was pre-dilated with NC balloon, and a 3.5 X 48 mm stent was deployed from distal to proximal LAD with the help of a Guide Extension Catheter [Figure 4]. A 4.0 X 18 mm stent was then deployed from the LM ostium to LAD and POT was done with a 4.5 mm NC balloon, there was no significant compromise of the LCx ostium [Figure 5]. A dissection at the distal edge of the LAD stent was covered with a 3.0 x 15 mm stent deployed with the help of a guide extension catheter. At the end of the procedure, the ECMO tubing at the site of sheath insertion was cut and the tube was reattached to the return cannula.IABP was removed on 2nd post-procedure day.ECMO weaning was started and finally, ECMO removal was possible after 20 days of ECMO.He was discharged on home nursing care without supplemental O2 requirement or inotropes after 32 days in the hospital.

Patients who present with stage D or E cardiogenic shock require prompt mechanical cardiac support before attempting revascularisation.It is possible to do complex coronary interventions safely under ECMO support using the ECMO arterial cannulae as a conduit in case the other access sites are engaged or not suitable.The guide extension catheter can be used if the guiding catheter's length is insufficient to provide good support.